bulimia nervosa

Bulimia Nervosa

Definition

Bulimia nervosa is a serious and sometimes life-threatening eating disorder affecting mainly young women. People with bulimia, known as bulimics, consume large amounts of food (binge) and then try to rid themselves of the food and calories (purge) by fasting, excessive exercise, vomiting, or using laxatives. The behavior often serves to reduce stress and relieve anxiety. Because bulimia results from an excessive concern with weight control and self-image, and is often accompanied by depression, it is also considered a psychiatric illness.

Description

Bulimia nervosa is a serious health problem for over two million adolescent girls and young women in the United States. The bingeing and purging activity associated with this disorder can cause severe damage, even death, although the risk of death is not as high as for anorexia nervosa, an eating disorder that leads to excessive weight loss.Binge eating may in rare instances cause the stomach to rupture. In the case of purging, heart failure can result due to loss of vital minerals such as potassium. Vomiting causes other serious problems, including acid-related scarring of the fingers (if used to induce vomiting) and damage to tooth enamel. In addition, the tube that brings food from the mouth to the stomach (the esophagus) often becomes inflamed and salivary glands can become swollen. Irregular menstrual periods can also result, and interest in sex may diminish.

Key terms

Binge — To consume large amounts of food uncontrollably within a short time period.Diuretic — A drug that promotes the formation and excretion of urine.Neurotransmitters — Certain brain chemicals that may function abnormally in acutely ill bulimic patients.Obsessive-compulsive disorder (OCD) — A disorder that may accompany bulimia, characterized by the tendency to perform repetitive acts or rituals in order to relieve anxiety.Purge — To rid the body of food and calories, commonly by vomiting or using laxatives.Most bulimics find it difficult to stop their behavior without professional help. Many typically recognize that the behavior is not normal, but feel out of control. Some bulimics struggle with other compulsive, risky behaviors such as drug and alcohol abuse. Many also suffer from other psychiatric illnesses, including clinical depression, anxiety, and obsessive-compulsive disorder (OCD).Most bulimics are females in their teens or early 20s. Males account for only 5-10% of all cases. People of all races develop the disorder, but most of those diagnosed are white.Bulimic behavior is often carried out in secrecy, accompanied by feelings of guilt or shame. Outwardly, many people with bulimia appear healthy and successful, while inside they have feelings of helplessness and low self-esteem.

Causes and symptoms

Causes

The cause of bulimia is unknown. Researchers believe that it may be caused by a combination of genetic and environmental factors. Bulimia tends to run in families. Research shows that certain brain chemicals, known as neurotransmitters, may function abnormally in acutely ill bulimia patients. Scientists also believe there may be a link between bulimia and other psychiatric problems, such as depression and OCD. Environmental influences include participation in work or sports that emphasize thinness, such as modeling, dancing, or gymnastics. Family pressures also may play a role. One study found that mothers who are extremely concerned about their daughters' physical attractiveness and weight may help to cause bulimia. In addition, girls with eating disorders tend to have fathers and brothers who criticize their weight.

Symptoms

According to the American Anorexia/Bulimia Association, Inc., warning signs of bulimia include:

eating large amounts of food uncontrollably (bingeing)
vomiting, abusing laxatives or diuretics, or engaging in fasting, dieting, or vigorous exercise (purging)
preoccupation with body weight
using the bathroom frequently after meals

depression or mood swings
irregular menstrual periods
onset of dental problems, swollen cheeks or glands, heartburn or bloating

Diagnosis

Bulimia is treated most successfully when diagnosed early. But because the bulimic may deny there is a problem, getting medical help is often delayed. A complete physical examination in order to rule out other illnesses is the first step to diagnosis.According to the American Psychiatric Association, a diagnosis of bulimia requires that a person have all of the following symptoms:

recurrent episodes of binge eating (minimum average of two binge-eating episodes a week for at least three months)
a feeling of lack of control over eating during the binges
regular use of one or more of the following to prevent weight gain: self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise
persistent over-concern with body shape and weight

