8. BULIMIA IN FEMALES BEYOND AGE
Bulimia may be underreported in women
over age 30. Population surveys have uncovered fewer
older bulimic patients. Jonas  reported a 56-year-old
woman with rapid-cycling bipolar disorder and unexplained
vomiting. She had no prior history of an eating disorder,
and during hospitalization the staff discovered surreptitious
vomiting. Bulimia disappeared with individual medication
trials, first with imipramine, and then phenelzine.
Older patients with affective disorder and unexplained
vomiting not secondary to psychotropic drug toxicity
should be screened for bulimia. Lithium use may be hazardous,
therapeutically unpredictable, or lethal in patients
with self-induced, surreptitious vomiting, due to electrolyte
disturbance. Patients taking lithium for bipolar disorder,
emotionally unstable character disorder, or recurrent
unipolar depression should be screened for bulimia.
Bipolar patients with bulimia may respond to carbamazepine
 as an alternative to lithium carbonate.