Bulima

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
zenman

zenman

Senior Member
7+ Year Member
15+ Year Member
Joined
Apr 1, 2004
Messages
2,180
Reaction score
16
What's the latest on meds for bulima? Picked up a lady today, nonpurging type, who was on Wellbutrin SR 150mg 3 tabs qam and Celexa 40mg. Probably was placed on Wellbutrin due to hypersomnia 10-12 hrs sleep per night plus 1-2 hrs daytime napping. I'm stopping Celaxa and going with Prozac and debating on whether to go down on the Wellbutrin, especially since it's not helping with her depression and due to sz risk.
Members don't see this ad.
 
Wellbutrin is contraindicated in bulimics. The cases of seizures with WBT originally were all bulimics.

Prozac is the preferred SSRI (best evidence base)
 
nitemagi said:
Wellbutrin is contraindicated in bulimics. The cases of seizures with WBT originally were all bulimics.

Prozac is the preferred SSRI (best evidence base)
Click to expand...

...at very high doses of IR, and with electroyle abnormalities.

For a non-purging type, I'd make a clinical risk-benefit judgment about it, though admittedly there's probably not much clinical benefit of being above 200 mg SR bid. And I'd r/o sleep apnea and get her exercising and doing CBT before I'd look for too much more from meds.
 
Members don't see this ad :)
OldPsychDoc said:
...at very high doses of IR, and with electroyle abnormalities.

For a non-purging type, I'd make a clinical risk-benefit judgment about it, though admittedly there's probably not much clinical benefit of being above 200 mg SR bid. And I'd r/o sleep apnea and get her exercising and doing CBT before I'd look for too much more from meds.
Click to expand...

Good call. Overlooked the non-purging type in the OP.

In purging type, the RCT cited involved pt's at doses of 300-375mg, so not really that high of a dose --
http://www.ncbi.nlm.nih.gov/pubmed/20302998
(citing)
http://www.ncbi.nlm.nih.gov/pubmed/3134343
 
Anyone have any success with Naltrexone in bulimics? Thanks for the sleep study suggestion.
 
What's the pt's goal?
How high is her motivation?
If we could somehow magically pay for a trainer and daily nutrition class and daily CBT (3 hrs treatment and 5hrs homework per day, would she do it?
I'm not saying treatment has to be contingent on that, but I think it helps to have very clear goals and know how much she is willing to sacrifice for those goals.

Once you and she know that, you can be clearer with each other about what meds can achieve.

I know. Not much help re: what meds to pick. I just don't want to portray to students/residents that a tx plan starts by picking a medicine.
 
How can someone be a non-purging non-exercising person who sleeps up to 14 hours a day and still qualify as bulimic? Can you describe the case in more detail? Is she an exerciser? And if so by what mechanism could naltrexone (or any medication) be hypothesized to work?

Is laxative abuse the issue? In that case can you definitely give us more info because there are medical complications to laxative abuse. If people are worried about electrolyte imbalances in purging-type bulimia (which I thought was the rationale for the sz issue with Wellbutrin) then shouldn't laxative abuse, if it's significant, raise the same concerns? I mean, if there is an actual physiologic basis for the Wellbutrin issue?

And, by the way, how does Naltrexone actually work? My understanding was that in EtOH dependence it helped people most who had family histories and who craved alcohol. But who has a family history of bulimia? I know it's used--but my question is, what's the mechanism of action? And could this be extended to laxative "abuse" which is unlike alcohol abuse in that it's not hereditary and it's victims don't "crave" it? Of course, I don't know what kind of bulimia your patient really has...
 
kugel said:
What's the pt's goal?
How high is her motivation?
If we could somehow magically pay for a trainer and daily nutrition class and daily CBT (3 hrs treatment and 5hrs homework per day, would she do it?
I'm not saying treatment has to be contingent on that, but I think it helps to have very clear goals and know how much she is willing to sacrifice for those goals.

Once you and she know that, you can be clearer with each other about what meds can achieve.

I know. Not much help re: what meds to pick. I just don't want to portray to students/residents that a tx plan starts by picking a medicine.
Click to expand...

Understand but she's been in therapy and on meds for years, starting in 2005. Her primary goal right now is to lose 50 pounds before she is kicked out of the military. She exercises but not to excess. No binging but did in the past. Probably more appropriate to label her Binge Eating Disorder plus MDD. Just reviewed her chart and looks like she may be OCD/OCPD also. Just getting her back from deployment. She was to be seen by another provider but they were out sick. Lucky me.😀
 
nancysinatra said:
How can someone be a non-purging non-exercising person who sleeps up to 14 hours a day and still qualify as bulimic? Can you describe the case in more detail? Is she an exerciser? And if so by what mechanism could naltrexone (or any medication) be hypothesized to work?

