Bulimia nervosa is a condition that occurs most commonly in adolescent females, characterized by indulgence in binge-eating, and inappropriate compensatory behaviors to prevent weight gain. The Diagnostic and Statistical Manual of Mental Disorders- 5th edition (DSM-V) defines the following diagnostic criteria for bulimia nervosa:
Episodes of binge eating:
Binging episodes are followed by inappropriate compensatory behavior to prevent weight gain:
The episodes should occur at least once a week for three months to establish a diagnosis.
The precise etiology of bulimia nervosa is unclear but is likely multifactorial. The abnormalities in interoceptive function, particularly of the insula, may contribute to the binging behavior associated with this condition. A 2016 study indicated that patients with anorexia and bulimia nervosa have widespread abnormalities with diffuse alterations in white matter structural and useful connectivity, particularly within appetite-regulating and taste-reward pathways. Other studies have indicated a possible altered function of intrinsic functional brain architecture.
Bulimia nervosa can affect both sexes but disproportionately affects females. The median age of onset is around 12.4 years old. The estimated prevalence of bulimia nervosa in the United States is 0.9% among adolescents, 1.5% among the general population of women, and 0.5% among the general population of men. While the prevalence of bulimia nervosa is unestablished in developing countries, prevalence estimates from North America, Australia, and Europe range from 0.1% - 1.3% among males and 0.5% - 2.0% among females.
A review of systems in patients with bulimia nervosa demonstrates sore throat, irregular menstruation, constipation, headache, fatigue, lethargy, abdominal pain, and bloating.
When conducting a physical exam on a patient with diagnosed or suspected bulimia nervosa, obtain the height, weight, vital signs, and orthostatic blood pressures. It is also necessary to examine a patient’s skin, mouth, and abdomen. A neurological examination is essential to check for primary neurological causes of weight loss or vomiting before diagnosing bulimia nervosa.
Common physical exam signs associated with bulimia nervosa include hypotension, dry skin, parotid gland swelling, dental erosion, and calluses on the dorsal aspect of the hand (known as “Russel’s sign.”) Bulimia nervosa can also be associated with hair loss, edema, and epistaxis.
A thorough evaluation of a patient with bulimia nervosa should include the following:
Laboratory abnormalities associated with bulimia nervosa include hypokalemia (including hypokalemic hypochloremic metabolic alkalosis), hyponatremia, and transaminitis.
The primary objective of treatment is a cessation of the binging and purging behavior.
Selective serotonin reuptake inhibitors such as fluoxetine, citalopram, and sertraline have shown to reduce symptoms of bulimia nervosa. Fluoxetine is the only FDA approved medication for bulimia nervosa. It appears that a higher dose (60 mg) is significantly better than a placebo in decreasing the frequency of binge and vomiting episodes. Evidence for other medication classes to treat this condition is limited. Trazodone has significantly reduced the frequency of binge-eating episodes when compared to placebo. Monoamine oxidase inhibitors and tricyclic antidepressants are reserved for resistant cases due to their lethality and potential side effects. Bupropion should not be used in patients with bulimia nervosa because of the increased risk of epileptic episodes. One of the antiepileptic medications, topiramate, has shown a reduction in binge episodes, but the side effects should be carefully monitored, especially weight loss and cognitive problems.
Clinical trials of cognitive-behavioral therapy and interpersonal psychotherapy have also demonstrated a benefit for patients with bulimia nervosa. Patients with bulimia nervosa should be screened for suicidality and comorbid psychiatric illness as they are at higher risk of other mental diseases than the general population.
Bulimia nervosa can lead to a variety of general medical complications, including metabolic alkalosis, dehydration, constipation, and cardiac arrhythmias. The most common cause of metabolic alkalosis in patients with bulimia nervosa is fluid volume depletion, for which saline administration is indicated in addition to the cessation of the purging behavior. For inpatients, consider intravascular administration; however, these patients require monitoring for signs of volume overload. The treatment for dehydration associated with bulimia nervosa is similar. In the uncommon cases of average or increased fluid volume with alkalemia in a patient with bulimia nervosa, intravenous saline has no role. Treatment for constipation associated with bulimia nervosa or with discontinuation of laxatives include adequate hydration, exercise, and dietary fiber. If laxatives are still needed, low doses of polyethylene glycol powder or lactulose may be used. For patients who experience severe or symptomatic cardiac complications of bulimia nervosa, which are generally caused by electrolyte derangements, consider obtaining a cardiology consult.
The clinician should make a diagnosis of bulimia nervosa after excluding all other medical causes of vomiting and excessive bowel activity, particularly if the patient states that binging or purging behavior is involuntary. Generally, these medical conditions are not associated with a pattern of binge eating or an excessive preoccupation with weight or body image. These medical conditions include the following:
General medical conditions involving increased food intake include the following:
Most patients who have bulimia nervosa will recover from the condition.
