BULIMIA NERVOSA

Introduction         

Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health. Bulimia nervosa, anorexia nervosa, and binge eating disorder are the most common specific forms in the United States. Though primarily thought of as affecting females (an estimated 5–10 million being affected in the U.S.), eating disorders affect males as well (an estimated 1 million U.S. males being affected). Although eating disorders are increasing all over the world among both men and women, there is evidence to suggest that it is women in the Western world who are at the highest risk of developing them and the degree of westernization increases the risk.²

Bulimia nervosa, in many ways, represents a failed attempt at anorexia nervosa, sharing the goal of becoming very thin, but occurring in an individual less able to sustain prolonged semi-starvation or severe hunger as consistently as classic restricting anorexia nervosa patients. These eating binges provoke panic as individuals feel that their eating has been out of control. The unwanted binges lead to secondary attempts to avoid the feared weight gain by a variety of compensatory behaviors, such as purging or excessive exercise.²

DEFNITION.

In the text revision of the 4th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), bulimia nervosa is defined as binge eating combined with inappropriate ways of stopping weight gain. Social interruption or physical discomfort that is, abdominal pain or nausea terminates the binge eating, which is often followed by feelings of guilt, depression, or self-disgust. Unlike patients with anorexia nervosa, those with bulimia nervosa may maintain a normal body weight.³

EPIDEMIOLOGY

Bulimia nervosa is more prevalent than anorexia nervosa. Estimates of bulimia nervosa range from 2 to 4 percent of young women. As with anorexia nervosa, bulimia nervosa is significantly more common in women than in men, but its onset is often later in adolescence than that of anorexia nervosa. According to DSM-IV-TR, the rate of occurrence in males is one tenth of that in females. The onset may even occur in early adulthood. Approximately 20 percent of college women experience transient bulimic symptoms at some point during their college years. Although bulimia nervosa is often present in normal-weight young women, they sometimes have a history of obesity.³

History

Russell described bulimia nervosa in 1979, using the term nervosa to unite the two forms of the eating disorders spectrum—the self-starving syndrome of anorexia nervosa and the newly recognized binge–purge disorder—psycho pathologically. Bulimia nervosa was initially described as “an ominous variant of anorexia nervosa,” but later descriptions incorporated the syndrome of bulimia nervosa at normal weight.

The recognition of bulimia nervosa was hidden for a number of reasons, including the shame and secrecy of sufferers, who were reluctant to reveal these symptoms even while being treated for other related comorbid disorders, such as depression; the seemingly normal weight of most bulimic patients; and the lack of requests for help. The “night-eating binge syndrome,” characterized by often unremembered binge eating while still in some stage of sleep, is even more difficult to diagnose, but increasingly is recognized as a true variant. Despite the relatively recent formal description of bulimia nervosa, evidence-based treatment strategies have emerged quickly and have proven more effective than those for anorexia nervosa.³

The recent history of eating disorders has focused on several areas, including (1) better delineation of the non compensating binge-eating disorder, (2) clearer descriptions of the prevalence and syndrome characteristics of eating disorders in men, and (3) studies recognizing the contributions of genetic and other predisposing neurobiological factors interacting with socio cultural norms..

 By the late 20th century, fatty, palatable foods were available to most populations in Western countries, and, paradoxically, high-fat foods became particularly cheap and available for many low-income populations. Obesity has become much more prominent among all social classes, particularly poorer populations. Concurrently, pressures to be thin, weight control efforts, and eating disorders as clinical problems have become increasingly associated with affluent societies.³

ETIOLOGY

Biological Factors

Some investigators have attempted to associate cycles of binging and purging with various neurotransmitters. Because antidepressants often benefit patients with bulimia nervosa and because serotonin has been linked to satiety, serotonin and norepinephrine have been implicated. Because plasma endorphin levels are raised in some bulimia nervosa patients who vomit, the feeling of well-being after vomiting that some of these patients experience may be mediated by raised endorphin levels. According to DSM-IV-TR, increased frequency of bulimia nervosa is found in first-degree relatives of persons with the disorder.⁴

Social Factors

Patients with bulimia nervosa, as with those with anorexia nervosa, tend to be high achievers and to respond to societal pressures to be slender. As with anorexia nervosa patients, many patients with bulimia nervosa are depressed and have increased familial depression, but the families of patients with bulimia nervosa are generally less close and more conflictual than the families of those with anorexia nervosa. Patients with bulimia nervosa describe their parents as neglectful and rejecting.⁴

Psychological Factors

Patients with bulimia nervosa, as with those with anorexia nervosa, have difficulties with
adolescent demands, but patients with bulimia nervosa are more outgoing, angry, and impulsive than those with anorexia nervosa. Alcohol dependence, shoplifting, and emotional

lability (including suicide attempts) are associated with bulimia nervosa. These patients generally experience their uncontrolled eating as more ego-dystonic than do patients with anorexia nervosa and so seek help more readily.

