> Table of Contents > Bulimia Nervosa
Bulimia Nervosa
Umer Farooq, MD, MBBS
Wajiha Illyas, MD
image BASICS
DESCRIPTION
  • A pattern of discrete periods of binge eating (within 2-hour period) along with lack of control over eating, followed by compensatory behaviors such as self induced vomiting, misuse of laxatives, and so forth.
  • Both binge eating and compensatory behaviors happening at least once per week for 3 months
  • DSM-5 classifies bulimia nervosa as
    • Mild: 1 to 3 episodes of compensatory behaviors
    • Moderate: 4 to 7 episodes of compensatory behaviors
    • Severe: 8 to 13 episodes of compensatory behaviors
    • Extreme: 14 or more episodes of compensatory behaviors
  • System(s) affected: oropharyngeal, endocrine/metabolic, gastrointestinal, dermatologic, cardiovascular, nervous
EPIDEMIOLOGY
  • Predominant age: adolescents and young adults
  • Mean age of onset: 18 to 21 years
  • Predominant sex: female > male (10:1)
Incidence
28.8 women, 0.8 men per 100,000 per year
Prevalence
  • More prevalent than anorexia nervosa
  • 1-3% in women age 16 to 35 years
  • 0.5% in young men (higher among gay and bisexual men)
ETIOLOGY AND PATHOPHYSIOLOGY
  • Combination of biologic, psychological, environmental, and social factors. Unique contribution of any specific factor remains unclear.
  • Strong evidence of serotonergic dysregulation in bulimia nervosa
  • Substantial literature shows genetic evidence for bulimia nervosa (1)[B].
RISK FACTORS
  • Female gender
  • History of obesity and dieting
  • Body dissatisfaction
  • Critical comments about weight, body shape, or eating
  • Severe life stressor
  • Low self-esteem
  • Perceived pressure to be thin
  • Perfectionist or obsessive thinking
  • Poor impulse control, substance abuse
  • Environment stressing high achievement, physical fitness (e.g., armed forces, ballet, cheerleading, gymnastics, or modeling)
  • Family history of substance abuse, affective disorders, eating disorder, or obesity
  • Type 1 diabetes
  • Sexual abuse is not causally related to bulimia.
GENERAL PREVENTION
  • Prevention programs can reduce risk factors and future onset of eating disorders (2)[A].
  • Target adolescents and young women ≥ 15 years
  • Realistic and healthy weight management strategies and attitudes
  • Decrease body dissatisfaction and promote self-esteem.
  • Reduce focus on thin as ideal.
  • Decrease anxiety/depressive symptoms and improve stress management.
COMMONLY ASSOCIATED CONDITIONS
  • Major depression and dysthymia
  • Anxiety disorders
  • Substance use disorder
  • Bipolar disorder
  • Obsessive-compulsive disorder
  • Borderline personality disorder
image DIAGNOSIS
PHYSICAL EXAM
  • Often normal
  • Bradycardia
  • Eroded tooth enamel
  • Perimylolysis
  • Cheilosis
  • Gingivitis
  • Sialadenosis
  • Asymptomatic, noninflammatory parotid gland enlargement
  • Epigastric tenderness to palpation
  • Calluses, abrasions, bruising on hand, thumb (Russell sign)
  • Peripheral edema
DIFFERENTIAL DIAGNOSIS
  • Anorexia, binge eating/purging type
  • Major depressive disorder
  • Addison disease
  • Celiac disease
  • Diabetes mellitus
  • Hyperthyroidism, hypothyroidism
  • Hyperpituitarism
  • Hypothalamic brain tumor
  • Kleine-Levin syndrome
  • Body dysmorphic disorder
  • Borderline personality disorder
DIAGNOSTIC TESTS & INTERPRETATION
All lab results may be within normal limits and are not necessary for diagnosis.
  • Psychological self-report screening tests may be helpful, but diagnosis is based on meeting the DSM-5 criteria:
    • SCOFF Questionnaire (3)[B]
    • Eating Disorder Screen for Primary Care
Initial Tests (lab, imaging)
  • Blood work, CBC, and CMP
    • Hypokalemia, hypochloremia
    • Hypomagnesemia, hyponatremia, hypocalcemia, hypophosphatemia
    • Serum amylase levels
    • Alkalosis
    • Elevated BUN
    • Hypoglycemia
  • Urinalysis
    • Increased urine specific gravity
Diagnostic Procedures/Other
  • Electrocardiogram
  • Bradycardia or arrhythmias
  • Conduction defects
  • Depressed ST segment due to hypokalemia
Test Interpretation
  • Esophagitis
  • Acute pancreatitis
  • Cardiomyopathy and muscle weakness due to ipecac abuse
  • Melanosis coli
  • Cathartic colon syndrome
  • Delayed or arrested skeletal growth
  • Stress fracture
  • Irreversible dental erosions
  • Osteopenia/osteoporosis
image TREATMENT
  • Cognitive-behavioral therapy (CBT) should be considered as first-line treatment (4,5)[A].
  • Interpersonal therapies and group therapies have been found to be helpful.
GENERAL MEASURES
  • Multidisciplinary team
    • Primary care physician, behavioral health provider, nutritionist
  • Build trust; increase motivation for change.
  • Assess psychological and nutritional status.
  • Consider evidence-based self-help program.
  • CBT for bulimia nervosa (4,5)[A]
    • Sixteen to twenty 50-minute appointments
    • Involve patient in establishing goals.
    • P.149

    • Self-monitoring of food intake, frequency of binges/purges, related antecedents, consequences, thoughts, and emotions
    • Self-monitoring of weight once per week
    • Educate about ineffectiveness of purging for weight control and adverse outcomes.
