Bulimia nervosa

Nervous bulimia is observed within the framework of mental disorders and borderline personality pathology of almost all types.

Bulimia nervosa involves recurrent episodes of compulsive overeating, accompanied by self-induced vomiting, use of laxatives and diuretics, excessive exercise, or fasting. Diagnosis is based on history and examination. Treatment consists of psychotherapy and SSRIs, especially fluoxetine.

Bulimia nervosa affects 1-3% of adolescents and young women. They are constantly and excessively concerned about their figure and body weight. Unlike patients with anorexia nervosa, patients with bulimia nervosa usually have normal body weight.

The syndrome of nervous bulimia is usually divided into two types: the first type - without a previous picture of nervous anorexia, the second type - with a previous picture of nervous anorexia (in the latter case, nervous bulimia is considered a special form of nervous anorexia or as a stage of the disease). The greatest significance in the formation of the syndrome of nervous bulimia is given to depression of various nature. Such a combination with psychopathological disorders makes it necessary for patients to consult with psychiatrists.

[ 1 ], [ 2 ], [ 3 ]

Causes and pathogenesis of nervous bulimia

Provoking factors of bulimic episodes are periods of prolonged abstinence from food with the formation of hypoglycemic states. A number of researchers have identified hypothalamic-pituitary disorders, which are assessed ambiguously. It is assumed that hypothalamic-pituitary disorders can be a reaction to mental and physiological (vomiting) stress. However, the possibility of primary pathology of the hypothalamic-pituitary system with initial neuroendocrine and motivational disorders that participate in the formation of pathological eating behavior with bouts of bulimia is not excluded. Serotonergic deficiency is determined in nervous bulimia. Disruption of serotonin synthesis and metabolism is the basis of depression, which is assigned a primary role in the origin of nervous bulimia.

[ 4 ], [ 5 ], [ 6 ]

Symptoms of Bulimia Nervosa

Symptoms of nervous bulimia are characterized by repeated episodes of consuming large amounts of high-calorie, easily digestible, carbohydrate-rich food in discrete periods of time. Typically, these periods last less than 2 hours. Such episodes alternate with measures aimed at maintaining normal body weight (diet, taking laxatives, diuretics). A bulimic episode usually ends with abdominal pain, self-induced vomiting, and, less often, sleep. During and after the bulimic period, patients realize that their eating behavior is abnormal, have a negative attitude towards it, and develop a depressive mood and self-protest against such food excesses. During a bulimic episode, a fear of being unable to stop eating at will often appears. As a rule, patients hide bulimic episodes from others. The body weight of patients is subject to frequent fluctuations within 5-6 kg. Alternating bulimic episodes with periods of fasting allows maintaining body weight within normal limits. Often, patients with bulimia experience amenorrhea or oligomenorrhea. Nervous bulimia can replace the clinical picture of previous nervous anorexia, but can also begin independently. A combination with various personality disorders of almost all types is typical.

Typical episodes of nervous bulimia have also been described in obesity, but they constitute a small percentage. The hyperphagic reaction to stress observed in obese patients does not fully correspond to the clinical picture of nervous bulimia. As a rule, with a hyperphagic reaction to stress in the context of obesity, bulimic episodes do not alternate with long fasts, but are replaced by periods of less pronounced permanent overeating. In addition, a bulimic episode usually does not end with self-induced vomiting. The hyperphagic reaction to stress can take on the features of nervous bulimia when a doctor prescribes a reduced diet. However, artificially induced vomiting is extremely rare in these cases.

Patients typically describe binge-purge behavior. A bulimic episode involves rapid consumption of food, especially high-calorie foods such as ice cream and cake. Binge-eating episodes vary in the amount of food consumed, sometimes amounting to thousands of calories. These episodes tend to be repetitive, are often triggered by psychosocial stress, occur several times a day, and are kept secret.

Many symptoms and somatic complications result from purging behavior. Induced vomiting results in erosion of the enamel of the anterior teeth and enlargement of the salivary glands. Severe disturbances of fluid and electrolyte balance, especially hypokalemia, sometimes occur. Very rarely, gastric or esophageal ruptures occur, which are life-threatening complications. Cardiomyopathy may develop as a result of long-term use of syrup of ipecac to induce vomiting.

Patients with bulimia nervosa are more self-aware and tormented by remorse and guilt than those with anorexia nervosa, and are more likely to admit their problems to a sympathetic physician. They are also less introverted and more prone to impulsive behavior, alcohol and drug use, and severe depression.

Diagnosis of nervous bulimia

The disorder should be suspected if the patient shows marked preoccupation with weight gain and there are large fluctuations in weight, especially with excessive laxative use or unexplained hypokalemia. Although patients with bulimia worry about becoming fat and may be overweight, most have a body weight that fluctuates around normal values. Enlarged parathyroid glands, scarring of the finger joints (due to self-induced vomiting), and dental erosion are danger signs. However, diagnosis depends on the patient's description of binge-purge behavior.

To be diagnosed (according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - DSM-IV), two bulimic episodes per week are required for at least 3 months, although a careful clinician will not limit himself to these criteria alone.

[ 7 ], [ 8 ]

Differential diagnosis

First of all, it is necessary to exclude somatic diseases accompanied by vomiting (pathology of the gastrointestinal tract, kidneys). As a rule, the typical picture of nervous bulimia is so characteristic that the presence of this syndrome does not raise any doubts.

[ 9 ], [ 10 ], [ 11 ]

Treatment of nervous bulimia

Treatment for bulimia nervosa includes psychotherapy and medication. Psychotherapy, usually cognitive behavioral therapy, has both short-term and long-term effects. SSRIs alone have some effectiveness in reducing binge eating and vomiting, but they are more effective when combined with cognitive behavioral therapy, and this combination is the treatment of choice.

Psychotropic therapy is necessary, the nature of which is determined by the leading psychopathological syndrome. The drugs of choice for the treatment of nervous bulimia are selective serotonergic antidepressants. Fluoxetine (Prozac), an inhibitor of serotonin reuptake in the presynaptic membrane, has the greatest effect. It is prescribed in doses of 40 to 60 mg / day - at one time, for 2-3 months. In addition, it is necessary to develop a new dietary stereotype with an explanation to the patient that periods of strict dieting are provocateurs of bulimic episodes. Regular nutrition with a decrease in easily digestible, carbohydrate-rich food in the diet helps prevent episodes of bulimia. Existing amenorrhea does not require hormone replacement therapy, and the menstrual cycle, as a rule, normalizes with the disappearance of episodes of bulimia.

To improve the functioning of the cerebral systems of neuroendocrine and motivational regulation, nootropil, aminalon, vascular drugs, and glutamic acid are used. If the EEG indicates a decrease in the threshold of seizure readiness of the brain, small doses of finlepsin (0.2 g 2 times a day) may be prescribed.