AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Bulimia nervosa (BN) is one of the eating disorders identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The word bulimia is derived from the Greek words bous (ox) and limos (hunger), indicating a state of excessive hunger. Bulimia nervosa is characterized by frequent episodes of binge eating associated with emotional distress and a sense of loss of control accompanied by compensatory behavioral patterns aimed at preventing weight gain.

Compensatory behaviors used by individuals with bulimia nervosa include excessive exercise, episodes of fasting or strict dieting, self-induced vomiting, diuretic abuse, laxative abuse, use of appetite suppressants, and/or medications intended to speed up the metabolism (eg, thyroid hormone). DSM-IV-TR diagnostic criteria require episodes of binge eating that occur at least twice weekly for 3 months. People with bulimia nervosa are also dissatisfied with their body shape, weight, or both.

Binge eating is defined as eating in a discrete period (eg, 1 h) an amount of food that is significantly larger than is typical for most people during the same defined period. This is associated with a perceived loss of control of eating during that same time. The mere consumption of an unusually large amount of food in a defined period without concomitant perception of loss of control is defined as an overeating episode. Similarly, the consumption of rather minimal amounts of food in a defined period with a perception of loss of control is referred to as a subjective bulimic episode.

Eating disorders (EDs) as a group are characterized by a fear of weight gain and a distorted body image with associated anomalies in mood, perception, response to physical and emotional cues, and eating behaviors. Within the syndromes of eating disorders, disordered eating and weight control efforts can manifest as dietary restriction, binge eating, or other compensatory behaviors intended to prevent weight gain, as noted above. Among the eating disorders, bulimia nervosa and anorexia nervosa (AN) are far more common in young females, while binge-eating disorder (BED) is the most common eating disorder overall, and is more common in adults, with a 2:1 female-to-male ratio.

Bulimia is considered distinct from the only recently recognized syndrome of binge-eating disorder, in which no regular or consistent compensatory behavior accompanies the bingeing episodes. The DSM-IV-TR recognizes 2 major variants of bulimia nervosa, as follows: purging and nonpurging (ie, bingeing with use of nonpurging compensatory measures such as excessive exercise, stimulant substances, or fasting).

Many reports suggest that people with bulimia often have a history of anorexia nervosa. Some reports have suggested this association in as many as 60% of cases. While people with uncomplicated binge-eating disorder tend to be obese, people with bulimia nervosa more typically are of normal weight. Overlap between nonpurging bulimia nervosa and binge-eating disorder is seen. The natural history of eating disorders is such that individuals may pass through several diagnoses over time, meeting criteria for anorexia nervosa, bulimia nervosa, and binge-eating disorder at various points.

Pathophysiology

Among the identified metabolic derangements identified in bulimia are low plasma insulin, C peptide, triiodothyronine, and glucose values, as well as increased beta-hydroxybutyrate and free fatty acid levels. Both fasting and postbinge/postvomiting hypoglycemia are seen in some patients with bulimia. The findings regarding the hypothalamo-pituitary-adrenal axis are more inconsistent. Some studies suggest an increased amplitude in cortisol and adrenocorticotropic hormone (ACTH) during a 24-hour period among persons with bulimia compared to persons without bulimia, as well as a blunted response to corticotrophin-releasing hormone (CRH). However, other groups reported normal adrenocortical dynamics in these individuals.

Reports have also suggested abnormal dexamethasone suppression tests akin to those seen in peoples with anorexia nervosa, suggesting that bulimia also may be associated with a pseudo-Cushing state. These findings tend to be more apparent among individuals with significant dietary restriction. Some data suggest that the findings on the dexamethasone suppression test may be the result of impaired dexamethasone absorption, which has been demonstrated in some persons with bulimia. Similar to findings in people with anorexia nervosa, patients with bulimia tend to have higher growth hormone levels at night, while the nocturnal prolactin levels tend to be less than those in controls.

Episodes of amenorrhea may occur in as many as 50% of women with bulimia. About half of women with bulimia have anovulatory cycles, while about 20% have luteal phase defects. The persons with anovulatory bulimia generally have reduced luteinizing hormone pulsatile secretion frequency and associated reduced estradiol and progesterone pulse amplitudes.

Frequency

United States

The condition is thought to be significantly underrecognized. Prevalence rates are estimated to be 1-3% of high school- and college-aged women in the United States. Even more common, although not meeting criteria for bulimia, is the trend of periodic combined binge eating and purging. Approximately 10-15% of those with bulimia are male, and the disorder is more common in men who are homosexual. Bulimia also is more common among those whose occupation or hobbies require gaining and/or losing weight rapidly, such as wrestlers.