    • Establish prescribed eating plan to develop regular eating habits and realistic weight goal.
    • Gradually introduce feared foods into diet.
    • Problem-solve how to cope with triggers.
    • Decrease ruminations about calories, weight, and purging.
    • Challenge fear of loss of control.
    • Establish relapse prevention plan.
    • Gradual laxative withdrawal
  • Interpersonal therapy
    • May act more slowly than CBT
  • Transdiagnostic CBT
  • Dialectical behavior therapy
  • Family therapy for adolescents
  • Nutritional education, relaxation techniques
  • Educate patient to brush teeth and use baking soda to rinse mouth after vomiting.
MEDICATION
First Line
  • Selective serotonin reuptake inhibitors (SSRIs) (6)[A], (7)[B], particularly fluoxetine (Prozac) titrated to 60 mg/day, are effective in reducing symptoms with relatively few side effects. Higher doses than standard doses for depression are often needed.
    • Combination of medication and CBT has been shown to have added benefit over medication or therapy alone.
  • To prevent relapse, maintain antidepressant at full therapeutic dose for at least 1 year.
  • Avoid bupropion: contraindicated due to its association with seizures in patients who purge
  • Precautions
    • Serious toxicity following overdose is common.
    • Patients may vomit medications.
Second Line
  • Select different SSRI.
  • Ondansetron (Zofran) 4 to 8 mg TID between meals can help prevent vomiting.
  • Psyllium (Metamucil) preparations, 1 tbs QHS with glass of water, can prevent constipation during laxative withdrawal.
ISSUES FOR REFERRAL
Patients with bulimia require a multidisciplinary team, including a primary care physician, behavioral health provider, and a nutritionist. Important part of treatment is to arrange mental health therapist for psychotherapy.
ADDITIONAL THERAPIES
Most patients can be treated as outpatients.
COMPLEMENTARY & ALTERNATIVE MEDICINE
Bright light therapy may help.
INPATIENT CONSIDERATIONS
  • If possible, admit to a specialized eating disorders unit.
  • Supervised meals and bathroom privileges
  • Monitor weight and physical activity.
  • Monitor electrolytes.
  • Gradually shift control to patients as they demonstrate improvement.
Admission Criteria/Initial Stabilization
Hospitalize if severe malnutrition, dehydration, electrolyte disturbances, cardiac dysrhythmia, uncontrolled binging and purging, psychiatric emergency (threat to self/others), or if outpatient treatment failed
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Binge-purge activity, including antecedents and consequences
  • Level of exercise activity
  • Self-esteem, comfort with body and self
  • Ruminations and depressive symptoms
  • Repeat any abnormal lab values weekly or monthly until stable.
DIET
  • Balanced diet, normal eating pattern
  • Reintroduce feared foods.
PATIENT EDUCATION
  • Astrachan-Fletcher E, Maslar M. The Dialectical Behavior Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. Oakland, CA: New Harbinger; 2009.
  • http://www.nami.org/helpline/bulimia.htm
PROGNOSIS
  • After effective CBT
    • In the short term, 50% of treated individuals do not meet criteria for diagnosis.
    • In the long term (2 to 10 years), 70% may be asymptomatic.
    • Symptomatic individuals may demonstrate remissions, relapses, subclinical, or other eating disorder-related behaviors.
  • Untreated
    • Likely to remain chronic/relapsing problem
  • Greater weight fluctuations, other impulsive behaviors, childhood obesity, low self-esteem, family history of alcohol abuse, psychiatric comorbidity, and personality disorder diagnoses (e.g., avoidant personality disorder) may predict poor prognosis.
  • Mortality rate: 0.4%
REFERENCES
1. Raevuori A. Genetic etiology of eating disorders. Duodecim. 2013;129(20):2126-2132.
2. Stice E, Shaw H, Marti CN. A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol. 2007;3:207-231.
3. Cotton MA, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. 2003;18(1): 53-56.
4. Hay PP, Bacaltchuk J, Stefano S, et al. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009;(4):CD000562.
5. Shapiro JR, Berkman ND, Brownley KA, et al. Bulimia nervosa treatment: a systematic review of randomized controlled trials. Int J Eat Disord. 2007;40(4):321-336.
6. Bacaltchuk J, Hay P, Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev. 2001;(4):CD003385.
7. Bellini M, Merli M. Current drug treatment of patients with bulimia nervosa and binge-eating disorder: selective serotonin reuptake inhibitors versus mood stabilizers. Int J Psychiatry Clin Pract. 2004;8(4):235-243.
Additional Reading
  • American Psychiatric Association. Practice Guideline for the Treatment of Patients with Eating Disorders. 3rd ed. Washington, DC: American Psychiatric Association. http://www.psychiatry.org/
  • National Institute for Clinical Excellence. Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders (NICE Guidelines). London, United Kingdom: National Institute for Clinical Excellence; 2004. http://www.nice.org.uk.
See Also
  • Anorexia Nervosa; Hyperkalemia; Laxative Abuse; Salivary Gland Tumors
  • Algorithm: Weight Loss
Codes
ICD10
F50.2 Bulimia nervosa
Clinical Pearls
  • Asking “Are you satisfied with your eating patterns?” and/or “Do you worry that you have lost control over how much you eat?” may help to screen for an eating problem.
  • Weight is not severely lowered as in anorexia nervosa.
  • Consider using a stepped care approach. Start with a guided self-help program using instructional aids; next, begin CBT (e.g., 16 to 20 sessions over 4 to 5 months).
  • SSRIs, particularly fluoxetine (60 mg daily), may be helpful as a first step or as an adjunctive treatment with CBT.