Bulimia nervosa
Bulimia nervosa: Excerpt from Professional Guide to Diseases (Eighth Edition)
The essential features of bulimia nervosa include eating binges followed by feelings of guilt, humiliation, and self-deprecation. These feelings cause the patient to engage in self-induced vomiting, use laxatives or diuretics, follow a strict diet, or fast to overcome the effects of the binges. Unless the patient spends an excessive amount of time bingeing and purging, bulimia nervosa seldom is incapacitating. However, electrolyte imbalances (metabolic alkalosis, hypochloremia, and hypokalemia) and dehydration can occur, increasing the risk of physical complications.
Causes and incidence
The cause of bulimia is unknown, but psychosocial factors may contribute to its development. These factors include family disturbance or conflict, sexual abuse, maladaptive learned behavior, struggle for control or self-identity, cultural overemphasis on physical appearance, and parental obesity. Bulimia nervosa is associated with depression, anxiety, phobias, and obsessive-compulsive disorder.
Eating disorders are most prevalent in affluent cultural groups and are essentially unknown in cultural groups where poverty and malnutrition are prevalent. In developing countries, almost no cases of eating disorders have been recognized.
Bulimia nervosa usually begins in adolescence or early adulthood and can occur simultaneously with anorexia nervosa. It affects nine women for every man. Nearly 2% of adult women meet the diagnostic criteria for bulimia nervosa; 5% to 15% have some symptoms of the disorder.
Signs and symptoms
The history of a patient with bulimia nervosa is characterized by episodes of binge eating that may occur up to several times per day. The patient commonly reports a binge-eating episode during which she continues eating until abdominal pain, sleep, or the presence of another person interrupts it. The preferred food is usually sweet, soft, and high in calories and carbohydrate content.
The patient with bulimia may appear thin and emaciated. Typically, however, although her weight frequently fluctuates, it usually stays within normal limits — through the use of diuretics, laxatives, vomiting, and exercise. So, unlike the patient with anorexia, the patient with bulimia can usually hide her eating disorder.
Overt clues to this disorder include hyperactivity, peculiar eating habits or rituals, frequent weighing, and a distorted body image. (See Characteristics of patients with bulimia.)
The patient may complain of abdominal and epigastric pain caused by acute gastric dilation. She may also have amenorrhea. Repetitive vomiting may cause painless swelling of the salivary glands, hoarseness, throat irritation or lacerations, and dental erosion. The patient may also exhibit calluses on the knuckles or abrasions and scars on the dorsum of the hand, resulting from tooth injury during self-induced vomiting, although it’s common for the patient with bulimia to induce vomiting chemically such as with ipecac.
A patient with bulimia commonly is perceived by others as a “perfect” student, mother, or career woman; an adolescent may be distinguished for participation in competitive activities such as sports. However, the patient’s psychosocial history may reveal an exaggerated sense of guilt, symptoms of depression, childhood trauma (especially sexual abuse), parental obesity, or a history of unsatisfactory sexual relationships.
Diagnosis
For characteristic findings in this condition, see Diagnosing bulimia nervosa, page 492.
Additional diagnostic tools include the Beck Depression Inventory, which may identify coexisting depression, and laboratory tests to help determine the presence and severity of complications. Serum electrolyte studies may show elevated bicarbonate, decreased potassium, and decreased sodium levels.
A baseline electrocardiogram may be done if tricyclic antidepressants will be prescribed for the patient.
Treatment
Treatment of bulimia nervosa may continue for several years. Interrelated physical and psychological symptoms must be treated simultaneously. Merely promoting weight gain isn’t sufficient to guarantee long-term recovery. A patient whose physical status is severely compromised by inadequate or chaotic eating patterns is difficult to engage in the psychotherapeutic process.
Psychotherapy concentrates on interrupting the binge-purge cycle and helping the patient regain control over her eating behavior. Inpatient or outpatient treatment includes behavior modification therapy, which may take place in highly structured psychoeducational group meetings. Cognitive behavioral therapy, group therapy, and family therapy, which address the eating disorder as a symptom of unresolved conflict, may help the patient understand the basis of her behavior and teach her self-control strategies. Antidepressant drugs may be used as an adjunct to psychotherapy.
The patient may also benefit from participation in self-help groups, such as Overeaters Anonymous, or in a drug rehabilitation program if she has a concurrent substance abuse problem.
Special considerations
❑ Supervise the patient during mealtimes and for a specified period after meals (usually 1 hour). Set a time limit for each meal. Provide a pleasant, relaxed environment for eating.
❑ Use behavior modification techniques, and reward the patient for satisfactory weight gain.
❑ Establish a contract with the patient, specifying the amount and type of food to be eaten at each meal.
❑ Encourage her to recognize and express her feelings about her eating behavior. Maintain an accepting and nonjudgmental attitude, controlling your reactions to her behavior and feelings.
❑ Encourage the patient to talk about stressful issues, such as achievement, independence, socialization, sexuality, family problems, and control.
❑ Identify the patient’s elimination patterns.
❑ Assess her suicide potential.
❑ Refer the patient and her family to the American Anorexia and Bulimia Association and to Anorexia Nervosa and Related Eating Disorders for additional information and support.
❑ Teach the patient how to keep a food journal to monitor treatment progress.
❑ Outline the risks of laxative, emetic, and diuretic abuse for the patient.
❑ Provide assertiveness training to help the patient gain control over her behavior and achieve a realistic and positive self-image.
❑ If the patient is taking a prescribed tricyclic antidepressant, instruct her to take the drug with food. Warn her to avoid consuming alcoholic beverages; exposing herself to sunlight, heat lamps, or tanning salons; and discontinuing the medication unless she has notified the physician.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
More About Bulimia nervosa
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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