Athletes as a subgroup are particularly prone to eating disorders; anorexia nervosa has received the greatest public attention. The female athlete triad of eating disorders, hypothalamic amenorrhea, and osteoporosis now is well recognized and is particularly common in sports where slimness and body shape are of great importance, such as gymnastics, diving, and figure skating. As the scope of the problem is more widely recognized, and as more high-profile athletes are identified with the problem, it also is being recognized as a problem in sports such as long-distance running, cycling, weight lifting, and wrestling.

Certain occupations, such as acting, modeling, and ballet dancing, also appear to be associated with a higher than average risk for these disorders. The most comprehensive study to date suggests that among elite female athletes, the prevalence of eating disorders may be close to 4 times greater than that in the general population.

The rates of bulimia nervosa among patients seeking assistance with weight control are significant. The prevalence of bulimia nervosa and binge-eating disorder among clients of commercial weight loss programs is about 30-50%. Among patients presenting for bariatric surgery, the prevalence reaches 25-70% in some cohorts.

While overall secular trends are difficult to assess given the changes in diagnostic criteria over time, most studies report a progressive increase in the prevalence of bulimia nervosa and, particularly, anorexia nervosa. Whether this secular trend is the result of environmental pressures encouraging unrealistic body shapes and weights is unclear.

International

The overall prevalence of bulimia certainly appears to have increased considerably after World War II, and it has been suggested that this is primarily the result of changing sociocultural expectations for young women. However, it does appear that bulimia specifically and eating disorders as a whole are predominantly Western diseases and occur most often in developed countries. Typically, reports of eating disorders outside of this setting are anecdotal.

The suggestion that environmental factors play a significant role in the prevalence and incidence of eating disorders is also borne out by the fact that immigrants from underdeveloped countries have a much higher risk for developing eating disorders than do their genetically similar relatives still resident in the countries of origin. Most studies tend to identify bulimia and other eating disorders more frequently among the middle and upper socioeconomic strata of society. Although often described as modern diseases, close review of the older medical literature suggests that similar conditions have been described since antiquity.

Mortality/Morbidity

See Prognosis.

Race

Bulimia is a cosmopolitan disorder that has been described in all ethnic, racial, and socioeconomic groups.

Sex

As with other eating disorders, bulimia occurs predominantly in women. Most reports suggest a female-to-male ratio of 10:1. While some reports suggest the prevalence in men may be as low as 5%, others suggest that it may be as high as 15%.

It is critical to be aware that men also may develop bulimia nervosa and other eating disorders and to maintain a high index of suspicion. Although few data are available, little evidence suggests that men have any significant differences in clinical course, complications, or response to management modalities compared to women.

The prevalence of eating disorders in males appears to have increased in the 1990s compared with earlier decades. Whether this finding demonstrates a true change in prevalence or whether more males are now seeking care is unclear. The psychopathology and attitudes of males with eating disorders are, as a whole, similar to those of females with eating disorders; both are associated with a significant family history.

Age

The typical age of onset for bulimia is in the teenage years and early third decade of life. This is slightly older than the peak age of onset for anorexia nervosa but generally lower than the age of onset of binge-eating disorder. The prevalence of bulimia nervosa in children younger than 14 years appears to be less than 5%.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

A common presenting scenario is a patient with a concern about weight and who seeks help with weight loss. Symptoms may include bloating, constipation, and menstrual irregularities. Far less often, people also may present with arrhythmias, which are often the result of electrolyte abnormalities. Bulimia is also characterized by an inappropriate premium placed on being slender and an associated distorted body image that exaggerates physical appearance, though less prominently than in anorexia nervosa.

A close dietary inventory may reveal that individuals attempt to control their weight by dieting and abstaining from high-calorie foods until the binge episode. Often, a morbid preoccupation with food and eating is present, and recurring cycles of extreme dieting and/or fasting may alternate with gorging behavior. Usually, bingeing episodes are well planned. Foods generally are selected as being easy to swallow, vomit, and regurgitate and tend to have a high caloric value. Up to 10 times the recommended daily allowance for calories (or more) may be rapidly ingested in a single binge episode. Situations in which control over food intake may be lost are avoided (eg, parties, eating out).

