History

Fact Explanation
Recurrent episodes of binge eating. This is characterised by; eating large amount of food that is definitely larger compared to most people would consume with similar time and circumstances. But excessive eating of food during a typical meal might be considered normal.(e.g. at a party). [1]
Recurrent inappropriate compensatory behavior in order to prevent weight gain. Self-induced vomiting; misuse of laxatives, enemas, diuretics, or other medications; fasting; or excessive exercise. [1]
The binge eating and in appropriate compensatory behaviors both occur, On average of, at least twice a week for 3 months is needed to make the diagnosis. [1]
Self-evaluation. Unduly influenced by body shape and weight and are the most important factors in determining the self- esteem. [1]
The disturbance does not occur exclusively during episodes of Anorexia Nervosa. A diagnosis of bulimia nervosa shouldn't be given if the concern over weight and body image only occurs during the episodes of anorexia nervosa. [2]
References
  1. FARIS PL, HOFBAUER RD, DAUGHTERS R, VANDENLANGENBERG E, IVERSEN L, GOODALE RL, MAXWELL R, ECKERT ED, HARTMAN BK. De-Stabilization of the Positive Vago-Vagal Reflex in Bulimia Nervosa Physiol Behav [online] 2008 Apr 22, 94(1):136-153 [viewed 29 June 2014] Available from: doi:10.1016/j.physbeh.2007.11.036
  2. EDDY KT, DORER DJ, FRANKO DL, TAHILANI K, THOMPSON-BRENNER H, HERZOG DB. Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa: Implications for DSM-V Am J Psychiatry [online] 2008 Feb, 165(2):245-250 [viewed 01 July 2014] Available from: doi:10.1176/appi.ajp.2007.07060951

Examination

Fact Explanation
General examination - Body weight It is possible to patient to have bulimia nervosa still maintain a above normal or normal body weight. Anorexia nervosa patients have a lower than normal body weight. [1]
General examination - pitted teeth Teeth may be pitted due to repeated vomiting of acidic gastric contents. [2]
General examination- bilateral swollen parotid glands. Due to non inflammatory stimulation of the salivary glands. [1]
General examination- Russell’s sign. Callosities, scarring, and abrasions on the scarring on the dorsum of the hands secondary to repeated self-induced vomiting. [1]
General examination- evidence of self-injurious behavior. Ecchymoses, cigarette burns which indicate self injurious behavior. [1]
General examination- indications of muscular irritability due to hypocalcaemia. Chvostek’s and Trousseau’s signs. [2]
Mental state examination- Appearance. Patients are typically neat and well dressed, They often show attention to detail. These may demonstrate a patient's concern about personal appearance. They generally avoid eye contact due to shame and embarrassment. [3]
Mental State Examination: Speech Generally normal. [4]
Mental State Examination: Mood. Patients may demonstrate a depressed mood,may also have significant anxiety. [4]
Mental State Examination: Thoughts Suicidal thoughts is a significant consideration, especially in patients with depressed mood. [4]
Mental State Examination: Perception. Delusions and hallucinations are typically absent. [4]
Mental State Examination: Cognitive function. Patients are alert, and oriented to their surroundings. Attention and concentration are generally normal. Immediate memory is normal. [4]
Mental State Examination: Insight Insight of the patient regarding the presence and significance of the disturbances is variable. Patients may admit to episodes of binge eating, but not appreciate their inappropriate fixation on eating or inappropriate ideas of body image and weigh oftent. [4]
References
  1. RUSHING JM, JONES LE, CARNEY CP. Bulimia Nervosa: A Primary Care Review Prim Care Companion J Clin Psychiatry [online] 2003, 5(5):217-224 [viewed 05 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419300
  2. WALSH JM, WHEAT ME, FREUND K. Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician J Gen Intern Med [online] 2000 Aug, 15(8):577-590 [viewed 05 July 2014] Available from: doi:10.1046/j.1525-1497.2000.02439.x
  3. CHAKRABORTY K, BASU D. Management of anorexia and bulimia nervosa: An evidence-based review Indian J Psychiatry [online] 2010, 52(2):174-186 [viewed 05 July 2014] Available from: doi:10.4103/0019-5545.64596
  4. MAZZEO SE, MITCHELL KS, BULIK CM, AGGEN SH, KENDLER KS, NEALE MC. A twin study of specific bulimia nervosa symptoms Psychol Med [online] 2010 Jul, 40(7):1203-1213 [viewed 05 July 2014] Available from: doi:10.1017/S003329170999122X

Differential Diagnoses

Fact Explanation
Anorexia Nervosa The binge - eating behavior only occurs during the episodes of anorexia nervosa. In anorexia nervosa individuals refuse to maintain the body weight above the normal for age and height , whereas in Bulimia nervosa the body weight is usually normal. [1]
Klein-Levin syndrome. Eating pattern is disturbed but there's no characteristic features - over concern about the body shape and weight. [2]
Major Depressive Disorder, With Atypical Features Do not engage in inappropriate compensatory behaviors and over concern about the body shape and weight is absent in depressive disorder. If criteria for both diseases are met, both diagnoses should be made as bulimia nervosa can be associated with depressive disorder. [3]
Borderline Personality Disorder. Impulsive behavior in the borderline disorder can include binge- eating behavior. [1]
References
  1. EDDY KT, DORER DJ, FRANKO DL, TAHILANI K, THOMPSON-BRENNER H, HERZOG DB. Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa: Implications for DSM-V Am J Psychiatry [online] 2008 Feb, 165(2):245-250 [viewed 05 July 2014] Available from: doi:10.1176/appi.ajp.2007.07060951
  2. MIGLIS MG, GUILLEMINAULT C. Kleine-Levin syndrome: a review Nat Sci Sleep [online] :19-26 [viewed 05 July 2014] Available from: doi:10.2147/NSS.S44750
  3. GRILO CM, PAGANO ME, SKODOL AE, SANISLOW CA, MCGLASHAN TH, GUNDERSON JG, STOUT RL. Natural Course of Bulimia Nervosa and of Eating Disorder Not Otherwise Specified: 5-Year Prospective Study of Remissions, Relapses, and the Effects of Personality Disorder Psychopathology J Clin Psychiatry [online] 2007 May, 68(5):738-746 [viewed 05 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2527481