Treatment

Early treatment is important otherwise bulimia may become chronic, with serious health consequences. A comprehensive treatment plan is called for in order to address the complex interaction of physical and psychological problems in bulimia. A combination of drug and behavioral therapies is commonly used.Behavioral approaches include individual psychotherapy, group therapy, and family therapy. Cognitive-behavioral therapy, which teaches patients how to change abnormal thoughts and behavior, is also used. Nutrition counseling and self-help groups are often helpful.Antidepressants commonly used to treat bulimia include desipramine (Norpramin), imipramine (Tofranil), and fluoxetine (Prozac). These medications also may treat any co-existing depression.In addition to professional treatment, family support plays an important role in helping the bulimic person. Encouragement and caring can provide the support needed to convince the sick person to get help, stay with treatment, or try again after a failure. Family members can help locate resources, such as eating disorder clinics in local hospitals or treatment programs in colleges designed for students.

Alternative treatment

Light therapy—exposure to bright, artificial light—may be useful in reducing bulimic episodes, especially during the dark winter months. Some feel that massage may prove helpful, putting people in touch with the reality of their own bodies and correcting misconceptions of body image. Hypnotherapy may help resolve unconscious issues that contribute to bulimic behavior.

Prognosis

Bulimia may become chronic and lead to serious health problems, including seizures, irregular heartbeat, and thin bones. In rare cases, it may be fatal.Timely therapy and medication can effectively manage the disorder and help the bulimic look forward to a normal, productive, and fulfilling life.

Prevention

There is no known method to prevent bulimia.

Resources

Organizations

American Anorexia/Bulimia Association, Inc. 293 Central Park West, Suite IR, New York, NY 10024. (212) 501-8351.Anorexia Nervosa and Related Eating Disorders, Inc. P.O. Box 5102, Eugene, OR 97405. (541) 344-1144.Center for the Study of Anorexia and Bulimia. 1 W. 91st St., New York, NY 10024. (212) 595-3449.Eating Disorder Awareness. & Prevention, Inc., 603 Stewart St., Suite 803, Seattle, WA 98101. (206) 382-3587.National Association of Anorexia Nervosa and Associated Disorders. Box 7, Highland Park, IL 60035. (708) 831-3438.National Eating Disorders Organization (NEDO). 6655 South Yale Ave, Tulsa, OK 74136. (918) 481-4044.

bulimia

[bu-le´me-ah] (Gr.) episodic binge eating usually followed by behavior designed to negate the caloric intake of the ingested food, most commonly purging behaviors such as self-induced vomiting or laxative abuse but sometimes other methods such as excessive exercise or fasting. While most commonly associated with bulimia nervosa, it may also occur in other disorders, such as anorexia nervosa. adj., adj bulim´ic.bulimia nervo´sa an eating disorder characterized by episodic binge eating followed by behaviors designed to prevent weight gain, including purging, fasting, and excessive exercise. Episodes of binge eating involve intake of quantifiably excessive amounts of food within a short, discrete period as well as a sense of loss of control over food intake during these periods. The person with bulimia nervosa has a preoccupying pathological fear of becoming overweight, feels an unusually strong tie between self-worth and body shape and size, is aware that the eating pattern is abnormal, and frequently experiences feelings of self-recrimination. In contrast to persons with anorexia nervosa, patients with bulimia nervosa tend to be somewhat older and more socially inclined, and to have fewer obsessive characteristics. Bulimia nervosa differs from anorexia nervosa in maintenance of a normal or near normal body weight; it is not diagnosed in the presence of anorexia nervosa.

bu·lim·i·a ner·vo·sa

a chronic morbid disorder involving repeated and secretive episodic bouts of eating characterized by uncontrolled rapid ingestion of large quantities of food over a short period of time (binge eating), followed by self-induced vomiting, use of laxatives or diuretics, fasting, or vigorous exercise to prevent weight gain; often accompanied by feelings of guilt, depression, or self-disgust. Synonym(s): boulimia, bulimia, hyperorexia

bulimia nervosa

(nûr-vō′sə)n. See bulimia.

