Chapter 8 Bulimia Nervosa
PATHOPHYSIOLOGY
Bulimia nervosa is a nutritional and psychologic disorder characterized by rapid consumption of large quantities of food (bingeing), followed by any of a number of behaviors used to prevent weight gain. Eating occurs during discrete periods of time. Self-induced vomiting is the most commonly used method to avoid weight gain. Other purging methods include use of laxatives, enemas, and diuretics, as well as of cathartics, thyroid medications, diet pills and appetite suppressants, stimulants, and nutritional supplements; diabetics may neglect to take their insulin.
Complications are related to the method of purging. Purging is ineffective when large quantities are consumed, because digestion begins rapidly and much of the food is digested and absorbed. Fluids and electrolytes are lost in the large intestine with laxative use, but digestion takes place in the small intestine. Fasting and excessive exercise may also be used as an attempt to compensate for intake and prevent weight gain. Most individuals develop a chronic pattern of binge/purge behavior. Bingeing may be triggered by dysphoria, stress, or negative feelings related to body image. Because of associated feelings of shame, bingeing is often done in secrecy. Individuals typically feel out of control during bingeing episodes. For some, vomiting becomes the goal in and of itself.
Impulse control problems such as alcohol abuse and shoplifting often coexist with bulimia. As in individuals with anorexia nervosa, there is an excessive focus on one’s body. Self-worth is connected to physical appearance. Unlike the individual with anorexia, the bulimic individual is likely to be within the normal weight range for age and height, but weight may also vary by 10 pounds or more. The diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), are presented in Box 8-1.
Box 8-1 Diagnostic Criteria for Bulimia Nervosa
1. Recurrent episodes of binge eating occur. An episode of binge eating is characterized by both of the following:
2. Recurrent inappropriate compensatory behavior occurs to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.
3. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.
4. Self-evaluation is unduly influenced by body shape and weight.
5. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Purging Type
During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
Nonpurging Type
During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
From American Psychiatric Association: Diagnostic and statistical manual of mental disorders, ed 4, text revision (DSM-IV-TR), Washington, DC, 2000, The Association.
Bulimia nervosa is difficult to diagnose because bulimics are normal or above average in weight, may not show any physical signs, and are not forthcoming about their condition; symptoms are typically concealed, and the family may be in denial. Minorities and men are largely overlooked, because clinicians see eating disorders as upper socioeconomic female disorders. Males are even more reluctant to disclose eating disorders behavior because of guilt and shame; the course is the same as for females in terms of secrecy and physical health problems.
The risk factors for men include athletic sports that require low body fat or are weight sensitive (swimming, gymnastics, and wrestling), negative life experiences, teasing, physical abuse, homosexuality, and the presence of a comorbid psychiatric condition. During the wrestling season, 17% of high school wrestlers meet short-term criteria for an eating disorder; a small minority do not recover after the season. Males generally use excessive exercise after bingeing rather than purging. In female clients, distorted body image leads to an overestimation of weight. Being a gay male is a documented risk, not because of sexual orientation but because of the value placed on lean muscularity. Because the ideal male form is lean and muscular, males are more likely to underestimate their weight. The reverse of anorexia, with body dismorphia at its core, is bigarexia. Often steroids are abused in an attempt to gain defined muscle mass and impossibly low body fat.
INCIDENCE
1. Bulimia nervosa affects about 2% to 4% of adolescent girls and fewer than 1% to 5% of adolescent boys.
2. Most individuals with bulimia manifest symptoms in the latter half of adolescence.
3. Female/male ratio is 10:1; there are community-based epidemiologic studies citing a 3:1 ratio.
4. Bulimia is independent of social class, unlike anorexia, which occurs predominantly in higher socioeconomic classes.
5. There is high comorbidity with anxiety and affective disorders and obsessive-compulsive disorder.
6. Fifty percent of bulimic individuals have an alcoholic relative and relatives with a high incidence of eating disorders, obesity, and affective disorders.
