Topiramate for Bulimia Nervosa in Epilepsy

Ms. A was a 34-year-old right-handed woman. Although she did not walk until she was 19 months of age, her intellectual development was considered age-appropriate during her school years. By age 8 she had began to experience a depressed mood, reduced motivation, compulsive overeating, excessive weight gain, and insomnia. She did not receive psychiatric treatment until age 16; that treatment consisted of individual psychotherapy. Despite recurrent depressive and vegetative symptoms, she graduated from high school and college and entered a graduate-level professional school. While in professional school she began to induce vomiting with her fingers or syrup of ipecac. She continued purging several times per week for the next decade. Her bulimic symptoms did not respond to treatment with fluoxetine, sertraline, or venlafaxine.

After graduation from professional school at age 29, Ms. A suffered two losses of consciousness. These were preceded by “altered visual perception” and an intense sensation of thirst. The second loss of consciousness was associated with tonic posturing of all of her extremities. Metabolic derangements secondary to her eating disorder were suspected but could not be confirmed. An EEG revealed left temporal slowing and left anterior temporal sharp waves. The results of computerized tomography and magnetic resonance imaging scans of her brain were unremarkable. She was prescribed phenytoin therapy.

Ms. A’s convulsions ceased when she had maintained adequate blood levels of phenytoin for about 5 years. She experienced occasional auras, which often included the sensation of thirst. Phenytoin therapy had no effect on her binge eating or purging. She had recurrent depressive episodes and one episode of self-mutilation with broken glass. After 5 years of phenytoin treatment, the auras began to appear more frequently, and she had a partial complex seizure with clonic movements of the right arm and leg, despite having a serum phenytoin level of 23.4 μg/ml. Topiramate was prescribed and gradually increased to 150 mg/day. Her auras and convulsions disappeared. In addition, she experienced a reduced appetite and a 10-lb weight loss. She became less concerned about her weight and had a reduced desire for binge eating, purging, and self-mutilation. As of this writing, she has remained free of these symptoms for 15 months.