Patient will present as → a 14-year-old is female who is brought to your clinic by her mother who claims to hear the child vomiting after dinner in the evenings. The patient reportedly denies vomiting and feels fine. On physical exam, you notice petechial hemorrhages of the soft palate and conjunctiva. Further exam reveals scars on her knuckles, swollen parotid glands, dental erosions. Her weight is normal. Lab tests reveal hypochloremia and hypokalemia.
To watch this and all of Joe Gilboy PA-C's video lessons you must be a member. Members can log in here or join now.
Key Points:
- Frequent binge eating with or without purging
- Purging commonly performed by self-induced vomiting resulting in metabolic alkalosis, urinary chloride < 20mEq, and volume depletion
- May abuse laxatives/diuretics
- May exercise excessively
- Patients are disturbed by their behavior
- Binging and compensatory behaviors occur at least once a week for 3 months
- On the exam look for these classic physical findings: scars on knuckles, swollen parotid glands + dental erosions + normal weight +hypokalemia
DSM-5 Diagnostic Criteria
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of anorexia nervosa.
Specify if:
- In partial remission: After full criteria for bulimia nervosa were previously met, some, but not all, of the criteria have been met for a sustained period of time.
- In full remission: After full criteria for bulimia nervosa were previously met, none of the criteria have been met for a sustained period of time.
Specify current severity:
- The minimum level of severity is based on the frequency of inappropriate compensatory behaviors (see below). The level of severity may be increased to reflect other symptoms and the degree of functional disability.
- Mild: An average of 1–3 episodes of inappropriate compensatory behaviors per week.
- Moderate: An average of 4–7 episodes of inappropriate compensatory behaviors per week.
- Severe: An average of 8–13 episodes of inappropriate compensatory behaviors per week.
- Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.
Hypochloremia with subsequent hypokalemia due to renal compensatory mechanisms
- Hypomagnesemia and metabolic alkalosis
- On the exam look for these classic physical findings: scars on knuckles, swollen parotid glands + dental erosions + normal weight
First you must restore nutritional state.
- Fluoxetine 60 mg PO once/day is recommended(this dose is higher than that typically used for depression). SSRIs used alone often reduce the frequency of binge eating and vomiting.
- Bupropion is contraindicated
- Second line medications: TCAs, MAOIs
- Behavioral/family/group therapy
- Hospitalization usually not needed
Question 1 |
OCD Hint: See E for explanation | |
Anorexia nervosa Hint: See E for explanation | |
Hypothyroidism Hint: See E for explanation | |
Crohn’s disease Hint: See E for explanation | |
Bulimia nervosa |
Question 2 |
Metabolic acidosis Hint: See C for explanation | |
Respiratory acidosis Hint: See C for explanation | |
Metabolic alkalosis | |
Respiratory alkalosis Hint: See C for explanation | |
Normal electrolytes Hint: See C for explanation |
Question 3 |
Side effects often include dry mouth, urinary retention, and blurred vision | |
The treatment of panic disorder typically requires higher doses than the recommended starting dose for depression. | |
The mechanism of action involves the reuptake of dopamine at the postsynaptic junction. | |
The drug has significant anticholinergic activity. Hint: SSRIs have very little anticholinergic activity (which can cause blurred vision, urinary retention, and dry mouth); thus, they are better tolerated. | |
Treatment of bulimia typically requires higher doses than the recommended starting dose for depression. |
List |