Bulimia Nervosa Flashcards
Define
AN = underweight; BN = normal/increased weight
ICD-10 diagnostic criteria (must have all 3):
(1) Binging or persistent preoccupation with eating and/or irresistible craving for food
- However, a ‘non-purging’ bulimia does exist as a sub-type
(2) Purging behaviours (attempts to counteract “fattening” effects of body)
Purging includes… diuretics, excessive exercise, laxatives, insulin therapy, vomiting
(3) Psychopathology (feeling of a loss of control, morbid dread of fatness, patient sets sharply defined weight threshold (well below premorbid weight/healthy weight), history of anorexia nervosa)
Epidemiology
Peak age of onset is in later adolescence and young adulthood (age 15-25 years)
1-2% in women aged 15-40 years
Aetiology
Combination of genetic, neurobiological and sociocultural factors:
Genetic
- Neurobiological factors
- Abnormal neurotransmitter activity (including serotonin and dopamine) and satiety-related hormones- unclear if this is involved with or a result of malnutrition
Psychological factors
- Anxiety, depression, perfectionism, low self-esteem, body dissatisfaction and overestimation of body size
- Successful weight loss enhances the patient’s sense of achievement, autonomy and perfectionism
- When life is uncontrollable, anorexia nervosa comforts by providing the ability to control something (weight)
Sociocultural
- Social pressure of being thin and promotion of dieting
- High risk groups include occupations where emphasis on weight or body image e.g. models, athletes, dancers
- Family history
NOTE: The individual is NOT significantly underweight and therefore does not meet the diagnostic requirements of Anorexia Nervosa
Symptoms
Recurrent episodes of binge eating
- Consuming an excessive amount of food in a discrete time period accompanied by a sense of loss of control overeating at the time
- In-between binges, there are also typically continuing attempts to restrict eating
Recurrent inappropriate compensatory behaviour to prevent weight gain
- Vomiting
- Purging
- Fasting
- Excessive exercise
- Laxative
- Diuretic
- Diet pill use
Weight is often within normal limits or above weight range for age
- Bulimia nervosa may be kept secret for many years as the appearance is unremarkable and they can often eat normally in public
Psychological features
- Over-evaluation of self-worth in terms of body weight and shape
- Fear of gaining weight, with a sharply defined weight threshold set by the person
- Mood disturbance and symptoms of anxiety and tension
- Persistent preoccupation and craving of food and feelings of guilt and shame about binge eating
- Self-harm, often by scratching or cutting
Physical symptoms
- Bloating, fullness, lethargy, gastro-oesophageal reflux, abdominal pain, sore throat (from vomiting)
Severe cases: Russell’s sign (knuckle calluses from induced vomiting), dental enamel erosion, salivary gland enlargement
Hypokalaemia, hypocalcaemia, hypotension, anaemia, metabolic alkalosis
DSM-V: behaviours occur at least once a week for 3 months
Investigations
SCOFF Questionnaire- ≥ 2 is suggestive of Anorexia Nervosa or Bulimia Nervosa
- ‘Do you ever make yourself sick because you feel uncomfortably full?’
- ‘Do you worry that you have lost control over how much you eat?’
- ‘Have you recently lost more than one stone in a 3-month period?’
- ‘Do you believe yourself to be fat when others say you are too thin?’
- ‘Would you say that food dominates your life?’
Basic observations
- Physical examination
- Bloods- FBC, U&Es, LFTs, blood glucose, TFTs, calcium, B12, FSH, LH, E2, prolactin
- Metabolic alkalosis
- Hypochloraemia
- Hypokalaemia- can lead to cardiac arrhythmia
- Hypocalcaemia
- Decreased red cell count
- Metabolic acidosis (if laxative use)
- ECG- may show arrhythmia
- ICD-10 diagnostic criteria (must have all 3):
(1) Binging or persistent preoccupation with eating and/or irresistible craving for food
However, a ‘non-purging’ bulimia does exist as a sub-type
(2) Purging behaviours (attempts to counteract “fattening” effects of body)
Purging includes… diuretics, excessive exercise, laxatives, insulin therapy, vomiting
(3) Psychopathology (feeling of a loss of control, morbid dread of fatness, patient sets sharply defined weight threshold (well below premorbid weight/healthy weight), history of anorexia nervosa)
Management
(n.b. no ‘watchful waiting’ period ever used; refer immediately**):
- Screen for immediate admission (see on pages prior) otherwise, mostly managed in the community
- Immediate referral (depending on severity):
Severe -> urgent referral to CEDS (community eating disorder service)
- Features: daily purging, significant electrolyte imbalance, comorbidity
Moderate -> guided self-help, recommend Beat charity, monitor for 8 weeks
Features: frequent binging and purging (>2/week), some medical consequences (chest pain)
- Routine referral to CEDS if failure to respond
- Mild -> guided self-help, recommend Beat charity, monitor for 12 weeks
- Features: infrequent binging and purging (≤2/week)
- Routine referral to CEDS if failure to respond
Management upon first presentation to GP… alongside one of the 3 referral pathways above…
- Treat medical complications (regular dental review for acid-wear on teeth)
- Treat co-morbid psychiatric illness (depression, OCD, substance misuse)
- Moderate to severe -> SSRIs (high-dose (60mg) fluoxetine) à reduce binging/purging + help impulses
- Plan going forward (with regular follow-up and review):
· Children: 1st line: Family therapy
· Adults: 1st line: Guided Self-Help Programme (Bulimia Nervosa-Focused)
2nd line (if 1st line ineffective for 4 weeks, if 1st line declined): CBT-ED
Complications / Prognosis
Emotional disturbances
- Social difficulties
- Physical abnormalities
- Cardiovascular- arrhythmias (hypoK), diet pill toxicity, valve prolapse, periopheal oedema
- Dermatological- knuckle calluses from induced vomiting (Russell’s sign)
- Dental- erosion of tooth enamel from vomiting
- Endocrine- amenorrhoea, irregular menses, hypoglycaemia, osteopaenia
- Gastrointestinal- acute gastric dilation, oesophageal rupture, Mallory-Weiss tears, parotid gland swelling, haematemesis
Metabolic- dehydration, electrolyte imbalance (e.g. HypoK), obesity-related complications)
Neurological- cognitive impairment (usually related to extreme dieting), peripheral neuropathy
Pulmonary- aspiration pneumonitis
Renal- renal calculi
Obstetric and gynaecological- risk of polycystic ovaries
Mortality
Prognosis
Better recovery rates than with anorexia nervosa (up to 80% recover completely)
Course of illness typically consists of cycles of remission and relapse
Bad prognostic indicators - v low weight, severe binging/ purging, comorbid depression
PACES
Explain the diagnosis (characterised by episodes of excessive eating followed by guilt and purging)
Explain the complications (low self-esteem, depression, problems with relationships, dehydration, tooth and gum disease, heart problems)
Explain the psychological management (guided self-help for 4 weeks to CBT-ED or just FT-BN)
Consider medical (high-dose fluoxetine)