A compulsive eating disorder characterised by binge eating, frequent fasting, laxative use, induced vomiting, and inappropriate compensation to prevent weight gain. Bulimia nervosa usually affects women at a slightly later onset—age 17–25—than anorexia nervosa, but shares its preoccupation with food; bulimics may consume enormous quantities of food, in a 'binge', followed by self-induced emesis, a 'purge'. Obesity is not usually seen in bulemics who may be normal weight to slightly overweight. Bulimia may alternate with anorexia nervosa or occur in combination as in bulemarexia. Bulimia is either 1 degree or a component of other diseases—e.g., schizophrenia, Klüver-Bucy, and Kleine-Levin syndromes; bulimics may have concomitant impulsive behavior—alcohol and drug abuse, poor peer and parental relations, sexual promiscuity; prostitution and stealing may be required to financially support the eating ‘addiction’

bu·lim·i·a ner·vo·sa

(bŭ-lĭm'ē-ă nĕr-vō'să) A chronic morbid disorder involving repeated and secretive episodic bouts of eating characterized by uncontrolled rapid ingestion of large quantities of food over a short period of time (binge eating), followed by self-induced vomiting, use of laxatives or diuretics, fasting, or vigorous exercise to prevent weight gain; often accompanied by feelings of guilt, depression, or self-disgust.
Synonym(s): bulimia.

Bulimia Nervosa

DRG Category:	887
Mean LOS:	4.8 days
Description:	MEDICAL: Other Mental Disorder Diagnoses

Bulimia nervosa (BN) is an eating disorder characterized by repeated episodes of binge eating. During binges, the individual rapidly consumes large amounts of high-caloric food (upward of 2,000 to 5,000 calories), usually in secrecy. The binge is followed by self-deprecating thoughts, guilt, and anxiety over fear of weight gain. There are two major variants: purging and nonpurging. Purging occurs with compensation for binges with self-induced vomiting and/or ingestion of laxatives. Nonpurging involves binge eating accompanied by excessive exercise, ingestion of stimulants, and/or fasting. The strict definition used by the Diagnostic and Statistical Manual of Mental Disorders indicates a person with BN needs to have two binge-eating episodes per week for at least 3 months. The individual is caught in a binge-compensation cycle that can recur multiple times each day, several times a week, or at an interval of up to 2 weeks to months. Patients with BN experience frequent weight fluctuations of 10 pounds or more, but they are usually able to maintain a near-normal weight.

As persons with anorexia nervosa (AN) mature, they may turn to bulimic behavior as a way of controlling food intake. In contrast to people with AN, individuals with BN are aware that their behavior is abnormal, but they conceal their illness because of embarrassment. Persons with bulimia typically have difficulty with direct expression of feelings, are prone to impulsive behavior, and may have problems with alcohol and other substance abuse. Because they can maintain a near-normal weight and, if female, have regular menstrual periods, the problem may go undetected. Bulimic behaviors have been known to persist for decades.

Depending on the severity and duration of the condition, there are significant health consequences. Chronic induced vomiting of stomach contents produces volume depletion and a hypochloremic alkalosis. Dizziness, syncope, thirst, orthostatic changes in vital signs, and dehydration occur with volume depletion. Renal compensation for the metabolic alkalosis and volume depletion leads to further electrolyte imbalances, which may predispose the BN patient to cardiac dysrhythmias, muscle cramps, and weakness. Discoloration of the teeth and dental caries are common because of chronic self-induced vomiting. Laxative abuse is a potentially dangerous form of purging, leading to volume depletion, increased colonic motility, abdominal cramping, and loss of electrolytes in a watery diarrhea. Irritation of intestinal mucosa or hemorrhoids from rapid and frequent stools may cause rectal bleeding. When laxative abuse stops, transient fluid retention, edema, and constipation are common.