7. Large numbers of adolescents do not meet full DSM-IV-TR criteria for bulimia or anorexia but experience psychologic and physiologic consequences of eating disorders.
CLINICAL MANIFESTATIONS
1. Some bulimic individuals are in the normal range for their height and weight, some a few pounds overweight, and some a few pounds underweight
2. Secret and solitary binge eating as means of dealing with anxiety and stress
3. In one episode, an individual may consume thousands of calories
4. A feeling of inability to stop eating or loss of control after the binge has begun
5. Though eating may be viewed as pleasurable, afterward there is depressed mood, guilt, and self-criticism.
7. Excusing of self to use bathroom during or after meals
8. Compulsive dieting and exercise
9. Preoccupation with weight and physical appearance. Clients may display concern for how they appear to others and undue concern for sexual attractiveness
10. Impaired body image and self-concept
12. Food cravings may be for any food, but typically for junk food or carbohydrates
13. Bingeing alternates with periods of fasting and normal eating
COMPLICATIONS
1. Integumentary: dry skin, dry mucous membranes, poor skin turgor, Russell’s sign—scarring of and callous formation on knuckles
2. Facial/ophthalmic: facial fullness, parotid and submaxillary gland swelling (sialadenosis, “chipmunk” facial appearance), conjunctival hemorrhages
3. Mouth and throat: acute or chronic esophagitis, esophageal rupture, discoloration of teeth, erosion of tooth enamel, multiple caries
4. Cardiopulmonary: arrhythmias, bradycardia, tachycardia, hypertension, palpitations, postural hypotension, myocardial toxicity from ipecac, aspiration pneumonia
5. Gastrointestinal: abdominal tenderness or pain, gastritis, gastric distention, irritable bowel syndrome, melanosis coli, delayed gastric emptying
6. Genitourinary: constipation, diarrhea, hemorrhoids, rectal bleeding, rectal prolapse, acute and chronic renal failure, hematuria, proteinuria
7. Musculoskeletal: tetany, cramps, poor abdominal muscle tone, weakness
8. Endocrine: hypercortisolism
9. Neuropsychiatric: seizures, peripheral neuropathy, insomnia, impairment of school and social functioning resulting from preoccupation with food, depression, dysthymia, anxiety, impulsivity, obsessive-compulsive disorder, substance abuse, suicidal ideation
LABORATORY AND DIAGNOSTIC TESTS
Refer to Appendix D for normal values and ranges of laboratory and diagnostic tests.
Most test results will be within normal limits, but that does not mean that these individuals do not have a high morbidity or mortality risk.
1. Serum electrolyte levels—to detect electrolyte imbalances due to purging such as hypokalemia, hyponatremia, hypochloremia, hypocalcemia, hypoglycemia, hypomagnesemia, metabolic alkalosis
2. Serum amylase level—possible elevation indicates client is practicing vomiting (increases 2 hours after vomiting and remains elevated for 2 weeks)
3. Lipid panel—assess for elevated levels; during fasting, stored triglycerides may be hydrolyzed into glycerol and fatty acids and released into blood
4. Electrocardiogram—perform to assess for the complications of cardiac arrhythmias
5. Complete blood count—to assess for anemia due to nutritional deficiencies
6. Renal function test—to assess for diuretic abuse
7. Stool test—to detect phenolphthalein in laxative abuse
8. Drug screen—to assess for methamphetamine that is taken for weight loss, appetite control, and thrill seeking
9. Blood gases—to assess for metabolic alkalosis (with vomiting) or metabolic acidosis (when laxatives are taken)
10. Other tests may be ordered to rule out or confirm comorbid conditions (e.g., hyperthyroidism, Crohn’s disease, neurologic disease, diabetes mellitus)
MEDICAL MANAGEMENT
Treatment is provided on an outpatient basis unless severe medical problems emerge. The factors that influence treatment modality are length and severity of illness, previous treatment approaches and outcomes, specific manifestations of disease, program availability, insurance, and financial resources. An interdisciplinary approach is needed to ensure optimal outcomes. The team is optimally composed of a pediatrician, nutritionist, nurse, psychiatrist, and therapist who specialize in eating disorders. Outpatient treatment includes medical monitoring, initiation of a dietary plan to restore nutritional state, and individual and family psychotherapy.
