A 21-year-old woman is referred for evaluation of sleep and appetite disturbance. The patient is a college senior who initially went to student health services following a romantic breakup a week ago. Her sleep has returned to normal, but "my eating is still out of control." The patient has been eating entire containers of ice cream and bags of cookies and chips. She says, "I'm sure one of the reasons he dumped me was because of my weight and disgusting body." The patient acknowledges that, throughout college, she has had a pattern of eating very large amounts of food several times a week and daily while preparing for final exams. She does not vomit but takes laxatives and exercises for several hours after one of these eating episodes. The patient has no medical issues but reports that her menstrual cycle is irregular. Her older sister has a history of anorexia nervosa.
Temperature is 37 C (98.6 F) , blood pressure is 108/62 mm Hg, pulse is 88/min, and respirations are 14/min. BMI is 21 kg/m². Physical examination is unremarkable. Pregnancy test is negative.
Which of the following is the most likely diagnosis?

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11ec193a_98bb_e156_853d_4d745f719e53_MD0002_00 This patient's recurrent pattern of binge eating, inappropriate compensatory behavior (excessive exercise, laxatives), and excessive preoccupation with weight and body shape suggest a diagnosis of bulimia nervosa. Patients with bulimia nervosa typically consume large amounts of food in a very short time and experience a sense of "loss of control." Self-induced vomiting is the most common compensatory behavior in bulimia nervosa and may cause electrolyte abnormalities (eg, hypokalemia, hypochloremia, metabolic alkalosis), erosion of dental enamel, and parotid hypertrophy. However, some patients engage in misuse of laxatives, enemas, diuretics, diet pills, fasting, or excessive exercise to control their weight. Binge-eating disorder also involves repetitive episodes of binge eating but does not include the inappropriate compensatory behaviors seen in bulimia nervosa (Choice C). (Choice A) Although this patient's binges and compensatory behaviors have likely intensified following the stress of her breakup, her disordered eating pattern has been going on for several years. An adjustment disorder is not diagnosed when the disturbance is explained by another disorder. (Choice B) Patients with the binge-eating/purging subtype of anorexia may also engage in binge eating and compensatory behavior. The key distinction is body weight. Patients with bulimia nervosa have normal to increased weight; those with anorexia nervosa have significantly low body weight (generally considered to be BMI <18.5 kg/m²). This patient's BMI of 21 kg/m² is within the normal range. ² ² (Choice D) Body dysmorphic disorder is characterized by intense preoccupation with a perceived defect in physical appearance. It is not diagnosed in an individual whose preoccupation with appearance is better explained by concerns about weight and who meets criteria for an eating disorder. Educational objective: Bulimia nervosa is characterized by excessive preoccupation with weight and recurrent episodes of binge eating and compensatory behaviors that include self-induced vomiting, laxative abuse, fasting, and excessive exercise. Patients are normal to overweight in contrast to the low weight seen in those with anorexia nervosa. __________ References: Eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27319605) Classification of eating disorders: comparison of relative prevalence rates using DSM-IV and DSM-5 criteria. (http://www.ncbi.nlm.nih.gov/pubmed/25745131) Binge-eating disorder and comorbid conditions: differential diagnosis and implications for treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28125173)

A 21-Year-Old Woman Is Referred for Evaluation of Sleep and Appetite