Bulimia nervosa

Bulimia nervosa (Bulimia nervosa)

1) Disease Description (Causes and Symptoms)

• Definition summary: An eating disorder characterized by recurrent binge eating (consuming a large amount of food in a short period and losing control) and repeated compensatory behaviors to prevent weight gain (self-induced vomiting, misuse of laxatives or diuretics, excessive exercise, etc.).
• Causes: Multifactorial (genetic vulnerability, abnormalities in the brain’s appetite and reward systems, psychosocial factors and stress, personality vulnerability and impulsivity, coexisting anxiety, depression, substance use, etc.). There is no known single exact cause.
• Pathophysiology (briefly): Abnormalities in neural circuits related to reward and impulse control (the reward and inhibition systems), along with stress and emotional regulation problems, create a vicious cycle of binge eating → anxiety/shame → compensatory behaviors (such as vomiting).
• Main symptoms:
  • Recurrent binge eating (a feeling of loss of control)
  • Weight gain is the primary concern, but actual body weight is often within the normal range
  • Compensatory behaviors: self-induced vomiting, misuse of laxatives, enemas, or diuretics, excessive exercise, etc.
  • Physical symptoms: abdominal pain, vomiting, dental erosion and periodontal disease, throat and esophageal injury, dehydration and electrolyte abnormalities (such as hypokalemia), and possible arrhythmia
  • Psychiatric comorbidities: depression, anxiety, impulse-control disorders, substance use disorder, etc.

2) Treatment Methods and Precautions

• Standard treatment
  • Psychotherapy: Cognitive behavioral therapy (CBT-E, a targeted therapy addressing binge eating and compensatory behaviors) is the first-line recommended treatment. Alternative approaches such as interpersonal therapy (IPT) are also used.
  • Nutritional treatment: A structured meal plan with a dietitian (regular meals and snacks), nutrition education, and management of weight and eating patterns.
  • Pharmacological treatment: SSRIs (particularly high-dose fluoxetine (e.g., 60 mg/day), for which there is evidence of reducing clinical symptoms). Other antidepressants and anticonvulsants (e.g., topiramate) have been reported to be effective in some patients, but side effects should be considered.
  • Combined treatment: Psychotherapy + nutritional management + medication when necessary is recommended.
• Indications for intensive inpatient admission
  • Severe electrolyte abnormalities (e.g., severe hypokalemia), arrhythmia, severe dehydration, suspected bleeding or perforation due to repeated vomiting, high risk of self-harm or suicide, or severe weight loss and functional decline that cannot be controlled in an outpatient setting.
• Lifestyle management and self-care precautions
  • Eat regular meals (do not skip meals), avoid situations and temptations that trigger binge eating, and practice alternative strategies (delay and coping techniques) for purging behaviors (vomiting and laxative use)
  • Do not brush your teeth immediately after vomiting (to prevent enamel damage); rinsing with water or using a fluoride solution is recommended
  • Stop misuse of laxatives, diuretics, and enemas; medical supervision is necessary when discontinuing them gradually
  • Exercise management: Avoid excessive exercise (follow the amount recommended by your doctor)
• Complications (points to watch)
  • Electrolyte imbalance (such as hypokalemia) → risk of arrhythmia and cardiac arrest
  • Esophageal mucosal injury, Mallory–Weiss tear (bleeding caused by vomiting), and gastrointestinal perforation (rare but severe)
  • Dental erosion and caries, oral and throat injury
  • Pancreatitis, renal failure, and chronic constipation (after laxative misuse)
  • Increased suicide risk and possible coexisting psychopathology
• Prognosis: Some cases resolve spontaneously, but recurrence is possible. Without treatment, long-term deterioration may occur; with treatment, improvement has been reported in approximately half of patients. Ongoing follow-up and relapse management are necessary.

3) Checklist Before an Outpatient Visit (Including Preparation Materials and Example Questions)

• Materials to bring
  • A list of all medications, supplements, and herbal medicines currently being taken (name, dose, and time of administration)
  • Recent weight and records of weight changes (dates and measurements, if possible)
  • Records of the frequency of binge eating and purging (vomiting, laxative use, diuretic use, and exercise) (covering the most recent 1 week to 1 month)
  • When symptoms began and triggering factors (stress, eating patterns, etc.)
  • Copies of previous test results (blood tests, ECG, hospitalization records, etc.), if available
  • Psychiatric treatment and medication history and family history (depression, eating disorders, etc.)
  • A record of any recent suicidal thoughts or self-harm ( 반드시 inform the doctor)
• Materials that can be shown to the doctor during the outpatient visit
  • A food and mood diary (brief daily notes), recent photographs (helpful for explaining physical changes)
• Basic tests to undergo before the outpatient visit (follow the doctor’s recommendations)
  • Blood tests: electrolytes (especially K+ and Na+), renal and liver function, blood glucose, and CBC
  • ECG (assessment of the risk of electrolyte abnormalities and arrhythmia)
  • Dental evaluation, abdominal imaging, or endoscopy if necessary (when bleeding or perforation is suspected)
• Questions useful to ask during the outpatient visit (for preparation)
  • “Is the frequency of binge eating and vomiting that I have recorded at a dangerous level?”
  • “What tests do I need (blood tests and ECG), and depending on the results, when would I need to be hospitalized?”

4) Examples of General Questions to Ask the Doctor

• What are the common and serious side effects of this medication (the recommended medication)?
• What is the expected prognosis in my case? How long will treatment take, and how high is the risk of relapse?
• What should I pay particular attention to in daily life (eating, exercise, work, and interpersonal relationships)?
• What are the criteria for requiring inpatient treatment?

5) Examples of Disease-Specific Questions

• How will you monitor and manage electrolyte abnormalities and cardiac (arrhythmia) risks caused by vomiting and laxative use?
• I have dental and oral damage caused by vomiting. When and how should I receive dental treatment or preventive measures?

(If necessary, printing or making notes of the questions above and reviewing them with the doctor during the visit can make the consultation more efficient.)

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Caution: This information is general medical information. Diagnosis and treatment must be determined through consultation with a medical specialist.