The level of physical activity that people with bulimia engage in often is cyclical in a fashion similar to that of the bingeing episodes. While most persons with bulimia induce vomiting, a minority choose to chew the food and then regurgitate it without actually swallowing it. Vomiting usually is achieved by activating the gag reflex through digital stimulation or by ingestion of emetics (eg, ipecac).

• People with bulimia may report the following symptoms:
• • Common gastrointestinal symptoms that occur in people with bulimia include abdominal pain (more common among persons who self-induce vomiting), bloating, flatulence, constipation, and obstipation.
  • Pulmonary symptoms in those with bulimia may be due to aspiration pneumonitis or, more rarely, pneumomediastinum.
  • Amenorrhea occurs in about 50% of women with bulimia, while a significant proportion of remaining patients have irregular periods.
• A high index of suspicion is required in identifying bulimia nervosa because patients often do not directly admit to the problem.
• • A set of screening questions, such as the SCOFF pneumonic questionnaire, is useful to obtain a quick impression as to the potential need for further in-depth questioning. The SCOFF questionnaire includes the following 5 questions:
    1. Do you make yourself Sick because you feel uncomfortably full?
    2. Do you worry you have lost Control over how much you eat?
    3. Have you recently lost more than One stone (about 14 lbs or 6.35 kg) in a 3 month period?
    4. Do you believe yourself to be Fat when others say you are too thin?
    5. Would you say that Food dominates your life?
  • The ESP questionnaire is an alternative screening tool. It contains the following 5 questions:
    1. Are you satisfied with your eating patterns?
    2. Do you ever eat in secret?
    3. Does your weight affect the way you feel about yourself?
    4. Have family members suffered from an eating disorder?
    5. Do you currently suffer with or have you in the past suffered with an eating disorder?
• The eating attitudes test (EAT) is a self-reporting instrument that can be included in the paperwork patients fill out while waiting to see their health care provider. EAT has also been extensively validated as a useful screening tool for identifying individuals with eating disorders.

Physical

Eating disorders are often concealed and require a high index of suspicion to diagnose. Patients with bulimia are often unremarkable in general appearance and frequently have no signs of illness or anomalies on physical examination.

• Physical findings may include the following:
• • Bilateral parotid enlargement, largely consequent to noninflammatory stimulation of the salivary glands, may be seen.
  • In patients with significant self-induced vomiting, erosions of the lingual surface of the teeth, periodontal disease, and extensive dental caries may be observed.
  • Russell sign (one of the few physical examination findings in psychiatry) manifests as callosities, scarring, and abrasions on the knuckles secondary to repeated self-induced vomiting.
  • Other nonspecific but suggestive findings that may reflect the severity of the disease include bradycardia, hypothermia, and hypotension. Edema, particularly of the feet (and less commonly the hands), is found more often among patients with a history of diuretic abuse, laxative abuse, or both or in patients with significant protein malnourishment causing hypoalbuminemia. Some patients may be clinically obese, but morbid obesity is rare.
• The evaluation of these individuals is not complete without a comprehensive mental status examination. This is of considerable importance as bulimia often coexists with mood disorders, particularly depression. These patients also commonly have associated neuroses (particularly anxiety neuroses), the management of which may be vital to the adequate management of the bulimia. Close attention must be paid to the patient's affect—especially the patient's level of depression, anxiety, or both.

  The mental status examination also helps to identify potential psychopathology known to accompany bulimia (and possibly predispose to its development), including alcoholism within the family, family history of eating disorders, and personality disorders. Other areas of concern during the course of the mental status examination include disturbed interpersonal relations and dynamics, difficulties with impulse control, and a history of prior or ongoing substance abuse.

  A typical mental status examination for a patient with bulimia is detailed below. (The Folstein Mini-Mental Status Examination [MMSE] is often ineffective in the evaluation of patients with bulimia nervosa because cognitive deficits that are typical of dementing illness are not common in those with bulimia.)

