​Kembara Xtra - Medicine - Bulimia Nervosa

​Kembara Xtra - Medicine - Bulimia Nervosa 

Introduction
an eating disorder characterized by binge eating and improper coping mechanisms 
Binge eating is characterized by eating in a discrete period of time (typically within 2 hours), eating an amount of food that is unquestionably greater than most people would eat during a similar period of time, and feeling uncontrollable while eating. This is followed by recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting, misuse of laxatives or diuretics (or other medications), excessive exercise, and fasting after meals.
Over the course of three months, binge eating and inappropriate compensatory behaviors both happen on average at least once a week.
According to the DSM-5, bulimia nervosa severity is categorized as follows:
- Mild: 1 to 3 episodes of inappropriate compensatory behaviors per week; Moderate: 4 to 7 episodes of inappropriate compensatory behaviors per week; Severe: 8 to 13 episodes per week; Extreme: 14 or more episodes per week System(s) affected:
gastrointestinal, dermatologic, cardiovascular, pulmonary, endocrine/metabolic, oropharyngeal, and mental

Incidence and prevalence in Epidemiology 
Adolescents and young adults are most commonly affected, however it can happen to people of various ages and races worldwide. 
Predominant sex is female (13:1) with an average age of onset of 18 to 21 years. 18.5% to 26.9%, decreasing with time according to recent studies
Prevalence
In their lifetime, up to 3% of females and 1% of males are affected.


Etiology and Pathophysiology 

Biological, psychological, environmental, and social variables all combined.
Multiple studies have shown that bulimia nervosa patients have changed brain structure and function, providing strong evidence of serotonergic dysregulation.
Genetics
Recent studies have found heritability to be as high as 41%. 

Risk Elements 
Female gender; a history of being overweight and dieting; body dissatisfaction brought on by criticism of one's weight, body shape, or diet; low self-esteem; depression; social anxiety; a significant amount of stress in one's life; poor impulse control; substance abuse 
Perfectionism or obsessive thinking; a culture that values excellence and physical fitness (such as the military, ballet, cheerleading, gymnastics, or modeling); A history of substance abuse, affective disorders, eating disorders, or obesity in the family; Diabetes: type 1 > type 2; Childhood trauma (sexual or physical abuse, neglect);

Prevention Realistic and wholesome weight-management techniques and mindsets 
Reduce body dissatisfaction and boost confidence.
Stop viewing thinness as the ideal.


The following conditions are related to substance use disorder: major depression, dysthymia, anxiety, obsessive-compulsive disorder, and bipolar disorder; borderline, schizotypal, and antisocial personality disorders;


Presenting History: Unhappiness and/or preoccupation with weight and dieting attempts; patients unlikely to self-identify binge eating or purging behaviors; corroborate with parent or relative; pattern of binge eating and compensatory actions - Vomiting (often without much effort) - Binging
- Hard aerobic exercise - Anxiety or guilt about losing control - A depressed mood and low self-esteem after binges - additional indications and symptoms - Asking for assistance with weight loss and being mildly underweight to overweight - Using/abusing diet pills, diuretics, laxatives, ipecac, and thyroid medications - Menstrual irregularities or amenorrhea - Fatigue and sluggishness - Abdominal pain, bloating, constipation, diarrhea, and rectal prolapse - A sore throat and heat sensitivity in the teeth
- Under- or omitted insulin doses in diabetic patients
Screening: Do you currently have an eating disorder or have you ever had one in the past? (Yes, that's unusual.) - Has anyone in your family battled an eating disorder? (Yes, that's unusual.) How do you feel about yourself in relation to your weight? (Yes, that's unusual.) Do you ever sneak a bite to eat? (Yes, that's unusual.)
- Do your eating habits make you happy? (No is unusual.) 


clinical assessment 
Tachycardia, dental enamel erosion, perimylolysis, cheilosis, gingivitis, sialadenosis (parotid gland swelling and/or asymptomatic, noninflammatory parotid gland enlargement), epigastric tenderness to palpation, calluses, abrasions, and bruising on the hand and thumb (Russell sign), peripheral edema, and often normal with normal weight or overweight range

Multiple Diagnoses 
Major depressive disorder, a kind of anorexia characterized by binge eating and purging, as well as other metabolic illnesses such Addison disease, celiac disease, diabetes mellitus, hyperthyroidism, hypothyroidism, and hyperpituitarism. 
Kleine-Levin syndrome, Prader-Willi syndrome, body dysmorphic disorder, and borderline personality disorder are examples of genetic syndromes.


Diagnostic and Laboratory Tests
All lab results can fall within normal ranges and not be required for a diagnosis.
Although psychological self-report screening tests may be useful, the DSM-5 criteria must be met for diagnosis:
Primary Care Evaluation of Mental Disorders SCOFF Questionnaire Health Questionnaire for Patients Complete blood count, complete metabolic panel, and liver function tests are the initial diagnostics (lab and imaging). - Low levels of potassium, chloride, magnesium, sodium, calcium, phosphate, and glucose - Serum amylase concentrations and pH imbalances
High blood urea nitrogen levels
Increased urine specific gravity following a urinalysis 

Electrocardiogram: bradycardia or arrhythmias, conduction abnormalities, depressed ST segment due to hypokalemia, pregnancy test, diagnostic procedures/other 

Treatment 
First-line treatments should include dietary rehabilitation and cognitive-behavioral therapy (CBT).