Is laxative abuse the issue? In that case can you definitely give us more info because there are medical complications to laxative abuse. If people are worried about electrolyte imbalances in purging-type bulimia (which I thought was the rationale for the sz issue with Wellbutrin) then shouldn't laxative abuse, if it's significant, raise the same concerns? I mean, if there is an actual physiologic basis for the Wellbutrin issue?

And, by the way, how does Naltrexone actually work? My understanding was that in EtOH dependence it helped people most who had family histories and who craved alcohol. But who has a family history of bulimia? I know it's used--but my question is, what's the mechanism of action? And could this be extended to laxative "abuse" which is unlike alcohol abuse in that it's not hereditary and it's victims don't "crave" it? Of course, I don't know what kind of bulimia your patient really has...
Click to expand...

She denies purging, laxatives, exercising to excess. This might help:

Neuropsychopharmacology. 2012 Nov;37(12):2593-604. doi: 10.1038/npp.2012.89. Epub 2012 Jun 20.
Antagonism of sigma-1 receptors blocks compulsive-like eating.
Cottone P, Wang X, Park JW, Valenza M, Blasio A, Kwak J, Iyer MR, Steardo L, Rice KC, Hayashi T, Sabino V.
SourceLaboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, USA. [email protected]

Abstract
Binge eating disorder is an addiction-like disorder characterized by episodes of rapid and excessive food consumption within discrete periods of time which occur compulsively despite negative consequences. This study was aimed at determining whether antagonism of Sigma-1 receptors (Sig-1Rs) blocked compulsive-like binge eating. We trained male wistar rats to obtain a sugary, highly palatable diet (Palatable group) or a regular chow diet (Chow control group), for 1 h a day under fixed ratio 1 operant conditioning. Following intake stabilization, we evaluated the effects of the selective Sig-1R antagonist BD-1063 on food responding. Using a light/dark conflict test, we also tested whether BD-1063 could block the time spent and the food eaten in an aversive, open compartment, where the palatable diet was offered. Furthermore, we measured Sig-1R mRNA and protein expression in several brain areas of the two groups, 24 h after the last binge session. Palatable rats rapidly developed binge-like eating, escalating the 1 h intake by four times, and doubling the eating rate and the regularity of food responding, compared to Chow rats. BD-1063 dose-dependently reduced binge-like eating and the regularity of food responding, and blocked the increased eating rate in Palatable rats. In the light/dark conflict test, BD-1063 antagonized the increased time spent in the aversive compartment and the increased intake of the palatable diet, without affecting motor activity. Finally, Palatable rats showed reduced Sig-1R mRNA expression in prefrontal and anterior cingulate cortices, and a two-fold increase in Sig-1R protein expression in anterior cingulate cortex compared to control Chow rats. These findings suggest that the Sig-1R system may contribute to the neurobiological adaptations driving compulsive-like eating, opening new avenues of investigation towards pharmacologically treating binge eating disorder.
 
billypilgrim37 said:
Compensatory behavior for a lot of bulimics is simply restricting. Criterion B is pretty loosey goosey.

Sent from my DROID RAZR using SDN Mobile
Click to expand...

Ah, I see. And I was incorrect about the meaning of "purging" -- it includes exercise, laxatives, everything!

Ok I have a philosophical question for the people who wrote the DSM-IV and made it possible to even have "non-purging" subtype bulimia. How can you maintain bulimia when all you do is binge but never purge? Binging at 3x/week for 3 months or more, even if the person fasts religiously the rest of the time, the result will be, at best, homeostatis. It WON'T be weight loss. And the goal of any bulimic is to lose weight, is it not? Isn't that the psychological motivation which is rooted in the disturbed body image? Whereas the binge eater is the person who drowns their sorrows in food and might regret being fat but doesn't have the same disturbed body image?

And what is restricting? Is it eating one calorie less than the metabolically needed amount to maintain a normal BMI or is it eating nothing? See that's a huge caloric range in between which would fit your binge eater and your bulimic. So again mere caloric intake is not enough to distinguish these two diagnoses.

For "distorted body image" to occur, the person must be normal weight or slightly below normal weight, correct? If the person is huge, then their perception that they are overweight is not a distortion. The realization may not be a pleasant one, but it is an accurate one. Therefore isn't it considered a hallmark of bulimia the "normal weight" or slightly underweight criteria?