• • Orientation: Determine whether the patient is oriented to time, place, and person. Patients with bulimia are typically oriented to their surroundings.
  • Appearance: Patients are typically neat, well dressed, and show attention to detail. Grooming is often meticulous and may further demonstrate a patient's concern about personal appearance.
  • Eye contact: Patients generally avoid eye contact.
  • Affect and mood: Patients often demonstrate a depressed mood but may also have significant anxiety. Suicidal ideation is a significant consideration, especially in patients with depressed moods. However, on closer questioning, the suicidal ideation is often restricted to thoughts rather than concrete plans.
  • Homicidal ideation: Homicidal ideation is not typically associated with patients with bulimia.
  • Delusions, hallucinations, or both: Delusions and hallucinations are typically absent in patients with bulimia.
  • Comprehension: Comprehension is typically normal.
  • Insight: Insight is variable. While patients typically admit to episodes of binge eating, they often do not appreciate their inappropriate fixation on eating nor their distorted ideas of body image and weight.
  • Judgment: Patients with bulimia generally demonstrate poor judgment. Weight-reducing strategies, such as induced vomiting and laxative and diuretic ingestion, are perceived as legitimate and appropriate methods of weight management.
  • Thought: Thoughts tend to revolve around food and concerns regarding body image and weight.
  • Speech: Content and articulation are generally normal.
  • Auditory: Patients with bulimia generally show no auditory deficits.
  • Memory: Immediate memory is normal, as is recent and remote memory recall.
  • Reading, writing, and drawing: Patients' abilities to read, write, and draw typically remain normal.
  • Reasoning: Basic reasoning and calculating skills, including the serial 7 and digit scan, are typically normal.
  • Motor abilities: Motor functioning and gait are typically normal with no significant deficits.
  • Intellect: Estimated intellectual ability is within normal limits. In some cases, demonstrated intellectual ability may be even better than average.

Causes

Among the potential precipitating events for a binge/purge cycle in those with bulimia are anxiety states, emotional tension, boredom, environmental cues about food and eating, alcohol use, substance abuse, and exhaustion. Hunger is a rather uncommon precipitant for the bulimic cycles. Although the exact cause for bulimia and other eating disorders is unclear, some factors identified as playing potentially important roles in its etiopathogenesis are as follows:

• Psychological factors: Among those suggested are difficulties with self-esteem and affective self-regulation. However, it is difficult to determine the premorbid status that predisposes persons to later develop eating disorders such as bulimia.
• Sociocultural factors: An inappropriate concern about body image and an excessive preoccupation with thinness seem central to both anorexia and bulimia nervosa. Some evidence suggests an association of bulimia (particularly the bingeing episodes) with disinhibition for food intake.
• Affective disorders: The rather common association of eating disorders with affective disorders suggests a possible relationship between them. Major depressive disorder (MDD) is particularly common in this regard. It is still unclear whether the association is causative (primary), secondary to the bulimia itself, or represents a common set of risk factors for bulimia and MDD. Furthermore, obsessive-compulsive disorder is more common in persons with bulimia than in those without bulimia. Anxiety disorders, other related neuroses, and phobias also have been noted to be more common.
• Genetics: Although no definitive inheritance patterns have been identified, a familial component appears to be involved in the development of eating disorders in general. The results of twin studies of both monozygotic and dizygotic twins suggest that the genetic component to the etiology of eating disorders is much greater in anorexia nervosa than in bulimia.
• Psychopathology: The role of sexual abuse in the development of eating disorders is controversial. Some reports suggest a strong association, while others detect no association. Some evidence suggests a relationship between addictions and eating disorders, particularly in binge-eating disorder. Borderline personality disorder is found frequently, and these patients usually have histories of trauma and abuse and may represent a distinct subgroup. Endogenous opioids and beta-endorphins have been implicated in the maintenance of binge eating.
• CNS and gastrointestinal peptide interactions: It appears that a complex dysfunctional interaction between orexigenic factors such as neuropeptide Y (NP-Y) and anorectic factors such as cholecystokinin (CCK) and beta-endorphin. The exact details of this interaction are under active investigation, but available data show that people with bulimia have normal NP-Y levels, which do increase after successful treatment. Furthermore, people with bulimia have reduced beta-endorphin, normal dynorphin, and low CCK levels. Reduced activity of the central serotonin system has been suggested to have a role in the development of bulimia.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Binge-eating disorder

This disorder is characterized by bingeing episodes but without the compensatory behaviors attempted on a consistent basis. It is the most common eating disorder (seen in about 2% of the general population and about 10% of obese people) and is more common in men than are the other eating disorders (estimates suggest 30-40% of people may be male). Recent reports suggest that binge-eating disorder may be particularly common among African American and Hispanic individuals. The mean age at diagnosis is also higher (in the late third decade of life) compared to both anorexia nervosa and bulimia nervosa.

