Bulimia Nervosa

Patients with bulimia nervosa typically describe binge-purge behavior. Binges involve rapid consumption of an amount of food definitely larger than most people would eat in a similar period of time under similar circumstances (however, the amount considered excessive for a normal meal versus a holiday meal may differ) accompanied by feelings of loss of control.

Patients tend to consume sweet, high-fat foods (eg, ice cream, cake) during binge episodes. The amount of food consumed in a binge varies, sometimes involving thousands of calories. Binges tend to be episodic, are often triggered by psychosocial stress, may occur as often as several times a day, and are usually carried out in secret.

Binge eating is followed by compensatory behaviors: self-induced vomiting, use of laxatives or diuretics, excessive exercise, and/or fasting.

Patients are typically of normal weight; only a minority have excess weight or obesity. However, patients are excessively concerned about their body weight and/or shape; they are often dissatisfied with their bodies and think that they need to lose weight.

Patients with bulimia nervosa tend to be more aware of and remorseful or guilty about their behaviors than those with anorexia nervosa and are more likely to acknowledge their concerns when questioned by a sympathetic clinician. They are also less socially isolated and more prone to impulsive behavior, drug and alcohol use disorders, and overt depression. Depression, anxiety (eg, concerning weight and/or social situations) and anxiety disorders are common among these patients.

Most physical signs of bulimia nervosa result from purging. Self-induced vomiting may lead to erosion of dental enamel of the front teeth, painless parotid (salivary) gland enlargement, and an inflamed esophagus. Physical signs include the following:

• Swollen parotid glands

• Scars on the back of the hand (from repeatedly inducing vomiting by using fingers to trigger gag reflex)

• Dental erosion

• Psychiatric assessment

• Sometimes laboratory tests

Clinical criteria for diagnosis of bulimia nervosa from the Diagnostic and Statistical Manual of Mental Disorders, 5th ed, Text Revision (DSM-5-TR) include the following (1):

• Recurrent episodes of binge eating (the uncontrolled consumption of unusually large amounts of food) that are accompanied by feelings of loss of control over eating and that occur, on average, at least once a week for 3 months

• Recurrent inappropriate compensatory behavior to influence body weight (on average, at least once a week for 3 months)

• Self-evaluation that is unduly influenced by body shape and weight concerns

Laboratory measurement of electrolytes can identify abnormalities, particularly hypokalemia (2).

• Cognitive behavioral therapy

• Interpersonal psychotherapy

• Selective serotonin reuptake inhibitors (SSRIs)

Cognitive behavioral therapy is the treatment of choice for bulimia nervosa (1–3). Therapy usually involves 16 to 20 individual sessions over 4 to 5 months, although it can also be done as group therapy. Treatment aims to

• Increase motivation for change

• Replace dysfunctional eating with a regular and flexible pattern

• Decrease undue concern with body shape and weight

• Prevent relapse

Cognitive behavioral therapy eliminates binge eating and purging in approximately 35 to 50% of patients (4, 5). Many others show improvement; some drop out of treatment or do not respond. Improvement is usually well maintained over the long-term.

In interpersonal psychotherapy, the emphasis is on helping patients identify and alter current interpersonal problems that may be maintaining the eating disorder. The treatment is both nondirective and noninterpretive and does not focus directly on eating disorder symptoms. Interpersonal psychotherapy can be considered an alternative when cognitive behavioral therapy is unavailable.

Selective serotonin reuptake inhibitors used alone do reduce the frequency of binge eating and vomiting but are not ideal as a sole treatment without psychotherapy (3, 6, 7). SSRIs are also effective in treating comorbid anxiety and depression. Fluoxetine is often used for the treatment of bulimia nervosa in adults, at a dose higher than that typically used for depression in adults (). SSRIs are also effective in treating comorbid anxiety and depression. Fluoxetine is often used for the treatment of bulimia nervosa in adults, at a dose higher than that typically used for depression in adults (2).