Bulimia
Bulimia: Excerpt from The 5-Minute Pediatric Consult
Nadja Peter, MD
Bulimia - BASICS
Bulimia - description
Bulimia nervosa is an eating disorder characterized by:
- Recurrent episodes of binge eating characterized by rapid consumption of large amounts of food in discrete periods of time, usually <2 hours
- Compensatory behavior such as self-induced vomiting, laxative or diuretic use, strict dieting, or vigorous exercise to induce weight loss
- Minimum average of 2 binge-eating episodes per week for at least 3 months
- Feeling of lack of control over eating behavior during eating binges
- Frenzied quality, often occurring alone and secretively
- Associated feelings of guilt, anxiety, low self-esteem, and depression
- Persistent overconcern with body shape and weight
- Symptoms and psychopathology may overlap with anorexia nervosa and eating disorder not otherwise specified
Bulimia - general prevention
Emphasize healthy self-esteem and body image during visits with preadolescents and adolescents.
Bulimia - epidemiology
- Onset in late adolescence to early adulthood (range: 13–28 years of age)
- Females account for 85–90% of cases.
- 83% of patients have lifetime history of an anxiety disorder, 63% have a lifetime history of depression.
Bulimia - prevalence
- Affects 1–3% of young females in Western countries
- Affects 4–10% of adolescent and college-age females
- 10 times more common than anorexia nervosa
Bulimia - risk factors
Bulimia - genetics
Recent studies, including twins studies, suggest that bulimia nervosa and binge eating is familial.
Bulimia - etiology
- Personality traits of low self-esteem, self-regulatory difficulties, frustration intolerance, and impaired ability to recognize and express feelings directly have been described in patients with bulimia nervosa.
- There appears to be a small positive association between childhood sexual abuse and the development of an eating disorder, but the size and nature of this association is as yet unknown.
- May be 2 subtypes:
- Multi-impulsive: Patient relies on bingeing and purging as a way of regulating intolerable states of tension, anger, and fragmentation.
- Postdieting: Binge eating is precipitated by dietary restraint with compensatory behaviors maintained by reduction of guilty feelings associated with fears of weight gain.
- Neuroendocrine abnormalities may also play a role: Abnormalities in serotonergic and vagal function have been demonstrated in patients with bulimia nervosa.
- Cholecystokinin response to a meal is decreased in patients with bulimia nervosa, which also may indicate abnormal satiety signaling.
- May be abnormalities in other hormones or neurotransmitters, such as leptin, dopamine, and endorphins, but unclear if these are cause or effect
Bulimia - DIAGNOSIS
Bulimia - signs & symptoms
Bulimia - history
- Eating-disorder specific:
- Eating habits
- Rituals, behaviors
- Body image
- Actual and desired weights, minimum and maximum weights
- Use of laxatives, diuretics, diet pills, emetics
- Presence of binge or purge behavior
- Menstrual history
- History of exercise
- General:
- Weakness or fatigue, or hyperactivity
- Thirst, frequent urination
- Headaches
- Abdominal pain, fullness, or bloating; nausea
- Constipation or diarrhea
- Psychiatric:
- Mood disorder
- Substance abuse
- Anxiety
- Personality disorders
- Suicidal tendencies
- Low self-esteem
- Feelings of ineffectiveness
- Family:
- Medical and psychiatric histories
Bulimia - physical exam
- Vital signs: Check for hypotension.
- Weight: May be normal, overweight, or underweight
- Edema of hands and feet: Evidence of low albumin or compensatory renal sodium and water retention
- Calluses on knuckles or hands: Russell sign secondary to inducing vomiting
- Erosion of dental enamel: Exposure to gastric juices secondary to frequent vomiting
- Muscle cramps or weakness: Hypokalemia
- Special questions:
- How much do you want to weigh?
- How do you control your weight?
- How do you feel about yourself?
- How often do you vomit, use diuretics or laxatives?
Bulimia - tests
Eating disorder questionnaires: Questionnaire assessments appear to be equivalent to diagnostic interview in diagnosing bulimia nervosa.