Causes

The cause of BN is unknown, but bulimia is generally attributed to a combination of psychological, genetic, and physiological causes. Onset occurs in late adolescence when the individual has left or is preparing to leave home. Experts suggest that the stress and depression that accompany this transition lead to binging and compensating as a way of coping with these changes. Obesity usually precedes the onset of bulimia, and strict dieting usually triggers the binge–purge cycling. Changes in neurotransmitter metabolism, in particular serotonin, and response to antidepressants suggest a biochemical component to the condition. Cultural pressures toward thinness may also contribute to the onset of bulimia.

Genetic considerations

There is significant evidence that bulimia runs in families. It is most likely that the combined effects of several genes and environment result in the disease. Studies suggest that environmental factors may be less important than the additive effects of genetic mutations. A polymorphism in the BDNF gene and an unknown gene on chromosome 10p have been associated with susceptibility to eating disorders in general.

Gender, ethnic/racial, and life span considerations

The most typical individual with BN is an adolescent female; onset usually occurs in late adolescence or early 20s. The typical patient with BN is a young, college-educated woman with high achievement at work and school. Hispanic and white non-Hispanic female adolescents are more likely to engage in eating disorders than are non-Hispanic, black female adolescents. Experts estimate that up to 5% of young women are bulimic. Eating disorders occur more frequently in men who participate in sports with requirements for low body weight or body fat.

Global health considerations

In developed countries, eating disorders seem to be more common than in developing countries. Reports from Iran, Japan, and Hungary indicate that the incidence ranges from 3% to 6% for adolescent females.

Assessment

History

Patients who are bulimic often report a family history of affective disorders, especially depression. The patient may describe patterns of weight fluctuation and frequent dieting, along with a preoccupation with food; this cluster of characteristics may be the first sign of bulimia. Complaints such as hematemesis, heartburn, constipation, rectal bleeding, and fluid retention may be the initial reasons the patient seeks care from a primary healthcare provider. Patients may also have evidence of esophageal tears or ruptures, such as pain during swallowing and substernal burning. If patients seek treatment for bulimia, they usually have exhausted a variety of ways to control their binging and purging behavior. A detailed history of dieting, laxative and diuretic use, and the frequency and pattern of binging and purging episodes is essential. You may need to make a direct inquiry about binging and purging patterns for those patients who are seeking help but are ashamed to volunteer the information. Assess which foods and situations are most likely to trigger a binge.

Physical examination

Often, no symptoms are noted on the physical examination. Obtain the patient’s weight and compare it with the normal weight range for age and height. In patients with chronic vomiting, you may notice parotid swelling, which gives the patient a characteristic “chipmunk” facial appearance. Assess the patient for signs of dehydration such as poor skin turgor, dry mucous membranes, hair loss, and dry skin. Note dental discoloration and caries from excessive vomiting, scars on the back of the hand from chronic self-induced vomiting, and conjunctival hemorrhages. Poor abdominal muscle tone may be evidence of rapid weight fluctuations. Tearing or fissures of the rectum may be present on rectal examination because of frequent enemas. A neurological assessment is important to rule out possible signs of a brain tumor or seizure disorder. Chronic hypokalemia from laxative or diuretic abuse may lead to an irregular pulse or even cardiac arrest and sudden death.

Psychosocial

Assess the patient’s current career goals, peer and intimate relationships, psychosexual development, self-esteem, and perception of body image. Pay particular attention to any signs of depression and suicidal ideation and behavior. Assess the patient’s ability to express feelings and anger; determine the patient’s methods for coping with anxiety as well as his or her impulse control. Assess the family’s communication patterns, especially how the family deals with conflict and solves problems. Assess the degree to which the family supports the patient’s growth toward independence and separation.

