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Causes and symptoms
- 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
- 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
bu·lim·i·a ner·vo·sa(bŭ-lĭm'ē-ă nĕr-vō'să)
|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.
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.
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.
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.
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.
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.
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
DiagnosisAltered nutrition: Less than body requirements related to recurrent vomiting after eating; excessive laxative and diuretic use; preoccupation with weight, food, or diets
OutcomesNutritional status: Food and fluid intake; Nutrient intake; Body mass; Energy
InterventionsEating disorders management; Nutrition management; Nutritional counseling; Nutritional monitoring; Weight management
Planning and implementation
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.
|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.
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%.
- 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.