General Strategy 

 Multidisciplinary team, including a primary care doctor, a mental health professional, and a nutritionist 
Increase incentive for change by increasing trust.
Evaluate your nutritional and psychological health.
Take into account evidence-based self-help programs.
CBT for bulimia nervosa: 20 sessions of 45 to 50 minutes each over a 16-week period
- Involve the patient in deciding on the goals.
- Self-monitoring of eating habits, frequency of binges and purges, associated causes, effects, thoughts, and feelings - Self-monitoring of weight once per week - Education of the dangers of purging for weight loss.
- Create a prescribed food plan to establish dependable eating patterns and a reasonable weight target.
- Substitute feared foods into your diet gradually and confront your fear of losing control.
- Find solutions for dealing with triggers.
- Reduce thoughts that involve calories, weight, and purging.
- Create a strategy for preventing relapses.
- Gradual cessation of laxative use

Family treatment for teenagers; Dialectical behavior therapy; Interpersonal therapy (may act more slowly than CBT); Transdiagnostic CBT; Nutritional education; Relaxation techniques 
Inform the patient to rinse their mouth with baking soda and wash their teeth after vomiting.

The First Line of Medicine
SSRIs, especially fluoxetine (Prozac) titrated to 60 mg/day, are beneficial in lowering symptoms with only a few side effects. For depression, higher doses than usual are frequently required.
- It has been demonstrated that using CBT in addition to medication provides additional benefits over using either one by itself.
– Keep taking the recommended dosage for at least 6 to 12 months (9).
– Bupropion should be avoided since it is contraindicated in people who purge and is linked to seizures 
If there is no improvement after treatment, individuals could vomit drugs.
Next Line
Choose an alternative SSRI (such as sertraline, fluvoxamine, or citalopram).
Taking 4 to 8 mg of ondansetron (Zofran) TID between meals can aid in preventing nausea.
When first- and second-line treatments fail, third-line medications are available but are rarely employed because of their negative effect profiles.
Topiramate, an anticonvulsant, may be helpful in reducing binge-purge episodes in bulimic individuals.


Motives for the Referral 
Bulimic patients need a multidisciplinary team that consists of a primary care doctor, a behavioral health professional, and a nutritionist. Arranging for psychotherapy with a mental health professional is a crucial component of treatment.


Furthermore Treated 
Bright light therapy has the potential to be extremely useful in treating mood and disordered eating.

Admission
One or more of the following situations warrant admission (if one is available) to a specialized eating disorders unit: - A median BMI for age and sex of 75%
- Electrolyte disturbances such as hypokalemia, hyponatremia, and hypophosphatemia; dehydration - Anomalies in the ECG, such as a prolonged QTc or severe bradycardia
Extreme bradycardia (daytime: 50 bpm; nighttime: 45 bpm) with hypotension (90/45 mm Hg)
- Hypothermia (body temperature less than 96°F, or 35.6°C)
- Orthostatic hypertension (>20 mm Hg systolic or >10 mm Hg diastolic) or an increase in pulse rate (>20 beats per minute). Acute medical problems of malnutrition, such as syncope, seizures, heart failure, and pancreatitis, include acute food rejection, uncontrollable bingeing, and failure of outpatient treatment. - A coexisting mental health or medical illness that prevents or restricts the use of suitable outpatient treatment, such as type 1 diabetes, severe depression, suicidal ideation, or obsessive compulsive disorder. 
During admission, the following will be observed: - Supervised meals and restroom access - Weight, physical activity, electrolytes, and heart activity.
- Gradually hand over authority to patients as they show signs of progress.

Patient Follow-Up Monitoring
Self-esteem, contentment with one's body and self, ruminations, and depressive symptoms Binge-purge activity, including causes and effects, degree of exercise 
Repeat any abnormal lab results every week until they become stable.

A balanced diet and a regular eating schedule are essential for nutrition, and nutritional rehabilitation seeks to reestablish these: Daily meals and snacks consist of three.

The prognosis is that between 45-70% of patients will fully recover or see an improvement in their symptoms, whereas between 20 and 30% may return.
Younger age at presentation, shorter illness duration, fewer symptoms per episode, lack of laxative use, close social relationships, and a good therapeutic response within the first month of treatment are positive prognostic factors. Negative prognostic factors include an excessive focus on body shape and weight, a history of physical abuse, disturbed family relationships, poor motivation, self-injurious behaviors, and the presence of a personality disorder.

Complications include: Substance use disorder; Osteopenia/Osteoporosis/Stress fracture; Gastric dilatation/Boerhaave syndrome/Mallory-Weiss tears; Spontaneous pneumomediastinum; Potassium depletion, Cardiac Arrhythmia, and Cardiovascular Arrest; Suicide. Pregnancy Considerations include: Binging/purging behaviors may persist, increase, or decrease with pregnancy;