Patients with bulimia nervosa lack superego control and the ego strength of their counterparts with anorexia nervosa. Their difficulties controlling their impulses are often manifested by substance dependence and self-destructive sexual relationships in addition to the binge eating and purging that characterize the disorder. Many patients with bulimia nervosa have histories of difficulties separating from caretakers, as manifested by the absence of transitional objects during their early childhood years. Some clinicians have observed that patients with bulimia nervosa use their own bodies as transitional objects. The struggle for separation from a maternal figure is played out in the ambivalence toward food; eating may represent a wish to fuse with the caretaker, and regurgitating may unconsciously express a wish for separation. ⁴

ICD 10 CLASSIFICATION

A. There are recurrent episodes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in short periods. B. There is persistent preoccupation with eating and a strong desire or a sense of compulsion to eat (craving). C. The patient attempts to counteract the “fattening” effects of food by one or more of the following:    (1) self-induced vomiting    (2) self-induced purging    (3) alternating periods of starvation    (4) use of drugs such as appetite suppressants, thyroid preparations, or diuretics; when bulimia occurs in diabetic patients, they may choose to neglect their insulin treatment D. There is self-perception of being too fat, with an intrusive dread of fatness (usually leading to underweight). Atypical bulimia nervosa Researchers studying atypical forms of bulimia nervosa, such as those involving normal or excessive body weight, are recommended to make their own decisions about the number and type of criteria to be fulfilled.2

Pathology and Laboratory Examinations

Bulimia nervosa can result in electrolyte abnormalities and various degrees of starvation, although it may not be as obvious as in low-weight patients with anorexia nervosa. Thus, even normal-weight patients with bulimia nervosa should have laboratory studies of electrolytes and metabolism. In general, thyroid function remains intact in bulimia nervosa, but patients may show nonsuppression on the dexamethasone-suppression test. Dehydration and electrolyte disturbances are likely to occur in patients with bulimia nervosa who purge regularly. These patients commonly exhibit hypomagnesemia and hyperamylasemia. Although not a core diagnostic feature, many patients with bulimia nervosa have menstrual disturbances. Hypotension and bradycardia occur in some patients.⁴

DIFFERENTIAL DIAGNOSIS

The diagnosis of bulimia nervosa cannot be made if the binge-eating and purging behaviors occur exclusively during episodes of anorexia nervosa. In such cases, the diagnosis is anorexia nervosa, binge eating-purging type.

Clinicians must ascertain that patients have no neurological disease, such as epileptic-equivalent seizures, central nervous system tumors. The pathological features manifested by Klüver-Bucy syndrome are visual agnosia, compulsive licking and biting, examination of objects by the mouth, inability to ignore any stimulus, placidity, altered sexual behavior (hypersexuality), and altered dietary habits, especially hyperphagia. The syndrome is exceedingly rare and is unlikely to cause a problem in differential diagnosis. Kleine-Levin syndrome consists of periodic hypersomnia lasting for 2 to 3 weeks and hyperphagia. As in bulimia nervosa, the onset is usually during adolescence, but the syndrome is more common in men than in women.

Patients with bulimia nervosa who have concurrent seasonal affective disorder and patterns of atypical depression (with overeating and oversleeping in low-light months) may manifest seasonal worsening of both bulimia nervosa and depressive features. In these cases, binges are typically much more severe during winter months. Bright light therapy (10,000 lux for 30 minutes, in early morning, at 18 to 22 inches from the eyes) may be a useful component of comprehensive treatment of an eating disorder with seasonal affective disorder.

Some patients with bulimia nervosa perhaps 15 percent have multiple comorbid impulsive behaviors, including substance abuse, and lack of ability to control themselves in such diverse areas as money management (resulting in impulse buying and compulsive shopping) and sexual relationships (often resulting in brief, passionate attachments and promiscuity). They exhibit self-mutilation, chaotic emotions, and chaotic sleeping patterns. They often meet criteria for borderline personality disorder and other mixed personality disorders and, not infrequently, bipolar II disorder.

