Monday, May 29, 2017

Bulimia nervosa

The essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self-deprecation. These feelings cause the patient to engage in self-induced vomiting, the use of laxatives or diuretics, following a strict diet, or fasting to overcome the effects of the binges. Electrolyte imbalances (including metabolic alkalosis, hypochloremia, and hypokalemia) and dehydration can occur, increasing the risk of physical complications.
Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. It affects nine women for every man affected. Nearly 2% of adult women meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder.

Bulimia nervosa has no known cause, but psychosocial factors may contribute to its development, including family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity.

Signs and symptoms
The history of a patient with bulimia nervosa is marked by episodes of binge eating that may occur up to several times per day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food usually is sweet, soft, and high in calories and carbohydrate content.
The bulimic patient may appear thin and emaciated. Typically, however, although her weight frequently fluctuates, it usually stays within normal limits through the use of diuretics, laxatives, vomiting, and exercise. So, unlike the anorexic patient, the bulimic patient can usually hide her eating disorder.
Overt clues to this disorder include hyperactivity, peculiar eating habits or rituals, frequent weighing, and a distorted body image.
The patient may complain of abdominal and epigastric pain caused by acute gastric dilation. She may also have amenorrhea. Repetitive vomiting may cause painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion. The patient may also exhibit calluses on the knuckles or abrasions and scars on the dorsum of the hand, resulting from tooth injury during self-induced vomiting.

Psychosocial factors

A bulimic patient commonly is perceived by others as a “perfect” student, mother, or career woman; an adolescent may be distinguished for participation in competitive activities such as sports. However, the patient’s psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships.
Diagnostic tools include the Beck Depression Inventory, which may identify coexisting depression, and laboratory tests to help determine the presence and severity of complications. Serum electrolyte studies may show increased bicarbonate levels and decreased potassium and sodium levels.
A baseline electrocardiogram may be done if tricyclic antidepressants will be prescribed for the patient.

Psychotherapy concentrates on interrupting the binge-purge cycle and helping the patient regain control over her eating behavior. Treatment is usually provided in an outpatient setting and includes behavior modification therapy for 4 to 6 months, which may take place in highly structured psychoeducational group meetings.
Individual psychotherapy and family therapy, which address the eating disorder as a symptom of unresolved conflict, may help the patient understand the basis of her behavior and teach her self-control strategies. Antidepressants, particularly fluoxetine (Prozac), a selective seratonin-reuptake inhibitor, is useful as an adjunct to psychotherapy.
The patient also may benefit from participation in self-help groups, or in a drug rehabilitation program if she also has a substance abuse problem.

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