Bulimia - lab
- Perform a laboratory evaluation as part of the diagnostic workup. Laboratory evaluation is most useful for assessing complications; there is no diagnostic or confirmatory laboratory test for bulimia nervosa. Many patients have normal laboratory studies.
- CBC: Iron-deficiency anemia
- Electrolytes, including calcium, magnesium, and phosphate: Abnormalities may occur as a result of prolonged vomiting or use of laxatives.
- Blood urea nitrogen (BUN) and creatinine: Renal function usually normal, but BUN may be elevated secondary to dehydration or low secondary to protein loss
- Glucose: Patient may be hypoglycemic.
- Cholesterol, lipids: May be elevated in starvation states
- Amylase: Pancreatitis
- Total protein, albumin, prealbumin: Usually normal, but may be low as evidence of malnutrition
- Liver function tests: Transaminases may be mildly elevated (up to twice normal).
- ESR: Almost invariably normal; if elevated, consider occult organic process
- Total carbon dioxide: Metabolic alkalosis from vomiting or metabolic acidosis if using laxatives
- Urine toxicology screen (optional): May be positive, as this disorder often is associated with substance abuse
Bulimia - imaging
- Electrocardiogram with rhythm strip: May reveal U waves associated with hypokalemia
- Consider upper GI series with small-bowel follow-through
- Consider dual-energy x-ray absorptiometry (DEXA) scan if prolonged amenorrhea, to evaluate bone density
Bulimia - differencial diagnosis
- Psychogenic vomiting
- Drug abuse
- Gastrointestinal obstruction
- Hiatal hernia
Bulimia - TREATMENT
Bulimia - initial stabilization
Hospitalize in cases of:
- Hypovolemia
- Severe electrolyte disturbances
- Intractable vomiting
- Acute psychiatric emergencies (e.g., suicidal ideation, acute psychosis)
- Medical complication of malnutrition (e.g., aspiration pneumonia, cardiac failure, pancreatitis, Mallory-Weiss syndrome)
- Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive-compulsive disorder, severe family dysfunction)
- Failure of outpatient therapy
Bulimia - general measures
- Outpatient psychotherapy
- Cognitive behavioral therapy (CBT):
- More effective than interpersonal psychotherapy or behavioral therapy alone
- Helps patients determine other ways to cope with the feelings that precipitate purging and to try to correct maladaptive beliefs about body image
- May also be done in a self-help format, which may be effective as well
- 1 study of CBT in adolescents showed considerable promise
- Individual psychotherapy
- Family treatment (to help with dysfunctional family dynamics)
- Group therapy
- During treatment, patients and their families may cause “splitting” of the hospital staff. To avoid this, always be supportive and maintain consistency in stating goals.
Bulimia - activity
Physical activity was shown in 1 study to reduce the pursuit of thinness and to decrease bingeing/purging behavior.
Bulimia - medication
- Antidepressants:
- Decrease the binge–purge behavior
- Improve attitudes about eating
- Lessen preoccupation with food and weight
- Fluoxetine (Prozac), sertraline (Zoloft), desipramine, citalopram and fluvoxamine (Luvox) have been used with good results in patients with bulimia nervosa.
- Effect of antidepressant may diminish over time, and patient may relapse when drug is stopped.
- Psychotherapy combined with antidepressant therapy appears to have the best outcome.
- Response rate to alternative treatments after cognitive behavioral therapy and antidepressant 1st-line therapy is generally low.
- Few studies either of medication or psychotherapy have included patients 18 years of age, so preferred therapy in these patients still uncertain.
- Stool softeners: Often of little use for constipation; consider nonstimulating osmotic laxatives if severe
- Ondansetron: Shown in 1 study to decrease vomiting frequency; may help normalize the physiologic mechanism controlling satiation
Bulimia - FOLLOW UP
- Reduction in binge and purge episodes may take months or years.
- Behavioral and thought disorders associated with bulimia nervosa may be of long duration.
