Happy Monday, and welcome to Medical Mondays! February 23 to March 1 is National Eating Disorders Awareness Week here in the United States, so I’m going to talk about bulimia nervosa this week.
(Trigger warning!) As with anorexia nervosa, I’m only going to be going into the facts that I’ve learned about it.
Bulimia nervosa is an eating disorder that involves binge eating combined with behaviors that are focused on counteracting weight gain. Although self-induced vomiting is the classic example, the use of laxatives, enemas, diuretics, or excessive exercise are also possible behaviors.
Persons with bulimia are often embarrassed by their binge eating, and are overly concerned with their body weight. Like with anorexia, bulimia nervosa is significantly more common in women (90-95%), and usually occurs in late adolescence or early adulthood, with a peak onset at ages 18-19.
This eating disorder is more common in developed countries, and there is a higher incidence of comorbid mood disorders, anxiety disorders, impulse control disorders, a history of sexual abuse, and/or substance abuse. There is often coexisting alcohol dependence and emotional lability, but they more readily seek help (as compared to persons with anorexia nervosa).
Bulimia nervosa must be distinguished from purging behavior, which is a behavior usually learned from peers and is short-lived, infrequent, and unassociated with physical symptoms (will be listed below).
There are two sub-categories:
- Purging: involves vomiting, laxatives, enemas, diuretics
- Non-purging: involves excessive exercise or fasting
- Recurrent episodes of binge eating (excessive food intake within a 2-hour period with a sense of lack of control)
- Recurrent + inappropriate attempts to compensate for overeating to prevent weight gain (e.g. laxative abuse, vomiting, diuretics, excessive exercise)
- Binge eating + compensatory behaviors occur > 2x/week for 3 months
- Perception of self-worth is excessively influenced by body weight + shape
- Behavior doesn’t only occur during an episode of anorexia nervosa
- Sialadenosis (salivary gland enlargement)
- Dental erosions/caries (cavities due to self-induced vomiting)
- Callouses/abrasions on dorsum (back) of hand – “Russell’s sign” from self-induced vomiting
- Esophageal tears (Mallory-Weiss syndrome) and rupture (Boerhaave syndrome)
- Petechiae (tiny pinpoint bruises)
- Peripheral edema
- Laxative abuse (e.g. bisacodyl, cascara, senna, high-fiber supplements) is very common in patients with bulimia nervosa, which can lead to severe constipation due to damaging effects on myenteric plexus
- Caffeine, pseudoephedrine, phenylpropanolamine, Synthroid, + diuretics may also be used to try to increase metabolic rate, calorie + weight loss (less common than laxatives, which are available over-the-counter)
- *Ask patients with bulimia about their use of natural herbal substances, as these agents can have profound effects on HR + BP
- Nutritional rehabilitation
- The patient should have regular, nutritionally balanced meals to replace the pattern of fasting, then binging with vomiting
- This should be supplemented with nutritional counseling
- Antidepressants + therapy (this combination is more effective in treating bulimia vs. anorexia)
- First-line = SSRI [selective serotonin reuptake inhibitor])
- Topiramate has been shown to be helpful for refractory bulimia
- Cognitive-behioral therapy, interpersonal psychotherapy, group therapy + family therapy
- Teach patient to deal with the underlying thought processes that drive bulimia
- Without psychotherapy, purging behaviors can return
- Avoid Welbutrin (buproprion) + check medications to make sure the patient isn’t on any medications that could lower their seizure threshold