29-06: Bulimia Nervosa

GENERAL CONSIDERATIONS

Bulimia nervosa is the episodic uncontrolled ingestion of large quantities of food followed by recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, diuretic or cathartic use, strict dieting, or vigorous exercise.

Like anorexia nervosa, bulimia nervosa is predominantly a disorder of young, white, middle- and upper-class women. It is more difficult to detect than anorexia, and some studies have estimated that the prevalence may be as high as 19% in college-aged women.

CLINICAL FINDINGS

Patients with bulimia nervosa typically consume large quantities of easily ingested high-calorie foods, usually in secrecy. Some patients may have several such episodes a day over multiple days; others report regular and persistent patterns of binge eating. Binging is usually followed by vomiting, cathartics, or diuretics and accompanied by feelings of guilt or depression. Periods of binging may be followed by intervals of self-imposed starvation. Body weight may fluctuate but generally is within 20% of normal BMI.

Family and psychological conditions are generally similar to those of patients with anorexia nervosa. Patients with bulimia, however, have a higher incidence of obesity, greater use of cathartics and diuretics, and more impulsive or antisocial behavior. Menstruation is usually preserved.

Medical complications are numerous. Gastric dilatation and pancreatitis have been reported after binges. Vomiting can result in poor dentition, pharyngitis, esophagitis, aspiration, and electrolyte abnormalities. Cathartic and diuretic abuse can also cause electrolyte abnormalities or dehydration. Constipation is common.

TREATMENT

Treatment of bulimia nervosa requires supportive care and psychotherapy. Individual, group, family, and behavioral therapy have all been utilized. Antidepressant medications may be helpful. The best results have been with fluoxetine and other SSRIs. Given the limited arsenal of pharmacologic agents, more research is needed to develop safe, effective, and targeted therapies. Although death from bulimia is rare, the long-term psychiatric prognosis in severe bulimia is worse than that in anorexia nervosa.

WHEN TO REFER

All patients with diagnosed bulimia should be co-managed with a psychiatrist.