Night eating disorder

This eating disorder is only recently defined and recognized. It is characterized by the consumption of large amounts of food (>20% of the total calorie intake) after evening meals. It is typically associated with early morning drowsiness and anorexia. No significant overlap is seen between binge-eating disorder or bulimia nervosa and night eating disorder.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Comprehensive blood chemistry panels are important in detecting possible occult metabolic complications of bulimia. A complete blood cell count should be obtained to exclude anemia or other occult hematologic abnormalities. An erythrocyte sedimentation rate (ESR) test is useful to exclude any potentially unrecognized chronic medical illness because ESR levels tend to be low in patients with eating disorders.
• Performing a urinalysis is important in order to evaluate urine specific gravity because patients may water load in an attempt to gain some weight before their health care visit.
• A pregnancy test should always be obtained to rule out pregnancy in female patients presenting with amenorrhea.
• With significant vomiting, hypokalemic metabolic alkalosis is possible.
• Among patients with significant laxative abuse, normokalemic metabolic acidosis may occur.
• Hyperamylasemia is found in up to 30% of persons with significant vomiting because of hypersecretion from the salivary glands.
• Hyponatremia, hypocalcemia, hypophosphatemia, hypomagnesemia, hyperuricemia, and hypoalbuminemia are less common but should be ruled out.
• Those who have significant intravascular depletion may have elevated blood urea nitrogen levels.

Other Tests

• Because of the potential for arrhythmias and cardiomyopathy as possible complications, an electrocardiogram should be performed.
• Because of the potential for osteoporosis in this group of people, a dual energy absorptiometry (DEXA) scan may also be indicated.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Initial care may be on an inpatient or outpatient basis, depending on the clinical presentation. Factors that may indicate a need for inpatient care include significant metabolic abnormalities, medical complications, risk of suicide, failed outpatient treatment, inability to care for self, and diagnostic uncertainty.

Treatment should be comprehensive and multidisciplinary and may include the following components:

• Cognitive behavioral psychotherapy (CBT): Distorted or maladaptive cognitions regarding weight and shape are identified and addressed. Irrational beliefs are explored and confronted. Behavioral approaches to avoiding undesirable eating habits are employed, including exposure to food. Cognitive distortions are examined to allow better understanding, enhanced self-control, and improved body image.
• Interpersonal psychotherapy (IPT): Interpersonal psychotherapy works with specific issues in the interpersonal arena that create the context for the patient's symptoms; these fall within the categories of grief, role transition, role conflict, or interpersonal deficits. Brief focused therapy in these areas can be effective in producing improvements in those with mood disturbance and low self-esteem, which may trigger and maintain the symptoms of bulimia. Its efficacy is similar to CBT in reducing binge eating but may be somewhat less effective in curbing purging.
• Supportive-expressive psychotherapy (SEP) or group therapy: SEP or group therapy may be helpful for patients with bulimia.
• Family therapy: Explores family dynamics and factors that may precipitate or perpetuate abnormal eating and bingeing behaviors. This technique often views eating as a means of communication within a family.
• Pharmacotherapy: Antidepressants as a group are the mainstay of pharmacotherapy. Pharmacotherapy is generally recommended as an adjunct to psychotherapy.
  • Selective serotonin reuptake inhibitors (SSRIs) are among the agents best validated for use in managing bulimia. Both fluoxetine (Prozac) and sertraline (Zoloft) are approved by the Food and Drug Administration (FDA) for treatment of bulimia. Antidepressant treatment using SSRIs is suggested regardless of whether the patient appears depressed. The exact mechanism underlying the efficacy of antidepressants in bulimia is unclear, but the effects may be mediated through their salutary impact on cerebral serotonin systems.
  • Bupropion (Wellbutrin) is relatively contraindicated in the treatment of bulimia nervosa because of a higher risk of seizures induced by the medication.
  • Other agents that are being explored for potential use in bulimia management include anticonvulsants, lithium, L-tryptophan, and naltrexone.
  • Some recent reports indicate that the selective serotonin antagonist, ondansetron (Zofran), which is indicated for use as an antiemetic, may have utility in the treatment of bulimia nervosa. Reports also show the potential utility of topiramate (Topamax). Trials investigating the potential utility of lithium (Eskalith) and naltrexone (ReVia) have, however, shown no significant benefit.
• Support and self-help groups (guided self-help): These are highly variable in constitution and methods used. While some are run by professionals, others are run by laypersons. Although anecdotal reports exist of their usefulness, no well-designed studies have confirmed these claims.
• Inpatient care for the patient with bulimia should be considered when any of the following are present, alone or in combination:
  • Diagnostic uncertainty
  • Associated secondary infections
  • Medical comorbidities (eg, arrhythmias, significant electrolyte derangements)
  • Suicidal ideation
  • Absence of a support structure at home
  • Severe impairments in the patient's capacity to function in regular daily activities (ie, severe psychosocial impairment)
  • Failed outpatient treatment
  • Significant concerns over follow-up (whether patient or program related)
• With CBP and maintenance treatment with follow-up, as many as 50% of patients with bulimia are asymptomatic 2-10 years after completing the treatment period. Evidence for similar improvements from other forms of psychotherapy (eg, IP, SEP) is currently not available.

