Bulimia: diagnosis and management in the primary care setting

Bulimia is an eating disorder characterized by episodic, uncontrollable overeating and frequently by purging after binges. It appears to afflict approximately 5 percent of female college students in the United States. Most sufferers are high-achieving but passive and unassertive young women from similarly high-achieving but disorganized families. Confusion over social roles for women is common in bulimic patients. Bulimia shows a strong association with affective disorders; depression is common in both bulimic patients and their close family members. Bulimic patients seem to have a pronounced affective vulnerability to rejection, loss, and failure. Bulimia presents a special diagnostic challenge to the primary care physician because of the paucity of clues provided by a typical review of systems and a physical examination, even a very thorough one. Making the diagnosis requires persistent and thorough history-gathering and is best accomplished through special attention to the psychosocial history (particularly history of depression and substance abuse, family dynamics, and recent stressors) as well as pointed questioning regarding eating behavior. Because of the severe, potentially lethal complications that may attend bulimia (including fluid and electrolyte imbalance, cardiac conduction abnormalities, gastric rupture, pneumonia), diagnosis and appropriate referral by the primary care physician may have a critical impact on the patient's life and health.