A 30-year-old woman comes to the office due to concerns about her weight despite losing 10.9 kg (24 lb) in the past 6 months. She says, "I still feel very unattractive and I am afraid that my weight problems are destroying my marriage." During the past 5 years, the patient has had wide fluctuations in her weight, and at one point weighed 104.3 kg (230 lb) . Much of this weight gain occurred surrounding her 2 pregnancies, the last being over 2 years ago. She is typically home all day caring for the children. At times the patient will consume large quantities of food, only to vomit intentionally before her husband returns from work. On weekends when her husband is home, she avoids this behavior and instead reduces her food consumption dramatically. She becomes anxious if her husband returns home early for fear that he will witness her overeating or vomiting. The patient is angry at her husband and also at herself for not having better control of her life. She denies feelings of depression or hopelessness but does feel overwhelmed.
On examination, the patient's vital signs are within normal limits. BMI is 25.3 kg/m².
In addition to psychotherapy, which of the following is the most appropriate management for this patient?

Question

Quizplus · Accepted Answer

11ec193a_98ac_50e9_853d_dfe721d9a25e_MD0002_00 Recurrent binge eating with subsequent self-induced vomiting and caloric restriction to prevent weight gain are consistent with bulimia nervosa (BN). Unlike in anorexia nervosa, the patient's weight is usually within or above the normal range. Contributing factors in BN include interpersonal stressors (eg, conflicts or tension in social relationships) and feelings of dysphoria and poor self-esteem related to body image. The mainstay of treatment for BN is a combination of nutritional rehabilitation (establishing a structured and consistent meal pattern), cognitive-behavioral therapy, and selective serotonin reuptake inhibitors. Among antidepressants, fluoxetine has the best evidence. Studies have shown that the combination of therapies is better than any component alone. However, if nutritional rehabilitation and psychotherapy are not available, pharmacotherapy alone has been found to be effective. (Choice A) Bupropion is contraindicated in patients with eating disorders due to the risk of seizures. (Choice C) Pharmacotherapy is effective for the behavioral and cognitive symptoms of BN and is considered a first-line treatment. (Choice D) Although nutritional education is helpful to teach patients about proper nutrition, education alone is unlikely to stop the cycle of bingeing and purging. Full nutritional rehabilitation involves structured meal planning and monitoring. (Choice E) Olanzapine is used as an adjunctive treatment in anorexia nervosa and can help these patients establish a healthier weight. However, antipsychotics are generally not indicated for patients with BN in the absence of psychotic symptoms. Educational objective: Selective serotonin reuptake inhibitors, particularly fluoxetine, have been shown to be effective in reducing bingeing and purging in patients with bulimia nervosa. __________ References: Evidence-based pharmacotherapy of eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/21414249) Biological therapies for eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23658094)

A 30-Year-Old Woman Comes to the Office Due to Concerns