Plus I thought a major reason we paid attention to bulimia in the first place was its medical complications. Those complications apply only to the purging type. Non purgers don't have to worry about low k+ or esophageal or gastric rupture.
 
zenman said:
She denies purging, laxatives, exercising to excess. This might help:

Neuropsychopharmacology. 2012 Nov;37(12):2593-604. doi: 10.1038/npp.2012.89. Epub 2012 Jun 20.
Antagonism of sigma-1 receptors blocks compulsive-like eating.
Cottone P, Wang X, Park JW, Valenza M, Blasio A, Kwak J, Iyer MR, Steardo L, Rice KC, Hayashi T, Sabino V.
SourceLaboratory of Addictive Disorders, Departments of Pharmacology and Psychiatry, Boston University School of Medicine, Boston, MA, USA. [email protected]

Abstract
Binge eating disorder is an addiction-like disorder characterized by episodes of rapid and excessive food consumption within discrete periods of time which occur compulsively despite negative consequences. This study was aimed at determining whether antagonism of Sigma-1 receptors (Sig-1Rs) blocked compulsive-like binge eating. We trained male wistar rats to obtain a sugary, highly palatable diet (Palatable group) or a regular chow diet (Chow control group), for 1 h a day under fixed ratio 1 operant conditioning. Following intake stabilization, we evaluated the effects of the selective Sig-1R antagonist BD-1063 on food responding. Using a light/dark conflict test, we also tested whether BD-1063 could block the time spent and the food eaten in an aversive, open compartment, where the palatable diet was offered. Furthermore, we measured Sig-1R mRNA and protein expression in several brain areas of the two groups, 24 h after the last binge session. Palatable rats rapidly developed binge-like eating, escalating the 1 h intake by four times, and doubling the eating rate and the regularity of food responding, compared to Chow rats. BD-1063 dose-dependently reduced binge-like eating and the regularity of food responding, and blocked the increased eating rate in Palatable rats. In the light/dark conflict test, BD-1063 antagonized the increased time spent in the aversive compartment and the increased intake of the palatable diet, without affecting motor activity. Finally, Palatable rats showed reduced Sig-1R mRNA expression in prefrontal and anterior cingulate cortices, and a two-fold increase in Sig-1R protein expression in anterior cingulate cortex compared to control Chow rats. These findings suggest that the Sig-1R system may contribute to the neurobiological adaptations driving compulsive-like eating, opening new avenues of investigation towards pharmacologically treating binge eating disorder.
Click to expand...

Thanks zenman!

See this actually helps with what I'm trying to ask here--in binge eating specifically, the binging is being conceptualized as "an addiction like disorder." That certainly seems reasonable.

But would anyone conceptualize the binging in classic, purging type bulimia in this manner? If you do that, then wouldn't you also have to apply the same conceptualization to anorexia nervosa binge-purge subtype? In essence you'd be calling all eating disorders (except pure restricting anorexia) addictive disorders. And most bulimics hate binging and purging. It's the body image distortion and the physiological effects of binging and purging that propel the cycle. Has Naltrexone been studied in that context?
 
zenman said:
Understand but she's been in therapy and on meds for years, starting in 2005. Her primary goal right now is to lose 50 pounds before she is kicked out of the military. She exercises but not to excess. No binging but did in the past. Probably more appropriate to label her Binge Eating Disorder plus MDD. Just reviewed her chart and looks like she may be OCD/OCPD also. Just getting her back from deployment. She was to be seen by another provider but they were out sick. Lucky me.😀
Click to expand...

I'm a tad confused--she does sound more binge eating than bulimic off the bat, but if she's not binging AND she's not purging, then what are the current behaviors that concern you? What is her BMI? Is her problem at the moment just obesity? For that--I don't think anyone knows...
 
nancysinatra said:
I'm a tad confused--she does sound more binge eating than bulimic off the bat, but if she's not binging AND she's not purging, then what are the current behaviors that concern you? What is her BMI? Is her problem at the moment just obesity? For that--I don't think anyone knows...
Click to expand...

Binging is her main concern as she needs to drop weight to stay in the military. My concern now is probable OCD/OCPD...at least in terms of treatment success.
 
zenman said:
Binging is her main concern as she needs to drop weight to stay in the military. My concern now is probable OCD/OCPD...at least in terms of treatment success.
Click to expand...

But you said she binged in the past, so I assumed she's not binging in the present?

Why are you saying OCD/OCPD? They are very different...
 
nancysinatra said:
For "distorted body image" to occur, the person must be normal weight or slightly below normal weight, correct?

Plus I thought a major reason we paid attention to bulimia in the first place was its medical complications. Those complications apply only to the purging type. Non purgers don't have to worry about low k+ or esophageal or gastric rupture.
Click to expand...


