Psychiatry and Behavioral Health Rotation

Psychiatry EOR: Bulimia nervosa (Lecture)

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.

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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
A 20-year-old college student presents to her dentist. Her vital signs are normal, and her weight is 120 lb. On examination, extensive upper dental erosion is noted. The most likely diagnosis is
A
OCD
Hint:
See E for explanation
B
Anorexia nervosa
Hint:
See E for explanation
C
Hypothyroidism
Hint:
See E for explanation
D
Crohn’s disease
Hint:
See E for explanation
E
Bulimia nervosa
Question 1 Explanation: 
The core features of bulimia nervosa are binge eating (i.e., eating an amount of food that is definitely larger than most people would eat under similar circumstances), inappropriate compensatory behavior to prevent weight gain, and excessive concern about body weight and shape. The prototypic sequence of behavior in bulimia nervosa consists of caloric restriction, followed by binge eating, and then self-induced vomiting. Other manifestations of compensatory behaviors include excessive exercise and the misuse of diuretics, laxatives, or enemas. Although the etiology of this disorder is unknown, genetic and neurochemical factors have been implicated. Bulimia nervosa is more common in women than men by a ratio of 3: 1, and the median age of onset is 20. The condition usually becomes symptomatic between the ages of 13 and 20 years, and it has a chronic, sometimes episodic, course. Unlike anorexia nervosa, those affected with bulimia are usually within 15% of their desirable weight. Common physical signs in bulimia nervosa include hypotension, tachycardia, and dry skin. In addition, menstrual irregularities are seen in approximately one-third to one-half of female patients. Regular vomiting can cause dehydration, hypokalemia, hypochloremia, metabolic alkalosis, and dental enamel erosion (particularly the upper dentition; the lower dentition is protected by the tongue during vomiting), as well as hypertrophy of the parotid glands and “puffy” cheeks. Severe cases may also result in gastric dilation, esophagitis, electrolyte abnormalities, aspiration, or pancreatitis. Treatment involves psychotherapy with behavior modification and the use of antidepressants (SSRIs, especially fluoxetine). Many patients relapse and require long-term therapy.
Question 2
Which of the following electrolyte abnormalities is associated with bulimic patients?
A
Metabolic acidosis
Hint:
See C for explanation
B
Respiratory acidosis
Hint:
See C for explanation
C
Metabolic alkalosis
D
Respiratory alkalosis
Hint:
See C for explanation
E
Normal electrolytes
Hint:
See C for explanation
Question 2 Explanation: 
Symptoms and signs of bulimia include reflux esophagitis, abdominal cramping, diarrhea, and rectal bleeding. Electrolyte abnormalities and metabolic alkalosis signal extreme purging habits in a bulimic patient. Patients with anorexia generally have laboratory test results within normal limits until the very late stage of the condition.
Question 3
Which of the following statements about fluoxetine is true?
A
Side effects often include dry mouth, urinary retention, and blurred vision
B
The treatment of panic disorder typically requires higher doses than the recommended starting dose for depression.
C
The mechanism of action involves the reuptake of dopamine at the postsynaptic junction.
D
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.
E
Treatment of bulimia typically requires higher doses than the recommended starting dose for depression.
Question 3 Explanation: 
Fluoxetine is U.S. Food and Drug Administration (FDA) approved for the treatment of depression, OCD, premenstrual dysphoric disorder (PDD), panic disorder, and bulimia nervosa. Other uses include the treatment of dysthymic disorder, posttraumatic stress disorder (PTSD), social phobia, and bipolar disorder depression in combination with other medication, fibromyalgia, and Raynaud’s phenomena. The medication is an SSRI and has advantages when compared with the older TCAs. SSRIs have very little anticholinergic activity (which can cause blurred vision, urinary retention, and dry mouth); thus, they are better tolerated. The starting dose of fluoxetine is usually 10 to 20 mg/ day, which can then tittered up to achieve a clinical response; 80 mg/ day is the maximum dosage. The full therapeutic response may take up to 4 weeks. Higher doses (e.g., 60 mg/ day or more) is recommended for the treatment of bulimia and OCD. The treatment of panic disorder often requires smaller initial doses. Initial doses of 20 mg often precipitate panic attacks and lead to a high discontinuation rate, so starting at 10 mg/ day for patients with panic disorder can be helpful. Side effects include headaches, anxiety, nervousness, excessive sweating, insomnia, anorexia, weight loss, nausea, diarrhea, and rash. Depressed patients should be monitored closely for suicidal thoughts or gestures, especially once their depression starts to improve. In most cases, medication for depression is complemented with counseling and is more effective than medication alone.
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