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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Define bulimia nervosa (BN) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 criteria.

  • Assess signs and symptoms commonly associated with the presentation of BN.

  • Name effective pharmacologic and nonpharmacologic treatment options for the management of BN.

  • Compare and contrast short-term and long-term complications of BN and discuss the associated therapeutic options for prevention and management.

  • Design a treatment plan including monitoring parameters and counseling points for a patient with BN.

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PATIENT PRESENTATION

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Chief Complaint

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“I’m so unpopular, I just want to die!”

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HPI

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Cady Greenwald is a 21-year-old female presenting to a behavioral acute care hospital referred by her outpatient psychiatrist for suicidal ideations and symptoms of an eating disorder. She reported worsening depressive symptoms after she was cut from the college dance team 6 months ago. She expressed anxious feelings of inadequacy and obsessions with her image after that incident, and she is now binge eating and purging up to 8 episodes a week. She explains she tries to withhold food for as long as possible and then loses control and impulsively binges on large amounts of food usually in private. She becomes overwhelmed with guilt and anxiety and subsequently purges. In addition, she uses laxatives about three to four times a week and engages in self-injurious behavior by cutting her forearm. She has now dropped out of school and expresses suicidal ideations with a plan, stating “no one would miss me.” She admitted daily use of alcohol and marijuana to help her depressive thoughts, calm her anxieties, and to regulate her appetite. Compounding the eating disorder is that Cady has a diagnosis of bipolar disorder, type II, treated with escitalopram, bupropion, and ziprasidone, and she has been experiencing a depressive episode.

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PMH

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  • Bipolar disorder, type II

  • Cluster B personality disorder traits

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FH

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Parents married for 25 years. Father has a history of depression. Maternal aunt diagnosed with bipolar disorder. Maternal uncle and paternal aunt have with a history of depression and substance use.

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SH

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Completed 2 years of college as a dance major but dropped out 2 weeks ago due to increasing stress. She lives alone in her apartment. She admits to smoking marijuana daily, because she claims “everything is OK after I smoke.” She also drinks until she passes out about two nights a week and just occasionally drinks otherwise. She uses tobacco 1 PPD × 2 years

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Meds

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  • Ziprasidone 40 mg PO BID (3 years)

  • Bupropion SR 200 mg PO BID (1 year)

  • Escitalopram 20 mg PO once daily (3 years)

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All

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NKDA

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ROS

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