Family therapy is very helpful for younger adolescents; older adolescents may benefit more from both individual and family therapy. Treatment involves helping the individual learn to self-monitor and to identify distorted thinking patterns about weight, food, body image, and relationships. The goal of treatment is to restore normal eating. Fluoxetine (Prozac) has been shown to be effective in reducing binge behavior. It is likely, if fluoxetine is not tolerated, that another selective serotonin reuptake inhibitor (SSRI) would be as effective. Prognosis is better if the condition is treated early, before purging is reinforced by weight loss. Day treatment and residential treatment are used only when outpatient and short hospitalization fail, because these treatments are costly, and some insurance benefits do not adequately cover treatment, leaving parents and practitioners with difficult and limited options.
NURSING ASSESSMENT
1. Perform thorough nursing history taking and assessment, including history of bulimic episodes, information related to family dynamics, and psychosocial functioning.
2. Screen all teenagers for body image perception and dieting history. Ask direct questions about purging, prefacing with the fact that it is not an unusual way for teenagers to lose weight. Other questions include gathering information on perception of body image, disclosure of frequent dieting, weight dissatisfaction, and preoccupation with food.
3. Conduct thorough physical examination that includes height, postvoiding weight in simple hospital gown (to prevent the carrying of hidden weights), and vital signs (to assess for orthostatic hypotension, hypertension, and bradycardia).
4. Gather data on family history and family’s communication styles and attitudes, degree of family support, and family’s fostering of adolescent’s independence and separation. Bulimic patients may report family history of affective disorders, especially depression.
5. Assess the adolescent’s peer and intimate relationships.
6. Evaluate the adolescent’s ability to express emotions, especially anger and fear, since the youth likely has difficulty identifying and expressing feelings.
7. Determine the adolescent’s method of coping with stress and anxiety, since the youth may have problems with impulsivity, stealing, drug and alcohol abuse, self-mutilation, and suicide attempts.
8. Assess psychologic status to determine the level of awareness that behavior is abnormal, which may be expressed as depression, isolation, guilt, self-criticism, difficulty concentrating, and/or insomnia.
NURSING INTERVENTIONS
1. Provide information about adequate nutritional intake and effect of inadequate intake on energy level and psychologic well-being.
2. Teach the importance of daily fluid intake of 2000–3000 ml. Monitor laboratory serum levels and report significantly abnormal values to physician.
3. Help adolescent reexamine negative perceptions of self and recognize positive attributes.
4. Assist adolescent to develop a realistic perception of body image.
5. Establish trusting relationship that promotes disclosure of feelings and emotions about body image, self-concept, frustrations, and fears.
6. Assist in the development and use of effective problem-solving and coping strategies.
7. Teach, practice, and role-play appropriate social skills. Set up group activity opportunities to use social skills.
8. Incorporate family-centered approach in providing services; include family in treatment decisions.
Discharge Planning and Home Care
1. Recommend psychotherapy for treatment of distorted body image and self-concept.
2. Stress the importance of adherence with counseling and follow-up visits for patient and family.
3. Refer to local eating disorder support group.
4. Review medication regimen, side effects, discontinuation, and emergency protocol.
CLIENT OUTCOMES
1. Adolescent will maintain weight within normal range for age.
2. Adolescent will use more effective mechanisms to cope with negative emotions.
3. Adolescent will practice normal patterns of eating.
4. Adolescent will be able to demonstrate increase in self-esteem as manifested by verbalizing positive aspects of self and misperceptions of body image.
5. Adolescent will engage in developmentally appropriate activities.
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