The five-year remission rate for bulimia nervosa using DSM-IV criteria has an estimate of 74%, and among those, 47% also had a relapse within those five years. Another study based on DSM-V criteria listed a 55% five-year recovery rate for bulimia nervosa in the community. At ten years, 52% of patients with bulimia nervosa treated with placebo had fully recovered.
Bulimia nervosa is a psychiatric disorder that can lead to potentially critical complications. Unlike in anorexia nervosa, in which complications are due to weight loss and malnutrition, the type and severity of medical complications of bulimia nervosa can be determined based on the frequency and the method the patient uses to purge.
It is important to educate patients who abuse laxatives that these medications work in the gastrointestinal tract after the areas where caloric absorption has occurred primarily. It is crucial to inform patients that a period of edema and weight gain may follow up to several weeks after discontinuation of purging behavior. Patients with bulimia nervosa who purge by vomiting often brush their teeth immediately after purging, which can accelerate dental erosion. The clinician should instruct the patients who persist in vomiting to rinse their mouths with water or fluoride rather than brushing their teeth within 30 minutes of each episode. Consider consulting a dentist to address dental issues associated with vomiting.
Patients with bulimia nervosa should undergo an initial medical evaluation to determine medical stability and whether the patient needs hospitalization. [Level 5] Patients with eating disorders, including bulimia nervosa, are best managed by an interprofessional team that includes a primary clinician, a therapist or psychiatrist, school personnel, a dietician, and an eating disorder specialist. [Level 5] Bulimia nervosa may be treated effectively with a selective serotonin reuptake inhibitor [Level 2] and psychotherapy, such as cognitive-behavioral therapy. [Level 2]
|||Harrington BC,Jimerson M,Haxton C,Jimerson DC, Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American family physician. 2015 Jan 1; [PubMed PMID: 25591200]|
|||Russell G, Bulimia nervosa: an ominous variant of anorexia nervosa. Psychological medicine. 1979 Aug [PubMed PMID: 482466]|
|||Forney KJ,Bodell LP,Haedt-Matt AA,Keel PK, Incremental validity of the episode size criterion in binge-eating definitions: An examination in women with purging syndromes. The International journal of eating disorders. 2016 Jul [PubMed PMID: 26841103]|
|||Hudson JI,Hiripi E,Pope HG Jr,Kessler RC, The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry. 2007 Feb 1 [PubMed PMID: 16815322]|
|||[PubMed PMID: 32744194]|
|||[PubMed PMID: 23767670]|
|||[PubMed PMID: 16925191]|
|||Fluoxetine in the treatment of bulimia nervosa. A multicenter, placebo-controlled, double-blind trial. Fluoxetine Bulimia Nervosa Collaborative Study Group. Archives of general psychiatry. 1992 Feb [PubMed PMID: 1550466]|
|||Shapiro JR,Berkman ND,Brownley KA,Sedway JA,Lohr KN,Bulik CM, Bulimia nervosa treatment: a systematic review of randomized controlled trials. The International journal of eating disorders. 2007 May [PubMed PMID: 17370288]|
|||Pope HG Jr,Keck PE Jr,McElroy SL,Hudson JI, A placebo-controlled study of trazodone in bulimia nervosa. Journal of clinical psychopharmacology. 1989 Aug [PubMed PMID: 2671058]|
|||[PubMed PMID: 3134343]|
|||[PubMed PMID: 16231337]|
|||[PubMed PMID: 24060917]|
|||Arcelus J,Mitchell AJ,Wales J,Nielsen S, Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Archives of general psychiatry. 2011 Jul [PubMed PMID: 21727255]|
|||Hoang U,Goldacre M,James A, Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. The International journal of eating disorders. 2014 Jul [PubMed PMID: 24599787]|
|||Johnson JG,Spitzer RL,Williams JB, Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynaecology patients. Psychological medicine. 2001 Nov [PubMed PMID: 11722160]|
|||Westmoreland P,Krantz MJ,Mehler PS, Medical Complications of Anorexia Nervosa and Bulimia. The American journal of medicine. 2016 Jan; [PubMed PMID: 26169883]|
|||Brown CA,Mehler PS, Successful [PubMed PMID: 22703572]|
|||Forney KJ,Buchman-Schmitt JM,Keel PK,Frank GK, The medical complications associated with purging. The International journal of eating disorders. 2016 Mar; [PubMed PMID: 26876429]|
|||[PubMed PMID: 20659142]|
|||[PubMed PMID: 12630772]|
|||Dejong H,Perkins S,Grover M,Schmidt U, The prevalence of irritable bowel syndrome in outpatients with bulimia nervosa. The International journal of eating disorders. 2011 Nov; [PubMed PMID: 21997430]|