Bulimia nervosa

• Overview:

  • BN is an eating disorder characterised by episodes of binge eating, where a person suffers a loss of control and eats more than usual
  • Other goes alongside compensatory mechanisms to prevent excess weight gain - self induced vomiting, laxatives and heavy exercise
  • Most common in women in their 20s and 30s
  • Peak age of onset is 15-25
• Genetic risk factors for bulimia include:

  • Family history of eating disorders
  • Family history of mental illness
  • Family history of impulse control disorders e.g. kleptomania
• Psychosocial risk factors for bulimia include:

  • Prior mental health diagnosis
  • Poor self-esteem
  • History of abuse or trauma
  • Co-morbid impulse control disorder
  • Having a career or hobby dependent on appearance
  • History of engaging in restricting and bingeing cycles
• Typical symptoms:

  • Binge eating behaviours
  • Distress over body image
  • Frequent bathroom trips following meals
  • Uncomfortable eating in front of others
  • Ritualistic eating habits and exercise routines
  • Use of substances to increase metabolism - stimulants
  • Mood fluctuations - especially post binge
  • Irritability around food
  • Shame and guilt
  • Intrusive thoughts
• The term ‘purging’ is used in relation to bulimia. This refers to an individual engaging in binge eating behaviours (consumption of a large volume of often restricted foods in one sitting) followed by ‘purging’ behaviours such as self-induced vomiting, strenuous exercise, using laxatives, enemas or diuretics to counteract their food binge.
• binges can occur even when the individual is not physically hungry and often continue to a painful point beyond the state of physical fullness. 
• Screening questionnaires:

  • SCOFF questionnaire
  • Eating disorder examination questionnaire (EDE-Q)
• SCOFF questionnaire:

  • Do you make yourself Sick because you feel uncomfortably full?
  • Do you worry you have lost Control over how much you eat?
  • Have you recently lost more than One stone (6.35kg) in three months?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say Food dominates your life?
• Two further questions can be asked that have a high sensitivity and specificity for bulimia nervosa:

  • Are you satisfied with your eating patterns?
  • Do you ever eat in secret?
• Risk assessment:

  • Important to conduct in all patients with suspected eating disorder as they commonly co-exist with other mental health disorders
  • Self harm
  • Suicidal ideations
  • Self neglect
• Clinical findings:

  • Often normal weight
  • Periorbital petechia from purging
  • Tooth erosion
  • Swollen parotid glands
  • Sore throat
  • Mouth ulcers
  • Halitosis - bad breath
  • GORD
  • Alkalosis - loss of hydrochloric acid from stomach
  • Hypokalaemia
  • Russel's sign - calluses on the knuckles where they have scraped against teeth
• Binge eating disorder: though these individuals do share the pattern of generally secretive episodic binges in response to emotional distress and feel deep shame around their behaviours, those with binge eating disorder do not engage in compensatory behaviours to negate the episodes of binging.
• Bedside investigations:

  • BMI
  • Basic observations
  • Blood glucose - may how hypoglycaemia
  • Urinalysis - may show ketones if patient has diabetes. some patients skip insulin to control their weight.
  • ECG - hypokalaemia - prolonged PR interval, ST depression, T wave flattening/inversion and prominent U waves
• Lab investigations:

  • U&Es - hypokalaemia, increased creatinine
  • Magnesium - may be low
  • FBC - may show anaemia
  • LFTs - may be abnormal as excessive exercise can raise aminotransferases
• ICD-11 diagnosis:

  • Frequent recurrent distressing binge eating episodes (>once a week for at least 3 months) during which an individual feels a loss of control
  • Repeated inappropriate compensatory behaviours - laxative abuse, purging, excessive exercise
  • Excessive preoccupation with weight or shape
  • Behaviours and distress are significant enough to impair functioning
  • Symptoms do not meet anorexia criteria
• Biological therapies:

  • SSRIs - fluoxetine first line, followed by sertraline
  • May be used when CBT isn't available or when it has been tried and the patient hasn't seen improvement
  • Medication should be given at a time of day when they are unlikely to be purged
  • SSRIs also useful in the case of comorbid disorders
• Psychological therapies:

  • CBT is first line
  • Often alongside nutritional and meal support by a dietician
  • Children with bulimia should be offered bulimia focused family therapy
• Patients with diabetes need input from an endocrinologist for glycemic control and insulin management. Admission to hospital may be required.

  Skipping insulin to control weight = diabulimia
• Complications:

  • Irregular menstrual cycles and fertility issues
  • Mental health conditions such as depression and anxiety
  • Gastric ulcers
  • Osteoporosis
  • Cardiovascular issues - arrhythmias, heart failure, MI, cardiomyopathy
• In terms of recovery, 45% do so fully, 27% make significant improvement, and 23% unfortunately suffer chronically with the disorder.