Bulimia Nervosa and Anorexia Nervosa

Question 1

Inappropriate ways of controlling weight seen in bulimia nervosa

Answer 1

• Fasting
• Excessive exercising
• Misuse of laxatives, diuretics, or enemas
• Postprandial vomiting

Question 2

Patients with bulimia are usually ___in weight

Answer 2

Patients with bulimia are usually average or near-average in weight

Question 3

Nonpurging type bulimia

Answer 3

Bulimia where fasting or excessive exercising are utilized without frequent purging

Question 4

Purging

Answer 4

Self-induced vomiting and/or missuse of laxatives, diuretics, or enemas for the purpose of preventing weight gain

Question 5

Risk of relapse following treatment for bulimia

Answer 5

About ~33%

Question 6

Physical exam and laboratory features of bulimia nervosa

Answer 6

• Physical Exam:
  
  • Parotid gland enlargement
  • Tooth erosion
  • Gastric dilation
  • Possible Mallory-Weiss or Boerhave syndrome
  • Signs of ipecac intoxication or related cardiomyopathy
• Laboratory:
  
  • Elevated serum amylase
  • Hypokalemia
  • Hypomagnesemia
  • Hypochloremic contraction alkalosis

Question 7

Ipecac

Answer 7

Rapidly acting emetic

Signs of toxicity: Pericardial pain, dyspnea, generalized muscle weakness, hypotension, tachycardia, EEG abnormalities. Chronically may cause cardiomyopathy.

(Basically, acute tachy EKG abnormalities with chest pain, chronic cardiomyopathy)

Question 8

What types of person tend to get anorexia or bulimia?

Answer 8

• High achievers
• FHx depression
• Respond to social pressures to be thin

Question 9

Hallmarks of bulimia

Answer 9

Binge eating

Purging behavior

Question 10

Diagnostic criteria for Bulimia Nervosa

Answer 10

• Recurrent episodes (at least once/week for 3 months) of binge eating and inappropriate compensatory behavior (purging, fasting, excessive exercise)
• Self-evaluation is largely (and unduly) based on body shape and weight
• Behavior does not occur only during an episode of anorexia nervosa

Question 11

Anorexia nervosa, binge-eating / purging type

Answer 11

Main DDx for Bulimia nervosa

The binge-eating/purging behavior is seen in both. However, anorexia is distinguished by the requirement of being:

1. Underweight
2. Amenorrheic

In contrast, patients with bulimia can be of near-average, average weight, or overweight

Question 12

Is binge-eating/purging behavior sufficient to diagnose bulimia?

Answer 12

NO

Anorexia is still on the Ddx, and conditions of chronicity and physical sequellae must be met.

Question 13

Short-lived episodes of binge-eating/purging behavior

Answer 13

Not necessarily bulimia, as they may be short-lived, infrequent, and unassociated with physical sequellae

These behaviors are often learned from peers, performed infrequently, and self-resolve. Bulimia is when they do not self resolve and become habit.

Question 14

Bulimia behavior in CNS syndromes

Answer 14

Can be seen in certain CNS tumor syndromes or rare infarcts, particularly Kluver-Bucy syndrome and Klein-Levin syndrome.

Thus, a full history and physical exam should be performed with attention to neurologic deficits, excessive sleepiness, hallucinations, and B symptoms.

Question 15

Treatment of Bulimia nervosa

Answer 15

Should have a three-pronged treatment:

1. CBT* (often family based or 12-step styple group therapy)
2. Nutritional rehabilitation
3. Treatment with an SSRI **

*For patients who are overweight, appetite-awareness training and a structured behavioral weight-loss program are preferable to group CBT. Otherwise, this population tends to discontinue therapy prematurely.

** Fluoxetine is the standard, sertraline is second-line. Should be continued for 9-12 months after symptoms remit.

Question 16

Patients with bulimia may not have any symptoms until ___, while symptoms in anorexia typically present in ___.

Answer 16

Patients with bulimia may not have any symptoms until early adulthood, while symptoms in anorexia typically present in adolescence.

This makse sense. If you don’t eat at all, you will see the symptoms sooner than the gradual tooth erosion and parotid hypertrophy in bulimia.

Question 17

Anorectic abnormal body weight

Answer 17

Body weight lower than the 15% percentile for the patient’s age that is produced by conscious weight-loss efforts

Question 18

Lanugo

Answer 18

Fine body hair present on prepubertal children and commonly seen in patients with anorexia

May also occur in other etiologies of malnutrition

Question 19

__ should always be a prominent part of the assessment for anorexia nervosa.

Answer 19

A family assessment should always be a prominent part of the assessment for anorexia nervosa.

There is strong evidence that family functioning plays an important role in he development of this disorder.

Question 20

Patients with anorexia nervosa tend to take great interest in. . .

Answer 20

. . . food and its preparation, despite that they severely restrict their own calorie intake.

They are living vicariously.

Question 21

A key part of anorexia is the belief that. . .

Answer 21

. . . they are overweight, despite being extremely low weight and even malnourished

Question 22

Signs of malnutrition commonly seen in anorexia

Answer 22

• Cachexia
• Amenorrhea (history)
• Hypothermia
• Dependent edema (due to hypoalbuminemia)
• Bradycardia with hypotension
• Lanugo

Question 23

Diagnostic criteria for anorexia nervosa

Answer 23

• Refusal to maintain weight at or above the normal weight for one’s age and height (<15%ile)
• Intense fear of gaining weight or becoming fat despite being underweight
• Disturbance of the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the severity of the current low body weight

Question 24

Insight in anorexia and bulimia

Answer 24

Patients with bulimia tend to have good insight

Patients with anorexia tend to have poor insight.

Question 25

Main “types” of anorexia

Answer 25

Restrictive type

Binge-eating/purging type

Question 26

Treatment of aorexia nervosa

Answer 26

• Medical stabilization is the initial step. In children/adolescents, this may need to be involuntary with parental consent.
• Following medical stabilization, if the patient is still 30% below expected weight or has been unresponsive to outpatient efforts to weight restoration, they will require psychiatric hospitalization for 2-6 months
• Once an outpatient again, CBT or family therapy are employed.
• Pharmacotherapy has not been definitively proven useful, however olanzapine is sometimes used. Comorbid psychiatric disorders should be treated appropriately.

Question 27

Patients with anorexia nervosa are at high risk of ___ upon initiation of treatment

Answer 27

Patients with anorexia nervosa are at high risk of refeeding syndrome upon initiation of treatment

So, careful monitoring of electrolytes and EKG during inpatient medical stabilization is necessary.

Question 28

Phases of family therapy for anorexia

Answer 28

1. Restoring the patient’s weight
2. Handing control over eating back to the patient
3. Discussion of adolescent development once healthy weight is attained and maintained

Question 29

Related psychiatric features sometimes observed in anorexia nervosa

Answer 29

Obsessions, rituals, and depression

These do not necessarily indicate another psychiatric disorder, unless diagnostic criteria per the DSM-5 are met

Question 30

___ is seen in 1/3 of patients with anorexia nervosa

Answer 30

Mitral regurgitation is seen in 1/3 of patients with anorexia nervosa

This presents as a holosystolic murmur on exam