Eating disorder: bulimia nervosa

Question 1

What are the features of bulimia nervosa?

Answer 1

• Preoccupation with body shape/weight
• Recurrent episodes of:
  
  • Binge eating
  • Excessive quantity
  • Loss of control of eating
• Compensatory behaviour(s)
  
  • Vomiting
  • Laxative abuse
  • Exercise/fasting/appetite suppressants
• Often normal weight

Question 2

What do patients with bulimia nervosa ‘look like’?

Answer 2

Normal weight

Question 3

How often do binges need to occur for diagnosis of bulimia nervosa?

Answer 3

The binge eating + compensatory behaviours both occur, on average, at least once a week for three months.

Question 4

What signs of compensatory behaviour may be found in bulimia nervosa?

Answer 4

Recurrent vomiting –>

1. Erosion of teeth
2. Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting

Question 5

Apart from vomiting, what are the other compensatory behaviours in bulimia nervosa?

Answer 5

Recurrent inappropriate compensatory behaviour in order to prevent weight gain may include:

• self-induced vomiting,
• misuse of laxatives,
• diuretics, or other medications,
• fasting,
• excessive exercise.

Question 6

What is a ‘binge’?

Answer 6

Eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances.

Question 7

What is the management of bulimia nervosa in adults? Is pharmacological treatment indicated?

Answer 7

1. Referral - for specialist care is appropriate in all cases
2. MDT involvement
3. Bulimia-nervosa-focused guided self-help for adults - NICE recommended. If this is unacceptable, contraindicated, or ineffective after 4 weeks of treatment:
   
   • Consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
4. Pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking

Question 8

What is the management of bulimia nervosa in children?

Answer 8

1. Referral to specialist services
2. Children should be offered bulimia-nervosa-focused family therapy (FT-BN)

Question 9

What are the complications of purging?

Answer 9

Cardiovascular

• Arrhythmia
• Respiratory
• Aspiration pneumonia
• Vocal cord damage

Gastrointestinal

• Dental erosion, caries
• GORD, oesophagitis
• Functional impairment (laxatives)

Metabolic

• Hypokalaemia
• Hypochloraemia
• Metabolic alkalosis
• Dehydration, hypovolaemia

Dermatological

• Russel’s sign

Question 10

Who is involved in the MDT in eating disorders?

Answer 10

• Medical
• Psychology (systemic therapy)
• Dietician
• OT