Correct me if I am wrong, but I do not believe there is anything in the DSM-IV about body image distortion specific to bulimia--more anorexia? Most bulimics are actually normal to slightly above weight. I agree that non-purgers do not have as much of a concern about the medical complications, but I don't think a lot of people would argue that binge eating alternating with periods of restrictions (possibly even fluid restriction) and/or exercise is exceptionally healthy. Moreover, in a patient with insight there's probably emotional distress either related to body image or that this is a disorder.

nancysinatra said:
Why are you saying OCD/OCPD? They are very different...
Click to expand...

They can be comorbid. I cannot pull articles up on my home computer, but I was looking at this the other day and found a few articles suggesting a 20-40% comorbidity as well as relationship between families of OCD vs OCPD. I kinda see a few loose similarities in diagnostic criteria and I've definitely had patients where I go back and fourth on whether its OCD vs OCPD as the driving force...often I pick the winner based on how much insight the patient has. For instance, hoarding, list writing, cleanliness, perfectionism and be obsessions/compulsions.


zenman said:
Binging is her main concern as she needs to drop weight to stay in the military.
Click to expand...

Note that bulimia--at least in some branches of service--can be a reason for writing a PEB (but not an ADSEP). A few reasons I am throwing this out there. First, if you think the health risks and mental health concerns are not something that will get better or service compatible its sometimes in everyone's best interest to not have someone in this environment that would require her to lose 50lbs in what I image will be a matter or months. Also a BCA failure would lead to an ADSEP, so if this is someone who has had a long career and she's about to get separated for a BCA failure anyway, you might want to look at the risks-benefits of just going straight for a PEB. I tend to let nature take its course, but just know this is might be an option. She'd probably fight it if she wants to stay in though.
 
SuperSoccer19 said:
Correct me if I am wrong, but I do not believe there is anything in the DSM-IV about body image distortion specific to bulimia--more anorexia? Most bulimics are actually normal to slightly above weight. I agree that non-purgers do not have as much of a concern about the medical complications, but I don't think a lot of people would argue that binge eating alternating with periods of restrictions (possibly even fluid restriction) and/or exercise is exceptionally healthy. Moreover, in a patient with insight there's probably emotional distress either related to body image or that this is a disorder.
Click to expand...

"D. Self-evaluation is unduly influenced by body shape and weight. "

This is only slightly different from the anorexia criteria... My understanding since medical school when I rotated at an eating d/o hospital is that this means "distortion" not just "influence." Although sure the hardcore restricter who's severely underweight is going to have a more distorted view

In any case my point wasn't really that a person who binges and then fasts wouldn't have psychological issues. Everyone who walks through the doors of a psychiatrist could be said to not be exceptionally healthy in an emotional sense and certainly no one walks out the door of a psychiatrist's office with a diagnosis of "emotionally healthy." My point was, what were the authors of the DSM thinking when they wrote the DSM section on bulimia? I think that's a perfectly fair question to ask, isn't it? Because I expect the authors of the DSM to do a good job. One single condition should not qualify as both binge eating (or EDNOS) AND bulimia. And being "not emotionally healthy" in and of itself is not enough for a diagnosis. I expect more than that, is what I'm trying to say.

SuperSoccer19 said:
They can be comorbid. I cannot pull articles up on my home computer, but I was looking at this the other day and found a few articles suggesting a 20-40% comorbidity as well as relationship between families of OCD vs OCPD. I kinda see a few loose similarities in diagnostic criteria and I've definitely had patients where I go back and fourth on whether its OCD vs OCPD as the driving force...often I pick the winner based on how much insight the patient has. For instance, hoarding, list writing, cleanliness, perfectionism and be obsessions/compulsions.
Click to expand...

Well ok but they're not always comorbid. Until otherwise stated by the OP I would assume they're not comorbid in this case, although I appreciate your point. However a lot of conditions can be comorbid, but a lot of workups can also just not be complete. For example, a person can have syncope that's caused by 2 things--i.e. orthostatic hypotension and vertigo, but if someone in the medicine forum wrote "my orthostatic/vertigo patient" people would rightly criticize them for not having narrowed their differential enough. If a condition is really caused by 2 things then the OP can explain that.
 
nancysinatra said:
But you said she binged in the past, so I assumed she's not binging in the present?

Why are you saying OCD/OCPD? They are very different...
Click to expand...

Sorry, meant purging in the past. Currently binging and not purging (according to her). Rigid, perfectionistic parents among other things so I don't as yet have a good handle on whether learned behavior, OCD or OCPD. Only seen her once so far.
 
You must log in or register to reply here.
Top