Bulimia Nervosa

Eating disorders

Clinicals - 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).
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).
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. 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.
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. 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.
Self-evaluation. Unduly influenced by body shape and weight and are the most important factors in determining the self- esteem. Self-evaluation.
Unduly influenced by body shape and weight and are the most important factors in determining the self- esteem.
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. 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.

Clinicals - 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. 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.
General examination - pitted teeth Teeth may be pitted due to repeated vomiting of acidic gastric contents. General examination - pitted teeth
Teeth may be pitted due to repeated vomiting of acidic gastric contents.
General examination- bilateral swollen parotid glands. Due to non inflammatory stimulation of the salivary glands. General examination- bilateral swollen parotid glands.
Due to non inflammatory stimulation of the salivary glands.
General examination- Russell’s sign. Callosities, scarring, and abrasions on the scarring on the dorsum of the hands secondary to repeated self-induced vomiting. General examination- Russell’s sign.
Callosities, scarring, and abrasions on the scarring on the dorsum of the hands secondary to repeated self-induced vomiting.
General examination- evidence of self-injurious behavior. Ecchymoses, cigarette burns which indicate self injurious behavior. General examination- evidence of self-injurious behavior.
Ecchymoses, cigarette burns which indicate self injurious behavior.
General examination- indications of muscular irritability due to hypocalcaemia. Chvostek’s and Trousseau’s signs. General examination- indications of muscular irritability due to hypocalcaemia.
Chvostek’s and Trousseau’s signs.
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. 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.
Mental State Examination: Speech Generally normal. Mental State Examination: Speech
Generally normal.
Mental State Examination: Mood. Patients may demonstrate a depressed mood,may also have significant anxiety. Mental State Examination: Mood.
Patients may demonstrate a depressed mood,may also have significant anxiety.
Mental State Examination: Thoughts Suicidal thoughts is a significant consideration, especially in patients with depressed mood. Mental State Examination: Thoughts
Suicidal thoughts is a significant consideration, especially in patients with depressed mood.
Mental State Examination: Perception. Delusions and hallucinations are typically absent. Mental State Examination: Perception.
Delusions and hallucinations are typically absent.
Mental State Examination: Cognitive function. Patients are alert, and oriented to their surroundings. Attention and concentration are generally normal. Immediate memory is normal. Mental State Examination: Cognitive function.
Patients are alert, and oriented to their surroundings. Attention and concentration are generally normal. Immediate memory is normal.
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. 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.

Investigations - Diagnosis

Fact Explanation
Serum Amylase levels. An elevated amylase level may suggest that a patient has been vomiting.Can identify purging type Bulimia nervosa. Serum Amylase levels.
An elevated amylase level may suggest that a patient has been vomiting.Can identify purging type Bulimia nervosa.

Investigations - Management

Fact Explanation
ECG (Electrocardiogram) Bulimia nervosa can causes electrolyte imbalance and cardiac arrhythmia.
May show prolonged QT interval due to hypokalemia.
ECG (Electrocardiogram)
Bulimia nervosa can causes electrolyte imbalance and cardiac arrhythmia.
May show prolonged QT interval due to hypokalemia.
Bone densitometry (DEXA scan) To assess the severity of bone loss.
Low-weight patients are at high risk for osteopenia/osteoporosis.
Bone densitometry (DEXA scan)
To assess the severity of bone loss.
Low-weight patients are at high risk for osteopenia/osteoporosis.
Full blood count (FBC) Look for low Hemoglobin concentrations.To detect anemia. Full blood count (FBC)
Look for low Hemoglobin concentrations.To detect anemia.
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.
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.
Urinalysis Bulimia nervosa can cause fluid imbalances . Urine specific gravity used to detect state of hydration. Urinalysis
Bulimia nervosa can cause fluid imbalances . Urine specific gravity used to detect state of hydration.

Management - Supportive

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. 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.
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.
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.
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. 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.
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. 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.
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. 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.

Management - Specific

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.
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.
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.
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.

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