Psychiatry · Year 3 · from Psychiatry
Case 2: Bulimia Nervosa
Patient Demographics
- Age: 22 years old
- Sex: Female
- Occupation: College senior, pre-law
Chief Complaint
"I can't stop the binge-purge cycle and I'm scared I'm going to hurt myself."
History of Present Illness
The patient is a 22-year-old female self-presenting to outpatient psychiatry with a 5-year history of binge eating and purging behaviors. She describes episodes occurring 2-3 times daily where she consumes large amounts of food (2,000-4,000 calories in one sitting), typically in secret, followed by self-induced vomiting. Binge foods include "forbidden" items like pizza, ice cream, and chips. Episodes are triggered by stress (upcoming finals, relationship conflicts) and by periods of dietary restriction. She feels a loss of control during binges, describing it as "like I'm watching myself from outside." After purging, she feels temporary relief but then intense shame and disgust. She has tried to stop multiple times but relapses within days. She is at normal weight (BMI 22), which has allowed her to hide her disorder from others. She reports using multiple methods to compensate for binges including vomiting, laxatives (10-15 daily), and excessive exercise. She has noticed her teeth are "falling apart" and has frequent sore throats. She reports low mood, anxiety about her eating, and social isolation due to shame, but denies suicidal ideation.
Mental Status Examination
Appearance: Well-groomed young woman of normal weight, calluses on dorsum of right hand (Russell's sign), slightly swollen parotid glands, wearing long sleeves
Behavior: Cooperative, tearful at times, appears ashamed, maintains eye contact
Speech: Normal rate, volume, rhythm
Mood: "Disgusted with myself"
Affect: Dysphoric, anxious, shame-laden, congruent
Thought Process: Linear, goal-directed, some rumination about food and weight
Thought Content:
- Preoccupation with shape and weight
- Overconcern about body shape influencing self-esteem
- Shame and self-criticism about eating behaviors
- Desire to stop but feels unable
- No suicidal ideation
- No psychotic symptoms
Perceptions: No hallucinations; normal body perception (unlike AN)
Cognition: Alert and oriented x4; intact attention and memory
Insight: Good - recognizes behaviors are harmful and wants help
Judgment: Fair - seeking treatment, continues behaviors despite wanting to stop
Physical Examination
Vital Signs:
- Blood pressure: 108/68 mmHg
- Heart rate: 72 bpm
- BMI: 22 kg/m²
Pertinent Findings:
- Russell's sign (calluses on knuckles from inducing vomiting)
- Bilateral parotid hypertrophy ("chipmunk cheeks")
- Dental enamel erosion, multiple cavities
- Pharyngeal erythema
- Petechiae on soft palate
Medical Workup
Laboratory Studies:
- CMP: K+ 2.8 mEq/L (hypokalemia from purging), Cl- 92 (hypochloremia), HCO3- 32 (metabolic alkalosis)
- CBC: Within normal limits
- Amylase: 168 U/L (elevated from parotid hypertrophy)
- BUN: 24 (elevated - dehydration)
ECG:
- Sinus rhythm at 74 bpm
- U waves present (sign of hypokalemia)
- QTc: 450 ms (slightly prolonged)
Diagnosis
Bulimia Nervosa, Moderate (F50.2)
DSM-5 Criteria Met: A. Recurrent episodes of binge eating characterized by:
- Eating large amounts of food in discrete time period (>2000 kcal)
- Sense of lack of control during episodes
B. Recurrent inappropriate compensatory behaviors to prevent weight gain:
- Self-induced vomiting (2-3x daily)
- Laxative abuse (10-15 daily)
- Excessive exercise
C. Binge eating and compensatory behaviors occur at least once weekly for 3 months (currently 2-3x daily x 5 years) D. Self-evaluation unduly influenced by body shape and weight E. Disturbance does not occur exclusively during episodes of anorexia nervosa
Severity: Moderate (8-13 episodes of compensatory behaviors per week)
Medical Complications Present:
- Hypokalemia with metabolic alkalosis (purging)
- Dental erosion
- Parotid hypertrophy
- Dehydration
Treatment Plan
Pharmacotherapy:
- Fluoxetine 60 mg daily (FDA-approved for bulimia nervosa, higher dose than depression)
- Start at 20 mg, titrate over 2 weeks
- Reduces binge-purge frequency and improves mood
Psychotherapy - Cognitive Behavioral Therapy for Eating Disorders (CBT-E):
- First-line psychological treatment for bulimia nervosa
- 20 sessions over 20 weeks
- Focus on:
- Self-monitoring of eating behaviors
- Establishing regular eating patterns
- Addressing dietary restraint
- Cognitive restructuring of shape/weight concerns
- Relapse prevention
Alternative Psychotherapy Options:
- Interpersonal Therapy (IPT) if CBT-E not effective
- DBT for patients with significant emotional dysregulation
Nutritional Counseling:
- Work with registered dietitian experienced in eating disorders
- Establish regular meal pattern (3 meals, 2-3 snacks)
- Challenge food rules and forbidden foods
- Address restriction that drives binge-purge cycle
Medical Management:
- Potassium supplementation until normalized
- Dental referral for enamel erosion
- Monitor electrolytes weekly initially
Safety:
- Laxative taper (sudden cessation can cause rebound edema)
- Education about medical risks of purging
- Harm reduction if unable to fully stop (safer alternatives)
Follow-up:
- Psychiatry in 2 weeks for medication adjustment
- Weekly CBT-E sessions
- Dietitian weekly initially
- Labs in 1 week
Image Attribution
Image: Medical illustration showing physical manifestations of eating disorders. Source: Wikimedia Commons. Used for educational purposes under Creative Commons license.