Diagnostic highlights

General Comments: No laboratory test is able to diagnose BN, but supporting tests are used to follow the response to treatment and progression of the illness.

Test	Normal Result	Abnormality With Condition	Explanation
Serum electrolytes and chemistries	Sodium 136–145 mEq/L; potassium 3.5–5.1 mEq/L; chloride 95–112 mEq/L; calcium 8.5–10.3 mEq/L; magnesium 1.5–2 mEq/L; glucose 70–105 mg/dL	Hypokalemia, hypochloremia, hypomagnesemia, hypocalcemia, or hypoglycemia	Values reflect loss of electrolytes from vomiting and poor nutrition
Complete blood count	Red blood cells (RBCs) 4–5.5 million/mL; white blood cells (WBCs) 4,500–11,000/mL; hemoglobin (Hgb) 12–18 g/dL; hematocrit (Hct) 37%–54%; reticulocyte count 0.5%–2.5% of total RBCs; platelets 150,000–400,000/mL	Anemia; RBCs < 4; Hct < 35%; Hgb < 12 g/dL; bleeding tendencies due to platelets < 150,000/mL	Caused by protracted undernutrition
Amylase	50–180 units/dL	Elevated	Elevated levels indicate patient is practicing vomiting behaviors; increases within 2 hours of vomiting and remains elevated for approximately a week
Albumin	3.5–5 g/dL	Hypoalbuminemia; albumin < 3.5 g/dL	Caused by protracted undernutrition

Other Tests: Other laboratory tests include arterial blood gases (metabolic alkalosis), blood urea nitrogen (elevated), cholesterol (elevated), luteinizing hormone (decreased), testosterone (decreased), thyroxine (mildly decreased), urinalysis, pregnancy test, electrocardiogram, and chest x-ray.

Primary nursing diagnosis

Diagnosis

Altered nutrition: Less than body requirements related to recurrent vomiting after eating; excessive laxative and diuretic use; preoccupation with weight, food, or diets

Outcomes

Nutritional status: Food and fluid intake; Nutrient intake; Body mass; Energy

Interventions

Eating disorders management; Nutrition management; Nutritional counseling; Nutritional monitoring; Weight management

Planning and implementation

Collaborative

Patients with bulimia generally do not need hospitalization unless they experience severe electrolyte imbalance, dehydration, or rectal bleeding. The bulimia is usually managed with individual behavioral and group therapy, family education and therapy, medication, and nutritional counseling. Cognitive behavioral therapy (CBT) has been found to be superior to psychoanalytic psychotherapy for improving symptoms. CBT allows the patient to address dysfunctional emotions, maladaptive behaviors, and cognitive processes systematically. It is problem focused (undertaken to address a specific problems, such as bulimia) and action oriented (the therapist tries to help the patient select specific strategies to address bulimia).

Work with the interdisciplinary team to coordinate efforts and refer the patient to the physician to evaluate the need for antidepressants and anti-anxiety medication. Work with the patient to evaluate the effectiveness of antidepressant or anti-anxiety medications as well as to explore ways to identify situations that precede depression and anxiety. Work with the dietitian to ensure that the patient is educated about appropriate nutrition and dietary intake. Encourage the patient to participate in individual, family, and group sessions to help the patient develop ways to express feelings, handle anger, enhance self-esteem, explore career choices, and develop sexual identity and assertiveness skills.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Potassium supplements	20–40 mEq PO	Electrolyte replacement	Replace potassium lost through vomiting

Other Drugs: Some experts recommend the use of monoamine oxidase inhibitors (tranylcypromine sulfate, phenelzine sulfate). Drugs that facilitate serotonergic neurotransmission, such as fluoxetine, sertraline hydrochloride, and paroxetine, may be used. Other drugs may be used such as tricyclic antidepressants, nortriptyline hydrochloride, or desipramine hydrochloride.

