Psychiatry · Year 2 · from Psychiatry
Case 2: Bulimia Nervosa
Patient Presentation
Demographics: 22-year-old female
Chief Complaint: "I can't stop binging and purging. It's ruining my teeth and my life."
History of Present Illness: A 22-year-old college senior presents requesting help for her eating disorder. She has been binging and purging for 4 years, beginning during her freshman year. She describes a typical pattern: restricts food during the day, then in the evening experiences an "uncontrollable urge" to eat, consuming large quantities of food (entire pizza, pint of ice cream, bags of chips) within 1-2 hours while feeling completely out of control. Afterward, she feels disgusted and ashamed and induces vomiting "until I see blood sometimes." She binges and purges 5-7 times per week. She has tried to stop many times but cannot control the urges. She exercises excessively and occasionally uses laxatives. Her self-worth is entirely based on her weight and shape; she weighs herself daily and her mood depends on the number. Her weight has fluctuated between 120-140 lbs at 5'5" (BMI 20-23, normal range). She reports that her dentist is concerned about her tooth enamel. She has noticed swelling in her cheeks and sometimes has blood in her vomit. She is embarrassed and has hidden this from family and friends.
Physical Examination:
- Vital signs: BP 108/68, HR 78
- Height: 5'5", Weight: 128 lbs, BMI: 21.3 (normal)
- General: Normal weight female
- Oral: Dental enamel erosion, especially on posterior surfaces (from stomach acid)
- Face: Bilateral parotid gland enlargement ("chipmunk cheeks")
- Hands: Calluses on dorsum of right hand (Russell's sign from inducing vomiting)
- Cardiac: Regular rhythm
Mental Status Examination:
- Appearance: Normal weight, well-groomed
- Behavior: Embarrassed but engaged
- Mood: "Ashamed, out of control"
- Affect: Anxious, dysphoric
- Thought content: Preoccupied with weight/shape, recognizes binge-purge cycle is harmful
- Insight: Good - motivated for treatment
- Judgment: Impaired around food/eating
Workup:
- CBC: Normal
- CMP: Potassium 2.9 (low from vomiting), chloride 92 (low), bicarbonate 32 (elevated - metabolic alkalosis from vomiting)
- Amylase: 180 (elevated - from salivary glands)
- Magnesium: 1.6 (low)
- ECG: Normal sinus rhythm, no arrhythmia despite low K
- EDE-Q (Eating Disorder Examination Questionnaire): Elevated scores across all subscales
Diagnosis: Bulimia Nervosa, purging type, moderate (4-7 episodes/week)
Treatment:
- Potassium and magnesium repletion
- Started fluoxetine 60 mg daily (FDA-approved for bulimia at this dose)
- Psychoeducation about medical complications and the binge-purge cycle
- Referral for CBT-E (enhanced cognitive behavioral therapy for eating disorders):
- Self-monitoring of eating, binging, and purging
- Regular eating pattern (3 meals, 2-3 snacks) to reduce dietary restriction
- Identifying triggers and developing alternative coping strategies
- Addressing over-evaluation of shape and weight
- Nutritionist for meal planning support
- Dental referral for enamel evaluation and protection
- At 12-week follow-up:
- Binge-purge episodes reduced to 1-2/week
- Electrolytes normalized
- Mood improved significantly
- Continuing CBT-E with goal of full remission
Clinical Pearl: Bulimia nervosa is characterized by binge eating with compensatory behaviors (purging, laxatives, fasting, excessive exercise) at normal or above-normal weight. The electrolyte pattern of hypokalemic, hypochloremic metabolic alkalosis is classic for purging via vomiting. Fluoxetine 60 mg daily is FDA-approved and effective - notably higher than the typical depression dose. CBT-E is the first-line psychotherapy. Russell's sign (calluses from teeth on knuckles) and parotid enlargement are physical exam clues. Unlike anorexia, patients with bulimia often have good insight and motivation for treatment.