Surgical Care

Major medical treatment requiring surgical intervention is rare, but medical care providers should be familiar with potential serious complications.

• Patients may develop an acute gastric obstruction and/or gastric dilatation (possibly resulting in gastric perforation leading to acute peritonitis), which presents with severe, continuous projectile vomiting that occurs soon after any oral intake. This should be considered in individuals with known bulimia who present complaining of uncontrollable vomiting. Consumption of nonfood material during binges or soon after should be considered, as well.
• • When the potential for gastric dilatation, outlet obstruction, or both is considered, an urgent surgical consultation is indicated for possible surgical management.
  • These conditions are surgical emergencies and, although uncommon, are the major cause of bulimia-related mortality.
• Emergency surgical review is also required if symptoms suggestive of esophageal tear (Mallory-Weiss syndrome) develop or in case of esophageal rupture (Boerhaave syndrome), which can precipitate acute mediastinitis.

Consultations

• Two subspecialty groups should be routinely involved in the treatment and follow-up care of these patients.
• • Psychiatrist or psychologist should be involved for review and treatment. Involvement of a psychotherapist with expertise in the management of eating disorders is strongly recommended.
  • Dietary review and counseling should be provided by a nutritionist.
• Further subspecialty reviews depend on specific presentations and the presence of specific complications.

Diet

As the disorder is treated, patient education regarding balanced diets, exercise, and long-term maintenance of a healthy weight is important and may reduce the risk of relapse or development of chronic symptoms.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Various medications have been investigated for treatment of bulimia. Antidepressants have proven useful in placebo-controlled double-blind trials. Specifically, SSRIs (eg, fluoxetine) and tricyclic antidepressants (TCAs, eg, imipramine, desipramine, amitriptyline) may have greater efficacy than placebo. Some reports indicate that mianserin, phenelzine, trazodone, and bupropion may be useful in some situations, but such drugs are usually not employed. Bupropion carries a relative contraindication because of the association with seizures when used in the context of eating disorders. Other medications investigated for utility in bulimia (without clear demonstrable efficacy) include lithium, venlafaxine, and naltrexone. Recent reports suggest the utility of ondansetron and topiramate as alternative pharmacotherapeutic options in the management of bulimia nervosa.

Drug Category: Antidepressants

Because of their demonstrated efficacy and favorable side effect profiles, SSRIs are the most commonly prescribed medications in bulimia. They are particularly useful in patients with other symptoms such as depression, anxiety, obsession, or certain impulse disorders.

Fluoxetine is the prototypical SSRI for bulimia management. Typically, as with fluoxetine, all the other SSRIs are generally prescribed at doses higher than those typically used for depression management.

Drug Name	Desipramine (Norpramin)
Description	Secondary-amine tricyclic that may increase synaptic concentration of norepinephrine in CNS by inhibiting reuptake by presynaptic neuronal membrane. May have effects in the desensitization of adenyl cyclase, down-regulation of beta-adrenergic receptors, and down-regulation of serotonin receptors.
Adult Dose	100-300 mg PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; narrow-angle glaucoma, recent postmyocardial infarction; current use of MAOIs or fluoxetine or use within previous 2 wk
Interactions	Decreases antihypertensive effects of clonidine and guanethidine but increases effects of sympathomimetics, cimetidine, and benzodiazepines; effects of desipramine increase with phenytoin, phenothiazines, carbamazepine, and barbiturates
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, glaucoma, hyperthyroidism, and thyroid replacement therapy; may impair mental and/or physical abilities

