Ms. A, a 40-year-old white married woman diagnosed with bulimia without purging, was referred for consultation and follow-up. She described episodes of depressed mood, crying spells, anger, irritability, and bloating that began before her menstruation and resolved with the onset of her period. She also described episodes of manic-like symptoms lasting up to a week that had begun in the past year: she felt full of energy and irritable and experienced decreased need to sleep and trouble concentrating. Ms. A was not taking any prescription medication other than levothyroxine for hypothyroidism.

A provisional diagnosis of premenstrual dysphoric disorder and mood disorder not otherwise specified was made in addition to bulimia nervosa. Fluoxetine was prescribed for Ms. A’s current depressed mood and bulimia. She was monitored for any manic-like symptoms. About 5 months later, Ms. A admitted that she had recently discontinued her regimen of fluoxetine. Her depressed mood had resolved, but her episodes of bingeing continued. Ms. A explained that it was important to lose weight so that people would notice her. Exercising up to 3 hours per day to lose weight was not enough. Ms. A now admitted that, for over a year, she had been periodically treating herself with herbal products from the health food store to augment her weight loss. These products contained ma-huang (ephedra), chromium picolinate, and caffeine. Further questioning revealed that when Ms. A took these products, she felt an increase in energy and a decrease in appetite. She would sleep 2–3 hours at night and be irritable the next day. Ms. A continued taking this combination for about 5–10 days until she reached a predetermined weight or was not able to function. When she stopped taking the herbal products, Ms. A experienced hypersomnia, dysphoria, poor concentration, and fatigue. She would return to the herbal regimen when she felt the urge to lose weight.