Basics
Description
Bulimia nervosa is an eating disorder characterized by the following:
- Recurrent binge eating episodes characterized by rapid consumption of large amounts of food in discrete periods of time, usually <2 hours
- Feeling of lack of control over eating behavior during eating binges
- Compensatory behavior such as self-induced vomiting, laxative or diuretic use, strict dieting, or vigorous exercise to induce weight loss
- Minimum average of one binge eating/compensatory behavior episode per week for at least 3 months
- Associated feelings of guilt, shame, low self-esteem, and depression
- Persistent overconcern with body shape and weight
- Symptoms and psychopathology may overlap with anorexia nervosa but does not occur exclusively during episodes of anorexia nervosa.
Epidemiology
- Onset in adolescence to young adulthood
- Approximately 10:1 female-to-male ratio
- 70% of the adolescents who meet criteria for full and partial syndrome eating disorders also met criteria for an Axis I disorder.
Prevalence
- Adolescents have a 1-1.5% 12-month prevalence of bulimia according to the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5).
- 25% of college-aged women use bingeing and purging as a weight management technique.
- Bulimia nervosa prevalence rates in Western countries for females range from 0.3% to 7.3%.
Risk Factors
Genetics
Recent studies, including twin studies, suggest that bulimia nervosa and binge eating may have a genetic vulnerability and familial transmission.
General Prevention
- Emphasize healthy self-esteem/body image with preadolescents and adolescents
- Regular family dinners may have some protective effect against eating disorders.
Etiology
- Personality traits of low self-esteem, self-regulatory difficulties, frustration, intolerance, and impaired ability to recognize and express feelings directly described in bulimia nervosa
- Small positive association between childhood sexual abuse and eating disorders, but size and nature of this association not known
- 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 bulimia nervosa, which may also indicate abnormal satiety signaling
- May be abnormalities in other hormones or neurotransmitters such as leptin, dopamine, and endorphins. Unclear if cause or effect.
Commonly Associated Conditions
- Lifetime rates of major depressive disorder in individuals with eating disorders 50-75%
- In adolescents, bulimia is associated with dysthymia more than major depression.
- 63.5% of bulimic patients have lifetime history of an anxiety disorder.
Diagnosis
History
- Eating disorder specific
- Eating habits
- Presence of binge or purge behavior
- Food rituals
- Body image
- Exercise history
- Actual and desired weights, minimum and maximum weights
- Use of laxatives, diuretics, diet pills, emetics, ipecac, or weight loss supplements
- Menstrual history-amenorrhea or oligomenorrhea
- Unease with others watching them eat
- Preoccupation with food/eating
- Preoccupation with body weight/shape
- Fear of loss of control over one's body
- General
- Weakness or fatigue or hyperactivity
- Thirst, frequent urination
- Headaches
- Dizziness
- Abdominal pain, fullness, or bloating; nausea
- Constipation or diarrhea
- Dental caries
- Irregular menses
- Psychiatric
- Mood disorder
- Substance abuse
- Anxiety
- Personality disorders
- Suicidal thoughts
- Low self-esteem
- Impulsivity
- Family
- Medical and psychiatric histories
- Specific questions
- Do you have a weight goal?
- How do you control your weight?
- How do you feel about yourself?
- Do you ever vomit, use diuretics, or laxatives? If so, how often?
Physical Exam
- Vital signs: Check for hypotension, orthostasis, and hypothermia.
- Weight: may be normal, overweight, or underweight
- Erosion of dental enamel: exposure to gastric acid secondary to frequent vomiting
- Parotid gland enlargement due to vomiting
- Calluses on knuckle or hands: Russell sign secondary to inducing vomiting
- Muscle weakness or cramps: electrolyte disturbance
Diagnostic Tests & Interpretation
Lab
- Part of the diagnostic workup. Most useful for assessing complications; no diagnostic or confirmatory laboratory test for bulimia nervosa. Many patients have normal labs.
- CBC: iron deficiency anemia
- Electrolytes, including calcium, magnesium, and phosphate: Abnormalities may occur as a result of prolonged vomiting or laxative use. Most common pattern for vomiting is hypokalemic-hypochloremic alkalosis.
- BUN and creatinine: Renal function usually normal, but BUN may be elevated secondary to dehydration or altered intake
- Glucose: patient may be hypoglycemic
- Cholesterol, lipids: may be elevated in starvation state
- Amylase: increased secondary to vomiting
- Lipase: increases may indicate severe complications such as pancreatitis
- Total protein, albumin, prealbumin: usually normal, but may be low if with malnutrition
- Liver function tests: Transaminases may be mildly elevated from starvation.
- Erythrocyte sedimentation rate (ESR): almost invariably normal; if elevated, consider occult organic process
- Bicarbonate level: metabolic alkalosis from vomiting or metabolic acidosis if using laxatives or dehydrated
- Urine toxicology screen (optional): may be positive as this disorder often is associated with substance abuse
Imaging
- Electrocardiogram with rhythm strip: may see U waves with hypokalemia, check QTc
- Consider upper GI series with small bowel follow-through if unclear etiology of vomiting
- Consider dual-energy x-ray absorptiometry (DEXA) scan if prolonged amenorrhea to evaluate bone mineral density.
Diagnostic Procedures/Other
Eating disorder questionnaires: Questionnaire assessments may be helpful and augment the diagnostic interview in diagnosing bulimia nervosa.