Drug Name	Amitriptyline (Elavil)
Description	Inhibits reuptake of serotonin and/or norepinephrine at presynaptic neuronal membrane, which increases concentration in CNS. May increase or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity.
Adult Dose	25-150 mg PO qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; MAOIs in past 14 d; acute phase after MI; history of seizures, cardiac arrhythmias, glaucoma, or urinary retention
Interactions	Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme (debrisoquin hydroxylase) system inhibitors (eg, cimetidine, quinidine) may increase amitriptyline levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, SSRIs, alcohol, CNS depressants, barbiturates, and disulfiram; if given with anticholinergic agents or sympathomimetic drugs, including epinephrine combined with local anesthetics, close supervision and careful adjustment of dosages is required; hyperpyrexia reported with concurrent use of anticholinergic agents or with neuroleptic drugs, particularly during hot weather; caution if patients receive large doses of ethchlorvynol concurrently (transient delirium has been reported)
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in cardiac conduction disturbances and history of hyperthyroidism, seizures, urinary retention, angle-closure glaucoma or increased intraocular pressure, and hepatic or renal impairment; avoid using in elderly persons

Drug Name	Imipramine (Tofranil)
Description	Dibenzazepine antidepressant, referred to as a tricyclic because of its chemical structure. Metabolized to desipramine, which is marketed separately. Inhibits reuptake of norepinephrine or serotonin (5-hydroxytryptamine, 5-HT) at presynaptic neuron. Use parenteral administration for starting therapy only in patients unable or unwilling to use oral medication. Has demonstrated clear superiority over placebo in double-blind trials for treating specific symptoms of bulimia nervosa.
Adult Dose	25 mg PO tid initially and increase 25-50 mg at weekly intervals prn to 200 mg/d; not to exceed 300 mg/d
Pediatric Dose	<6 years: Not established 6-12 years: 10-30 mg/d PO or 1-5 mg/kg/d PO in divided doses
Contraindications	Documented hypersensitivity; narrow-angle glaucoma; acute recovery phase following myocardial infarction; current use of MAOIs or fluoxetine or use within previous 2 wk
Interactions	Increases toxicity of sympathomimetic agents such as isoproterenol and epinephrine by potentiating effects and inhibiting antihypertensive effects of clonidine; coadministration with or use within 2 wk of MAOIs or fluoxetine may cause serotonin syndrome or hypertensive crisis
Pregnancy	D - Unsafe in pregnancy
Precautions	May impair mental or physical abilities required for performance of potentially hazardous tasks including handling machinery, driving; caution in cardiovascular disease, conduction disturbances, seizure disorders, asthma, mental illness, Parkinson disease, increased intraocular pressure or angle-closure glaucoma, benign prostatic hypertrophy, GI disease, gastroesophageal reflux disease (GERD), urinary retention, hyperthyroidism, or receiving thyroid replacement; can induce or exacerbate hiatal hernia, and can cause paralytic ileus or constipation; anticholinergic effects may increase lens discomfort (eg, mydriasis, disturbance of accommodation, dry eyes) for contact lens wearers; avoid abrupt discontinuation (may cause nausea, vomiting, or diarrhea); agranulocytosis, thrombocytopenia, eosinophilia, leukopenia, and purpura reported; photosensitivity may occur with prolonged exposure to sunlight or tanning equipment

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Outpatient Care

• The proper management of bulimia is with a multidisciplinary approach. Among the bare minimum of care providers who should be involved in the care of these patients are the primary care physician, psychiatrist, psychotherapist, and dietitian. Depending on circumstances and complications, those with bulimia also may require the services of an endocrinologist or surgeon.

Deterrence/Prevention

• All eating disorders appear to arise within a cultural context that places too high a value on thinness and engenders unreasonable expectations regarding physical appearance. Awareness of the cultural and social forces and education for both children and their parents regarding the attitudes and behaviors that foster eating disorders may reduce the prevalence of these syndromes. Opportunities for this kind of intervention abound in primary care, athletic, and educational settings.

