A 26-year-old woman comes to the office due to recent weight gain. She has eaten more than usual over the last 5 months, has gained 3.2 kg (7 lb), and feels guilty and depressed about it. Further questioning reveals that she consumes a large pizza and two large bags of chips in one sitting several times a week. Afterward, the patient feels ashamed about being unable to control her intake and fasts to make up for it. She is very distressed about being unable to lose weight despite exercising 2-3 hours a day. Vital signs are within normal limits. BMI is 23.7 kg/m². Despite being told that her BMI is normal, the patient insists that she is overweight. Which of the following is the most likely diagnosis?

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11ec160b_360b_d851_9249_a554b4660ed8_MD0001_00 This patient's recurrent episodes of eating large amounts of food and sense of loss of control, together with compensatory behaviors (fasting, exercising) to prevent weight gain, is consistent with bulimia nervosa (BN). Patients with BN are excessively preoccupied with their weight and body shape. Although self-induced vomiting is the most common compensatory behavior, patients may also fast and exercise excessively or misuse laxatives, enemas, diuretics, or diet pills. In DSM-5, both binges and inappropriate compensatory behaviors must occur at least once a week for 3 months for diagnosis. Patients with BN are normal weight or overweight, in contrast to individuals with anorexia nervosa. Signs of BN in patients who vomit regularly may include hypotension, tachycardia, dry skin, menstrual irregularities, erosion of dental enamel, parotid hypertrophy, calloused knuckles, and electrolyte abnormalities (eg, hypokalemia, hypochloremia, metabolic alkalosis). (Choice A) This patient's depressive and guilty feelings after a binge are characteristic of BN. (Choice B) Both BN and anorexia nervosa may be characterized by preoccupation with weight, binge eating, and compensatory behavior (there is a binge-eating/purging subtype of anorexia). Patients with anorexia nervosa have significantly low body weight (BMI <18.5 kg/m²). In BN, body weight is typically normal to increased. (Choice C) In binge-eating disorder, patients engage in recurrent episodes of binge eating but do not use inappropriate compensatory behaviors as in BN. (Choice D) Body dysmorphic disorder is characterized by intense preoccupation with a perceived defect in physical appearance leading to significant functional impairment. It is not diagnosed when weight gain is the preoccupation of an individual who meets the criteria for an eating disorder. (Choice F) This patient's 5-month history of frequent binge-eating episodes, followed by fasting and exercising, meets criteria for BN. Educational objective: Bulimia nervosa (BN) is characterized by recurrent episodes of binge eating followed by compensatory behaviors to prevent weight gain (eg, fasting, exercising, vomiting, using laxatives). In contrast to patients with anorexia nervosa, BN patients are normal weight to overweight. __________ References: Eating disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27319605) Medical complications of bulimia nervosa. (http://www.ncbi.nlm.nih.gov/pubmed/29240508)

A 26-Year-Old Woman Comes to the Office Due to Recent