A 27-year-old woman is brought to the emergency department after fainting at home. The patient is an avid runner and follows a strict diet and exercise regimen. She has been on a special juice fast and is training for a marathon with her husband. The patient describes feeling "out of control" and has periods during which she craves sweet foods and eats "everything in sight"; afterward, she feels depressed and guilty and tries to compensate by fasting and running an additional 5 miles the next day. She breaks down in tears and says she is afraid that her husband will leave her because of her "disgusting body." Review of systems is unremarkable except for menstrual irregularity. Temperature is 37 C (98.6 F), blood pressure is 98/62 mm Hg, pulse is 96/min, and respirations are 14/min. BMI is 20 kg/m². Physical examination is unremarkable. Which of the following is the most likely diagnosis for this patient?

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11ec25c8_d7ae_3d4f_bc81_b55243704cde_MD0003_00 This patient's preoccupation with body shape and recurrent eating binges followed by fasting and excessive exercise are suggestive of bulimia nervosa. Loss of control during binges, followed by feelings of disgust, guilt, and depression, is common. Although patients with bulimia nervosa often engage in self-induced vomiting, this symptom is not necessary for the diagnosis. Other compensatory behaviors include fasting, excessive exercise (as in this patient), and misuse of laxatives, enemas, diuretics, and diet pills. Binges and inappropriate compensatory behaviors must occur at least once a week for 3 months for the diagnosis. In contrast to individuals with anorexia nervosa, patients with bulimia nervosa are normal weight to overweight. Signs of bulimia nervosa may include hypotension, tachycardia, dry skin, and menstrual irregularities. Electrolyte abnormalities (eg, hypokalemia, hypochloremia, metabolic alkalosis), erosion of dental enamel, and parotid hypertrophy can be seen in patients who vomit regularly. Treatment consists of nutritional rehabilitation, cognitive-behavioral therapy, and pharmacotherapy with fluoxetine. (Choice A) Anorexia nervosa may also involve binge eating and compensatory behavior (binge eating/purging subtype of anorexia). The key distinction is body weight. Patients with bulimia nervosa have normal to increased weight, whereas those with anorexia nervosa generally have a BMI of ≤18.5 kg/m². This patient's BMI (20 kg/m²) is within normal range. (Choice B) Avoidant/restrictive food intake disorder typically begins in infancy or early childhood and is characterized by food avoidance due to dislike of the sensory components of certain foods or the experience of eating. (Choice C) Binge eating disorder is characterized by recurrent episodes of binge eating but does not include the inappropriate compensatory behaviors seen in bulimia nervosa. (Choice D) Body dysmorphic disorder is characterized by intense preoccupation with a perceived defect (or defects) in physical appearance. It would not be diagnosed in an individual preoccupied with weight gain who meets the criteria for an eating disorder. Educational objective: Bulimia nervosa involves recurrent binge eating and compensatory behaviors. In contrast to patients with anorexia nervosa, those with bulimia nervosa are normal weight to overweight. References: Medical complications of anorexia nervosa and bulimia. (http://www.ncbi.nlm.nih.gov/pubmed/26169883) Epidemiology, course, and outcome of eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/24060914) Bulimia nervosa-nonpurging subtype: closer to the bulimia nervosa-purging subtype or to binge eating disorder? (http://www.ncbi.nlm.nih.gov/pubmed/24282157)

A 27-Year-Old Woman Is Brought to the Emergency Department After