Bulimia - prognosis
- Very low mortality: 0.3% (but may be underestimated secondary to poor follow-up in studies)
- Most patients have episodic course with trend toward improvement.
- No studies of long-term prognosis in adolescents
- Adult studies: 5–10-year follow-up:
- 50% made full recovery.
- 30% relapsed.
- 20% still met full criteria for bulimia nervosa.
- Poor prognostic indicators:
- Concomitant depression, personality disorder, or substance abuse
- Frequent vomiting
- History of substance abuse
- Good prognostic indicators:
- High motivation for treatment
- No concurrent disruptive psychopathology
- Good self-esteem
Bulimia - complications
- Pulmonary:
- Aspiration pneumonia
- Pneumomediastinum
- GI:
- Pancreatitis
- Parotid or salivary gland enlargement
- Gastric and esophageal irritation and gastroesophageal reflux
- Mallory-Weiss tears
- Paralytic ileus (due to laxative abuse and hypokalemia)
- Severe constipation (due to laxative abuse and subsequent dependence)
- Metabolic:
- Hypokalemia (due to laxative abuse or vomiting)
- Secondary cardiac dysrhythmias, myopathy, ileus
- Electrolyte imbalances, including hypomagnesemia; acid–base disturbances
- Fluid imbalances
- Hyperamylasemia
- Edema (secondary to hypoproteinemia or renal sodium and water retention secondary to hypovolemia and secondary hyperaldosteronism)
- Bone loss (if amenorrhea; significantly more common in anorexia nervosa)
- Dental:
- Enamel erosion
- Caries and periodontal disease
Bulimia - patient monitoring
Signs to watch for:
- Weight loss or major weight fluctuations
- Electrolyte abnormalities
- Muscle cramps
- Fatigue
- Depression or mood disturbance
- Willful behavior or acting out
Bulimia - bibliography
- Agras WS, Walsh BT, Fairburn CG, et al. A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Arch Gen Psychiatry. 2000;57:459–466.
- Faris PL, Eckert ED, Kim SW, et al. Evidence for a vagal pathophysiology for bulimia nervosa and the accompanying depressive symptoms. J Affective Dis. 2006;92:79–90.
- Kaye WH, Klump KL, Frank GK, et al. Anorexia and bulimia nervosa. Annu Rev Med. 2000;51:299–313.
- Keel PK, Mitchell JE. Outcome in bulimia nervosa. Am J Psychiatry. 1997;154:131–321.
- Kreipe RE, Birndorf SA. Eating disorders in adolescent and young adults. Med Clin North Am. 2000;84:1027–1049.
- Mehler PS. Clinical practice. Bulimia nervosa. N Engl J Med. 2003;349:875–881.
- Schapman-Williams AM, Lock J, Courturier J. Cognitive-behavioral therapy for adolescents with binge eating syndromes: A case series. Int J Eat Disord. 2006;39:252–255.
- Smolak L, Murnen SK. A meta-analytic examination of the relationship between childhood sexual abuse and eating disorders. Int J Eat Disord. 2002;31:136–150.
Bulimia - CODES
Bulimia - icd9
- 307.51 Bulimia nervosa
- 783.6 Bulimia
Bulimia - FAQ
- Q: How do I determine if a patient has anorexia with vomiting or bulimia?
- A: The key feature of bulimia nervosa is the binge episode, which distinguishes it from anorexia nervosa. If there are not at least 2 binge eating episodes per week for at least 3 months, the diagnosis is not bulimia.
- Q: What laboratory abnormalities should I look for in my patients with bulimia?
- A: Electrolyte abnormalities, particularly hypokalemia. Patients may develop a hypochloremic metabolic alkalosis. If electrolytes are significantly abnormal, the patient should be hospitalized until they have normalized.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
More About Bulimia nervosa
More Medical Textbooks Online about Bulimia nervosa
Review other book chapters online related to Bulimia nervosa:
Medical Books Excerpts
- Weight Loss
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Bulimia
- "The 5-Minute Pediatric Consult" (2008)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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