Investigations - for Diagnosis

Fact Explanation
Serum Amylase levels. An elevated amylase level may suggest that a patient has been vomiting.Can identify purging type Bulimia nervosa. [1]
References
  1. RUSHING JM, JONES LE, CARNEY CP. Bulimia Nervosa: A Primary Care Review Prim Care Companion J Clin Psychiatry [online] 2003, 5(5):217-224 [viewed 05 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419300

Investigations - Fitness for Management

Fact Explanation
ECG (Electrocardiogram) Bulimia nervosa can causes electrolyte imbalance and cardiac arrhythmia. May show prolonged QT interval due to hypokalemia. [1]
Bone densitometry (DEXA scan) To assess the severity of bone loss. Low-weight patients are at high risk for osteopenia/osteoporosis. [2]
Full blood count (FBC) Look for low Hemoglobin concentrations.To detect anemia. [2]
Serum electrolytes. Hypokalemia, hypochloremia, hyperphosphatemia, and metabolic alkalosis may be present. Due to use of diuretics, laxatives, and repetitive vomiting in bulimic patients. Electrolyte abnormalities depend on patient's behavior. Patients who purge by vomiting may present with metabolic alkalosis (elevated serum bicarbonate levels) due to volume contraction. Patients who primarily abuse laxatives may present with metabolic acidosis (decreased serum bicarbonate levels) due to loss of alkaline fluid from the bowel. [3]
Urinalysis Bulimia nervosa can cause fluid imbalances . Urine specific gravity used to detect state of hydration. [3]
References
  1. BUCHANAN R, NGWIRA J, AMSHA K. Prolonged QT interval in bulimia nervosa BMJ Case Rep [online] :bcr0120113780 [viewed 05 July 2014] Available from: doi:10.1136/bcr.01.2011.3780
  2. WALSH JM, WHEAT ME, FREUND K. Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician J Gen Intern Med [online] 2000 Aug, 15(8):577-590 [viewed 05 July 2014] Available from: doi:10.1046/j.1525-1497.2000.02439.x
  3. RUSHING JM, JONES LE, CARNEY CP. Bulimia Nervosa: A Primary Care Review Prim Care Companion J Clin Psychiatry [online] 2003, 5(5):217-224 [viewed 05 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419300

Management - General Measures

Fact Explanation
Assess the severity of the condition, presence of depressive disorder and family problems. Depressive disorder can co- exist with bulimia nervosa. Identifying patients problems gives an idea of the precipitating and maintaining factors of the disease. [1]
Establish a good working relationship with the patient. This help is gaining patient's confidence about the treatment process and improves patient's compliance. Have an agreement on monitoring interval, agreement to keep food, exercise, and binge/purge diaries, and agreement on what parameters will be followed and how frequently they will be followed. [2]
Advice the patient about healthy eating habits. Educate the patient about healthy eating habits, nutrients in food, how to include adequate nutrients in a diet and educate on the bad effects of unnecessary control of diet and cut down of nutrients. [1]
Agree on realistic targets on weight gain. The targets set up should be realistic and practical. Otherwise will result in patient disappointment and lose of compliance to the agreed treatment plan. [1]
Arrange with regular follow up and monitoring. Come to an agreement on a plan on regular follow up and monitoring which will reduce the risk of relapsing. [2]
References
  1. CHAKRABORTY K, BASU D. Management of anorexia and bulimia nervosa: An evidence-based review Indian J Psychiatry [online] 2010, 52(2):174-186 [viewed 05 July 2014] Available from: doi:10.4103/0019-5545.64596
  2. WALSH JM, WHEAT ME, FREUND K. Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician J Gen Intern Med [online] 2000 Aug, 15(8):577-590 [viewed 05 July 2014] Available from: doi:10.1046/j.1525-1497.2000.02439.x

Management - Specific Treatments

Fact Explanation
Cognitive-behavioral therapy (CBT) The CBT method has 3 phases. During the first phase, patients are taught about bulimia nervosa and actions that perpetuate the disease. The patient keeps detailed food records, including the frequency of bingeing or purging. The second phase consists of teaching the patient to broaden food choices, and additional time is spent on correcting dysfunctional food and body thoughts. The main target is to break or to decrease the binge-purge cycle. The third stage focus on maintenance and relapse prevention. [1]
Pharmacological treatment- SSRI. May be a primary or adjunct therapy for bulimia nervosa. Fluoxetine- significantly decrease overall binge eating and vomiting. The combination of CBT with fluoxetine therapy has been shown to be superior to medication or CBT alone. Gastrointestinal effects - nausea, vomiting, dyspepsia, constipation, diarrhea. Serious side effects - seizures, hyponatremia, increase suicidal risk in children and adolescents. The patient should be carefully assessed for suicidal ideation. [2]
References
  1. HALLER E. Eating disorders. A review and update. West J Med [online] 1992 Dec, 157(6):658-662 [viewed 05 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1022101
  2. CHAKRABORTY K, BASU D. Management of anorexia and bulimia nervosa: An evidence-based review Indian J Psychiatry [online] 2010, 52(2):174-186 [viewed 05 July 2014] Available from: doi:10.4103/0019-5545.64596