Independent

Teach the patient to choose correct portion sizes. Encourage the patient to eat slowly and avoid performing other activities, such as reading or watching television, while eating. Most patients are encouraged not to use diet foods or drinks until a stable body weight is established. Encourage the patient to eat a low-sodium diet to prevent fluid retention. Fluid retention is common until the body readjusts its fluid balance; the patient may need support if she or he experiences edema of the fingers, ankles, and face. As he or she begins to eat and drink normally, support the patient if he or she becomes upset about weight gain and reassure the patient that the weight gain and swelling are temporary. Also encourage the patient to establish a normal exercise routine but to avoid extremes.

The goals of nursing interventions are to enhance self-esteem, facilitate growth in independence, manage separation from the family, develop sexual identity, and make career choices. Explore ways for the patient to identify and express feelings, manage anger and stress, develop assertive communication skills, and control impulses or delay gratification. Help the patient learn ways other than binging and purging to cope with feelings of anxiety and depression. Explore ways to reduce the patient’s vomiting, laxative, and diuretic abuse. Some patients respond well to contracting or behavioral management to reduce these behaviors. Educate the family about appropriate nutrition. Explore ways the family can manage conflict and support the patient’s move toward independence.

Evidence-Based Practice and Health Policy

Keski-Rahkonen, A., Hoek, H. W., Linna, M. S., Raevuori, A., Sihvola, E., Bulik, C. M., …Kaprio, J. (2009). Incidence and outcomes of bulimia nervosa: A nationwide population-based study. Psychological Medicine, 39(5), 823–831.

In a nationwide longitudinal cohort study of health behaviors in 2,881 twins, 42 cases of bulimia nervosa were identified. However, only 38% of cases were detected by healthcare professionals prior to the study.
Among those diagnosed, 79% of women engaged in purging activities such as self-induced vomiting, laxative, or diuretic use. The remainder of those diagnosed used excessive exercise, fasting, or repeated dieting to compensate for binge eating.
In this sample, the 5-year recovery rate was 57%.

Documentation guidelines

Nutrition: Diet planning and food intake, frequency and duration of binge–purge episodes
Volume depletion: Signs of dehydration, pertinent laboratory findings if available
Response to care and teaching: Understanding of the disease process and the relationship of dehydration and self-induced vomiting, laxative abuse, and diuretic abuse; understanding of ways to identify and cope with anxiety, anger, depression, and own impulses and needs
Family meeting: Family interactions and support of move toward independence

Discharge and home healthcare guidelines

Teach the patient ways to avoid binge–purge episodes through a balanced diet. Discuss effective ways of coping with needs and feelings. Explore ways to identify and handle stress and anxiety. Teach the patient strategies to increase self-esteem. Explore ways to maintain increased independence and the patient’s own choices.

bu·lim·i·a ner·vo·sa

(bŭ-lē'mē-ă nĕr-vō'să) Chronic morbid disorder involving repeated and secretive episodic bouts of eating characterized by uncontrolled rapid ingestion of large quantities of food over a short period of time, followed by self-induced vomiting and other means. Synonym(s): bulimia, hyperorexia

bulimia nervosa

bulimia ner·vo·sa

bulimia nervosa

Bulimia Nervosa

Definition

Description

Key terms

Causes and symptoms

Causes

Symptoms

Diagnosis

Treatment

Alternative treatment

Prognosis

Prevention

Resources

Organizations

bulimia

bu·lim·i·a ner·vo·sa

bulimia nervosa

bu·lim·i·a ner·vo·sa

Bulimia Nervosa

Causes

Genetic considerations

Gender, ethnic/racial, and life span considerations

Global health considerations

Assessment

History

Physical examination

Psychosocial

Diagnostic highlights

Primary nursing diagnosis

Diagnosis

Outcomes

Interventions

Planning and implementation

Collaborative

Pharmacologic highlights

Independent

Evidence-Based Practice and Health Policy

Documentation guidelines

Discharge and home healthcare guidelines

bu·lim·i·a ner·vo·sa