Differential Diagnosis
- Psychogenic vomiting
- Drug abuse
- GI obstruction
- Hiatal hernia
- Achalasia, gastroesophageal reflux
- Brain tumor
Treatment
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) used with good results
- Antidepressant effect may diminish over time; may relapse when drug stopped
- Psychotherapy and cognitive behavioral therapy combined with antidepressant therapy appears to have the best outcome.
- Low response rate to alternative treatments after cognitive behavioral therapy and 1st-line antidepressant therapy
- Few studies either of medication or psychotherapy in those <18 years of age; however, cognitive behavioral therapy and family-based therapy appear promising
- 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.
Additional Therapies
- Cognitive behavioral therapy (CBT) with family involvement effective
- Can be done in group or individual formats
- 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 thoughts and beliefs about body image
- May also be effective in a self-help format, including self-help manual format
- One study of CBT in adolescents showed considerable promise.
- Family-based treatment (FBT): Therapist empowers parents to disrupt behaviors such as binge eating, purging, restrictive eating, and other compensatory behaviors. The treatment has shown positive research outcomes.
- Individual interpersonal psychotherapy (IPT) is helpful but takes longer to have an effect.
- Dialectical behavioral therapy (DBT): Skill-based treatment shown to be helpful for adult patients with binge eating disorder and less severe symptoms of bulimia nervosa.
- Family therapy
- Group therapy
- Outpatient supportive psychotherapy
Additional Therapies
Physical activity shown in one study to reduce pursuit of thinness and decrease bingeing/purging behavior. Both physical activity and yoga have shown promise as adjunct treatments.
Inpatient Considerations
Initial Stabilization
Hospitalize in cases of the following:
- Dehydration
- 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
Ongoing Care
Follow-up Recommendations
- Reduction in binge and purge episodes may take time.
- Behavioral and thought disorders associated with bulimia nervosa may be of long duration.
Patient Monitoring
Signs to watch for:
- Weight loss or major weight fluctuations
- Electrolyte abnormalities
- Muscle cramps
- Fatigue
- Depression or mood disturbance
- Mood swings/irritability
- Increasing emotional lability
- Menstrual function/irregular menses
Prognosis
Eating disorders have the highest mortality rate of any mental disorder. Reported mortality rates vary between studies. Part of the variance is because those with an eating disorder may ultimately die of heart failure, organ failure, malnutrition, or suicide. Crude mortality rates reported in 2009 were the following:
- 4% for anorexia nervosa
- 3.9% for bulimia nervosa
- 5.2% for eating disorder not otherwise specified
- Most patients have episodic course with trend toward improvement.
- No studies of long-term prognosis in adolescents
- Adult studies: 5- to 10-year follow-up
- Up to 85% of patients achieve recovery from bulimia nervosa in various studies.
- Poor prognostic indicators: concomitant depression, personality disorder, substance abuse, frequent vomiting
- Good prognostic indicators
- High motivation for treatment
- No concurrent disruptive psychopathology
- Good self-esteem
Complications
- Pulmonary
- Aspiration pneumonia
- Pneumomediastinum
- GI
- Pancreatitis
- Parotid or salivary gland enlargement
- Gastric and esophageal irritation and gastroesophageal reflux
- Mallory-Weiss tears
- Paralytic ileus (from laxative abuse/hypokalemia)
- Severe constipation (due to laxative abuse and subsequent dependence)
- Metabolic
- Hypokalemia (due to laxative abuse/emesis)
- Secondary cardiac dysrhythmias, myopathy
- 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
- Hormonal
- Irregular menstrual bleeding
Additional Reading
- Crow SJ, Peterson CB, Swanson SA, et al. Increased mortality in bulimia nervosa and other eating disorders. Am J Psychiatry. 2009;166(12):1342-1346. [View Abstract]
- Kreipe RE, Birndorf SA. Eating disorders in adolescent and young adults. Med Clin North Am. 2000;84(4):1027-1049. [View Abstract]
- LeGrange D, Crosby RD, Rathouz PJ, et al. A randomized controlled comparison of family-based treatment and supportive psychotherapy for adolescent bulimia nervosa. Arch Gen Psychiatry. 2007; 64(9):1049-1056. [View Abstract]
- Lock J. Treatment of adolescent eating disorders: progress and challenges. Minerva Psichiatr. 2010; 51(3):207-216. [View Abstract]
- Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence, and mortality rates. Curr Psychiatry Rep. 2012; 14(4):406-414. [View Abstract]
Codes
ICD09
- 307.51 Bulimia nervosa
- 783.6 Polyphagia
ICD10
- F50.2 Bulimia nervosa
- F50.9 Eating disorder, unspecified
SNOMED
- 78004001 Bulimia nervosa (disorder)
- 32721004 Bulimia nervosa, purging type
- 59645001 Bulimia nervosa, nonpurging type
FAQ
- Q: How do I determine if a patient has anorexia with vomiting or bulimia?
- A: The key feature of anorexia nervosa that distinguishes it from bulimia nervosa is the degree of malnutrition and presence of bingeing. There is a definite crossover between patients with anorexia nervosa and bulimia nervosa. If bingeing and purging is seen in the setting of significant malnutrition and low weight, the patient is diagnosed with anorexia nervosa.
- 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, hospitalize until normalized.