Bulimia Nervosa

Binging behavior can be seen with what other medical conditions?

- central nervous system tumors, - Klüver-Bucy syndrome, and - Klein-Levin syndrome.

What are the best treatment modalities for bulimia?

- nutritional rehabilitation, - cognitive behavioral psychotherapy, and - treatment with an antidepressant (SSRI).

Ipecac intoxication can cause what physical symptoms?

- pericardial pain, - dyspnea, and - generalized muscle weakness, associated with - hypotension, - tachycardia, and - electrocardiogram (ECG) abnormalities.

According to American Psychiatric Association practice guidelines, individuals with bulimia nervosa should have a three-pronged approach to treatment:

1. There should be a plan developed for nutritional rehabilitation in which the patient has regular, nutritionally balanced meals to replace the pattern of fasting then binging with vomiting often seen in this population. This should be supplemented with nutritional counseling. 2. Cognitive behavioral psychotherapy on an individual basis to deal with the underlying cognitive patterns that drive bulimia, combined with group therapy (often based on an addiction-model 12-step program) is the best way for dealing with the immediate issues. If the patient moves back in with her parents, this should be supplemented with family therapy. 3. Treatment with an antidepressant, usually an SSRI, can produce a decrease in vomiting and binging behavior, but it is important to realize that without psychotherapy, purging behaviors can return. Fluoxetine has the most evidence for efficacy and should be the first medication tried, with sertraline being the only other SSRI demonstrated as being effective in bulimia. Medication should be continued for 9 to 12 months after symptoms have gone into remission.

Bulimia nervosa is estimated to occur in 1% of adolescent and young adult females, but eating-disorder-like behavior (brief times of purging) can affect up to what percent of young women?

5% to 10%

Question 2: A 34-year-old woman presents with a 10-year history of episodes in which she eats large quantities of food, such as eight hamburgers and three quarts of ice cream, at a single sitting. Because of her intense feelings of guilt, she then repeatedly induces vomiting. This cycle repeats itself several times a week. She is extremely ashamed of her behavior but says, "I can't stop doing it." On examination, which of the following physical findings is most likely to be seen? A Dental caries B Lanugo C Muscle wasting D Alopecia E Body weight at less than the 10th percentile of normal

A Dental caries The most likely diagnosis for this woman is bulimia nervosa. Physical findings can include dental caries, a round face caused by enlarged parotid glands, or calluses on the fingers resulting from recurrent self-induced vomiting. Lanugo and muscle wasting result from the severe weight loss characteristic of anorexia nervosa.

True or false: A diagnosis of bulimia nervosa requires both recurrent binging and purging or other compensatory behaviors to prevent weight gain. This behavior cannot occur exclusively during an episode of anorexia nervosa.

True

True or false: Abnormalities revealed in laboratory studies can include hypochloremic-hypokalemic alkalosis, hyperamylasemia, hypomagnesemia, and various electrolyte imbalances.

True

True or false: Binge eating is part of the impulsive behavior common to borderline personality disordered patients, but they have a long history of other impulsive behaviors, including self-harm, as well.

True

True or false: Binging and purging behavior may be a part of anorexia, but these patients must have a significantly low body weight in addition.

True

True or false: Bulimic patients can be underweight, of normal weight, or even overweight. Despite their purging, the sheer amount of high-caloric food eaten more than compensates for the amount purged.

True

True or false: Individuals with bulimia can be underweight, of normal weight, or overweight.

True

True or false: Ipecac intoxication can cause a toxic cardiomyopathy that can lead to death.

True

True or false: It is a common finding that binging episodes increase during times of stress.

True

True or false: Patients with binge-eating disorder have the binge eating without inappropriate compensatory behaviors and are often overweight.

True

True or false: Physical findings include dental caries, enlarged parotid or salivary glands, and esophageal tears.

True

True or false: Selective serotonin reuptake inhibitors are helpful in reducing both binging and purging behavior, but should be offered in association with cognitive behavioral psychotherapy or other evidence-based psychotherapies.

True

True or false: It should be noted that resent studies show that a growing proportion of patients with bulimia nervosa are obese or significantly overweight.

True Being both overweight and bulimic may require a substantially different approach to the treatment of the patient.

True or false: Patients with bulimia are usually normal or near normal in weight.

True However, their self-evaluation of themselves is often very dependent on their weight and perception of their body shape.

True or false: Generally, studies of the effects of medication alone show that they are not as effective as when given in combination with psychotherapy.

True In cases of effective treatment, a reduction of the purging rate by more than 50% over the first 4 weeks of treatment is often seen.

True or false: Studies have shown that cognitive behavioral therapy as usually practiced (focused on cognitive distortions of body image) in bulimia nervosa is ineffective in reducing weight, and may result in overweight patients with this disorder dropping out of treatment.

True In overweight patients with bulimia, appetite awareness training and a structured behavioral weight loss program along with a modified type of cognitive behavioral therapy that is appetite-focused is preferable.

What is non-purging type of bulimia?

Type of bulimia where fasting and excessive exercise is utilized without frequent purging.

Elaborate on other effective therapies aside from CBT.

Adolescents living at home often benefit from family-based therapy that includes parents in an effort to disrupt pathological eating and weight control behaviors. After this initial work, the responsibility for maintenance of remission then transitions to the adolescent. Group therapy is effective because bulimic patients often feel ashamed of their symptoms and have difficulty dealing with interpersonal problems. Groups show them that they are not alone and give them opportunities to practice interpersonal problem-solving skills.

After 5 to 10 years of treatment, what is the recovery rate for bulimics? What is the relapse rate?

Approximately 50% of bulimic patients will be recovered, 30% will be partially recovered, and 20% will meet full criteria for active bulimia. 1/3 of recovered bulimic patients will have a relapse within 4 years of recovery.

