Review Question - QID 100036

Physical exam findings of multiple dental carries and calluses on the dorsum of the hand suggest repeated episodes of self-induced vomiting. In a patient with a decreased BMI this is consistent with anorexia nervosa - purging type.

There are two major types of eating disorders: anorexia nervosa and bulimia nervosa. For bulimia nervosa, purging and restrictive types are no longer classifications per the DSM-V. For anorexia nervosa, the restrictive type differs from purging type in that the former primarily consists of strict dietary restrictions, while the latter may include self-induced vomiting, laxative use, or excessive exercise. Having been diagnosed with one eating disorder in the past does not preclude diagnosis of an alternate disorder in the future. A major distinguishing characteristic between anorexia and bulimia is that in anorexia, the BMI must be less than 17.5 with or without amenorrhea.

Williams et al. describe the diagnosis and treatment of eating disorders in outpatients. The authors note that lifetime prevalence estimates for anorexia nervosa and bulimia nervosa are 0.6 and 1.0 percent, respectively, with the risk up to threefold higher in women than men. The median age of onset is 18 to 21 years.

Bacaltchuk et al. published a Cochrane review of all RCTs comparing antidepressants with psychological approaches or comparing their combination with each single approach for the treatment of bulimia nervosa. The authors conclude that combination treatments were superior to single psychotherapy. Interestingly, psychotherapy appeared to be more acceptable to subjects.

Illustration A shows Russel's sign which is the presence of calluses on the dorsum of the hand resulting from repeated episodes of self-induced vomiting.

Incorrect Answers:
Answers 1: The restrictive type of anorexia nervosa would not be associated with what seems like purging behavior or self-induced vomiting. A better diagnosis is the purging type.
Answer 3: Bulimia nervosa is more consistent with patients that have normal or elevated BMI who exhibit signs of purging. The BMI is key to making a diagnosis. Bulimia nervosa is no longer subdivided into purging and restrictive type.
Answer 4: Obsessive compulsive disorder is associated with patients who have repetitive or ritualistic behaviors that relieve their anxiety related to something. For example a patient that washes their hands excessively due to a fear of germs. SSRI's and behavioral therapy are important treatment modalities to be aware of.
Answer 5: The diagnosis of ED-NOS is reserved for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include individuals who meet criteria for bulimia nervosa EXCEPT that frequency of symptoms is less than twice a week or for less than three months' duration.