Complications

• Compared to anorexia nervosa, the medical complications associated with bulimia are generally benign, and the mortality rate from bulimia is actually low.
• While the results of formal gastric emptying studies in patients with bulimia have yielded variable results (some suggesting delayed emptying time and others suggesting normal emptying time), acute gastric dilatation is a significant risk. This may result in gastric rupture, which appears to be the most common cause of death related to bulimia.
• Among the rare potential complications that may follow bulimia (especially in variants associated with vomiting) are Mallory-Weiss tears of the esophagus, esophageal rupture, reflux esophagitis, and cardiomyopathies secondary to ipecac use or from chronic hypokalemia.
• Ipecac toxicity may be associated with skeletal myopathy, while chronic hypokalemia may also cause intestinal ileus with abdominal distension, exertional rhabdomyolysis, or both.
• Hypokalemia-related distal tubulopathy is very rare but has been described in association with bulimia.
• Xerosis (dry skin) is a common finding in bulimia, which appears to be related to the chronic dehydration to which persons with bulimia are often prone.
• In the subgroup of individuals who abuse laxatives, chronic constipation, "cathartic colon," melanosis coli, steatorrhea, and a protein-losing enteropathy may develop.
• Obese individuals may also present with any of the various obesity-associated comorbidities.
• Other potential complications associated with bulimia nervosa include osteopenia or osteoporosis, menstrual irregularities and infertility, and cognitive changes.

Prognosis

• Relatively little is known about the long-term outcome of bulimia. Research to date suggests that the prognosis is varied.
• The illness may pursue a long-term, fluctuating course over many years or may be more episodic and may be precipitated by life events and crises. In the shorter term, some reports suggest a 50% improvement in binge eating and purging behavior among patients who are able to engage in treatment.
• Consistent predictors of outcome have not yet been identified. However, the severity of the purging sequelae may be an important indicator of prognosis; electrolyte imbalances, esophagitis, and hyperamylasemia reflect more severe purging and may predict a poorer outcome.

Patient Education

• While still the subject of debate, based on the perspective of interviewed patients with bulimia, family psychopathology may play a significant role in the development of the condition.
• • Generally, patients with bulimia view their families as conflicted, badly organized, noncohesive, and lacking in nurturance and caring. Detailed psychologic evaluation of these patients generally suggests that they are angrily submissive to rather hostile and neglectful parents.
  • For individuals still resident with their parents, a careful professional evaluation of the family dynamics and family psychotherapeutic and counseling sessions aimed at improving dysfunctional relationships may be of benefit to the patient.
  • The usefulness of family therapy in the management of bulimia is not as well defined as in anorexia nervosa. A few studies suggest that family therapy is an effective modality of management, while other studies suggest the opposite.
• Among people with bulimia in married or other cohabiting consensual adult relationships, the research is limited. The available information is rather sketchy, but overall it is suggested that these relationships are generally suboptimal, with the appearance of impaired levels of intimacy in such relationships and suboptimal communication skills. Counseling and openness about these problems may assist with the management of the bulimia.
• While cognitive behavioral therapy remains the therapeutic method of choice for bulimia, various modifications of this technique are currently being rigorously investigated. Most of these modifications are based on the premise that education about bulimia in a nonthreatening environment has a therapeutic effect. These types of therapy are usually conducted in a group setting. However, no scientifically rigorous studies have been performed comparing the psychoeducational programs in individual or group settings to definitively prove the superiority of one over the other. Whether in the individual, group, or other hybrid educational sessions, these programs should include some instruction on the following:
• • The multifactorial etiology of eating disorders with biologic, genetic, psychologic, familial and sociocultural factors
  • Medical complications related to vomiting, laxative, and diuretic abuse
  • The setpoint theory of weight regulation and the potential consequences of weight cycling and cyclic dieting
  • Basic nutritional information
  • Sociocultural and body image issues
  • Cognitive and behavioral strategies
  • Relapse prevention as distinct from episodic bingeing "slips"
• More than 70% of published management studies of bulimia involve some form of psychoeducational program. The exact efficacy of these is difficult to determine because most management programs for bulimia are multimodality based. Anecdotal reports and personal experience of many practitioners and subjects suggest that for at least some patients with bulimia, they have a significant role in management.
• For excellent patient education resources, visit eMedicine's Eating Disorders Center and Women's Health Center. Also, see eMedicine's patient education articles Bulimia.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• One must maintain a high index of suspicion for the condition in at-risk patients. Medical complications should be carefully considered, investigated, and managed, as appropriate.
• Marked vomiting may be associated with metabolic derangements, which, depending on severity, may require inpatient evaluation and management. Acute medical or surgical emergencies may arise from severe vomiting.
• Some studies suggest that patients with bulimia have increased rates of substance abuse, anxiety disorders, bipolar 1 disorder, dissociative disorders, and sexual abuse; these conditions should be considered and managed as necessary. Mortality and morbidity associated with depression (suicidal thoughts or self-injury) and poor impulse control (eg, substance abuse, sexually transmitted diseases, unintended pregnancy, accidental injuries) should always be anticipated and assessed.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Dec 1, 2005