Question 1: Bulimia differs from anorexia nervosa in which one of the following ways? A Patients with bulimia tend to be low achievers in academics compared to patients with anorexia. B Patients with bulimia may not have any symptoms until early adulthood while anorexia typically begins in early adolescence. C Patients with bulimia are less likely to abuse alcohol and have less emotional lability than patients with anorexia. D Bulimic patients tend to be overweight, whereas anorexic patients are underweight. E Patients with bulimia are more resistant to receiving help and often must be forced to see a therapist.

B Patients with bulimia may not have any symptoms until early adulthood while anorexia typically begins in early adolescence. Patients with both disorders tend to be high achievers but patients with bulimia tend to be less resistant to getting help, have more alcohol abuse, and have more emotional lability than patients with anorexia, who tend to be more emotionally constricted. Bulimia often has a later onset than anorexia.

What are hallmarks of the disease?

Binge eating and purging are the hallmarks of the disease.

Question 3: Which of the following laboratory abnormalities would most likely be found in the patient in Question 31.2? A Hypermagnesemia B Hypoamylasemia C Hypochloremic-hypokalemic alkalosis D Elevated thyroid indices E Hypercholesterolemia

C Hypochloremic-hypokalemic alkalosis Laboratory abnormalities found in individuals with bulimia nervosa demonstrate hypochloremic-hypokalemic alkalosis resulting from repetitive emesis. Hyperamylasemia and hypomagnesemia are also not uncommonly seen in such patients. Various electrolyte imbalances can occur because of frequent laxative abuse. Thyroid abnormalities are not common in individuals with bulimia nervosa.

What is the most effective type of psychotherapeutic intervention?

Cognitive behavioral psychotherapy to resolve cognitive distortions.

Question 4: Which of the following treatment options would be a contraindicated treatment option for the patient in Questions 2 and 3? A Nutritional rehabilitation B Cognitive behavioral psychotherapy C Careful use of SSRIs D Group psychotherapy E Atypical antipsychotic medications

E Atypical antipsychotic medications There is no clinical evidence for the use of atypical antipsychotics in a patient with bulimia, and they may only serve to increase the patient's appetite and binging.

Define binge eating.

Eating an amount of food definitely larger than most people would eat during a similar period of time and experiencing a sense of lack of control.

What SSRI has been shown to be the most effective with bulimic patients? How long should medication be continued?

Fluoxetine Medication should be continued for 9-12 months after symptoms have gone into remission.

Elaborate on the possible PE and lab findings for a pt with bulimia.

Frequent exposure to gastric juices from vomiting can result in severe dental erosion. The parotid glands can enlarge. The patient can have elevated serum amylase levels. The self-induced vomiting can cause acute gastric dilatation and esophageal tears. Severe abdominal pain in these patients requires: nasogastric suction tubes, x-ray studies, and possible surgical consultation. Electrolyte abnormalities, especially low magnesium and potassium, are common. Laboratory abnormalities found in individuals with bulimia nervosa demonstrate hypochloremic-hypokalemic alkalosis, resulting from repetitive emesis. If they use ipecac to cause vomiting, they can have ipecac intoxication with pericardial pain, dyspnea, and generalized muscle weakness associated with hypotension, tachycardia, and electrocardiogram (ECG) abnormalities. Ipecac intoxication can cause a toxic cardiomyopathy that can lead to death.

How are bulimics different than anorexic patients?

In contrast to patients with anorexia, those with bulimia often exhibit coexisting alcohol dependence and emotional lability, but more readily seek help.

What is the mortality rate of bulimia?

It has a mortality rate of up to 3%.

What is the typical onset of bulimia?

Its onset is usually later in adolescence than that of anorexia nervosa, and it can also start in adulthood.

Repeated emesis can cause what abnormality found on labs?

Laboratory abnormalities found in individuals with bulimia nervosa demonstrate hypochloremic-hypokalemic alkalosis, resulting from repetitive emesis.

How are bulimics similar to anorexic patients?

Like individuals with anorexia, bulimic patients tend to be high achievers, have a family history of depression, and respond to social pressures to be thin.

How is anorexia distinguished from bulimia?

One of the main disorders in the differential diagnoses is anorexia nervosa, binge-eating/purging type. Although binging and purging behavior can be seen in anorexia as well as in bulimia, anorexia is distinguished by the requirement of being underweight and amenorrheic.

What should be included in the PE and labs for a pt suspected of bulimia?

PE: Parotid glands, mouth, teeth for caries, abdominal examination for esophageal or gastric injury, dehydration from laxative use, ipecac-associated hypotension, tachycardia, and arrhythmias. Labs: - serum electrolytes, - magnesium, and - amylase levels should also be checked.

Typical onset is in females during adolescence or early adulthood, with the peak onset at what age range?

Peak onset: ages 18-19

Give the diagnostic criteria for bulimia nervosa.

Recurrent episodes (at least once a week for 3 mo) of binge eating and inappropriate compensatory behavior such as purging, fasting, or excessive exercise. Self-evaluation is largely (and unduly) based on body shape and weight. The behavior does not occur only during an episode of anorexia nervosa.

Another concern is individuals who present with purging behavior who do not necessarily meet the criteria for bulimia nervosa. It is not uncommon for adolescents and young adults (especially women) to engage in purging behavior in order to lose weight. This behavior is usually learned from peers, and is distinguished from bulimia - how?

distinguished from bulimia by being: short lived, infrequent, and unassociated with physical sequelae.

These patients use inappropriate ways of controlling weight - including what?

fasting, excessive exercise, and misuse of laxatives, diuretics, or enemas along with the often-seen vomiting.

What is purging?

Self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas for the purpose of preventing weight gain.