COURSE AND PROGNOSIS

Bulimia nervosa is characterized by higher rates of partial and full recovery compared with anorexia nervosa. As noted in the treatment section, those treated fare much better than those untreated. Patients untreated tend to remain chronic or may show small, but generally unimpressive degrees of improvement with time. In a 10-year follow-up study of patients who had previously participated in treatment programs, the number of women who continued to meet full criteria for bulimia nervosa decline

as the duration of follow-up increased. Approximately 30 percent continued to engage in recurrent binge-eating or purging behaviors. A history of substance use problems and a longer duration of the disorder at presentation predicted worse outcome. Depending on definitions, 38 to 47 percent of women were fully recovered at follow-up.⁴

TREATMENT

Most patients with uncomplicated bulimia nervosa do not require hospitalization. In general, patients with bulimia nervosa are not as secretive about their symptoms as patients with anorexia nervosa. Therefore, outpatient treatment is usually not difficult, but psychotherapy is frequently stormy and may be prolonged. Some obese patients with bulimia nervosa who have had prolonged psychotherapy do surprisingly well. In some cases—when eating binges are out of control, outpatient treatment does not work, or a patient exhibits such additional psychiatric symptoms as suicidality and substance abuse—hospitalization may become necessary. In addition, electrolyte and metabolic disturbances resulting from severe purging may necessitate hospitalization.²

Psychotherapy

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) should be considered the benchmark, first-line treatment for bulimia nervosa. The data supporting the efficacy of CBT are based on strict adherence to rigorously implemented, highly detailed, manual-guided treatments that include about 18 to 20 sessions over 5 to 6 months. CBT implements a number of cognitive and behavioral procedures to (1) interrupt the self-maintaining behavioral cycle of bingeing and dieting and (2) alter the individual's dysfunctional cognitions; beliefs about food, weight, body image; and overall self-concept.²

Dynamic Psychotherapy

Psychodynamic treatment of patients with bulimia nervosa has revealed a tendency to concretize introjective and projective defense mechanisms. In a manner analogous to splitting, patients divide food into two categories: items that are nutritious and those that are unhealthy. Food that is designated nutritious may be ingested and retained because it unconsciously symbolizes good introjects. But junk food is unconsciously associated with bad introjects and, therefore, is expelled by vomiting, with the unconscious fantasy that all destructiveness, hate, and badness are being evacuated. Patients can temporarily feel good after vomiting because of the fantasized evacuation, but the associated feeling of âll good is short-lived because it is based on an unstable combination of splitting and projection.⁴

Pharmacotherapy

Antidepressant medications have been shown to be helpful in treating bulimia. This includes the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine. This may be based on elevating central 5-hydroxytryptamine levels. Antidepressant medications can reduce binge eating and purging independent of the presence of a mood disorder. Thus, antidepressants have been used successfully for particularly difficult binge-purge cycles that do not respond to psychotherapy alone. Imipramine (Tofranil), desipramine (Norpramin), trazodone (Desyrel), and monoamine oxidase inhibitors (MAOIs) have been helpful. In general, most of the antidepressants have been effective at dosages usually given in the treatment of depressive disorders. Dosages of fluoxetine that are effective in decreasing binge eating, however, may be higher (60 to 80 mg a day) than those used for depressive disorders. Medication is helpful in patients with comorbid depressive disorders and bulimia nervosa. Carbamazepine (Tegretol) and lithium (Eskalith) have not shown impressive results as treatments for binge eating, but they have been used in the treatment of patients with bulimia nervosa with comorbid mood disorders, such as bipolar I disorder.¹

Nursing Intervention.

IMBALANCED NUTRITION:MORE THAN BODY REQUIRMENT  related to

[Compulsive eating]

Excessive intake in relation to metabolic needs

[Sedentary lifestyle]

[Genetics]

[Unmet dependency needs—fixation in oral developmental stage]evidenced

Weight 20 percent over ideal for height and frame

[Body mass index of 30 or more]

Goals/Objectives

Short-Term Goal

Client will verbalize understanding of what must be done to lose weight.

Long-Term Goal

Client will demonstrate change in eating patterns resulting in a steady weight loss.

Interventions with Selected Rationales

1. Encourage the client to keep a diary of food intake. A food diary provides the opportunity for the client to gain a realistic picture of the amount of food ingested and provides data on which to base the dietary program.

2. Discuss feelings and emotions associated with eating. This helps to identify when client is eating to satisfy an emotional need rather than a physiological one.

3. With input from the client, formulate an eating plan that includes food from the basic food pyramid with emphasis on low-fat intake. It is helpful to keep the plan as similar to the client’s usual eating pattern as possible. Diet must eliminate calories while maintaining adequate nutrition. Client is more likely to stay on the eating plan if he or she is able to participate in its creation and it deviates as little as possible from usual types of foods.

4. Identify realistic increment goals for weekly weight loss. Reasonable weight loss (1 to 2 lb/wk) results in more lasting effects. Excessive, rapid weight loss may result in fatigue and irritability and may ultimately lead to failure in meeting goals for weight loss. Motivation is more easily sustained by meeting “stair-step”  goals.

5. Plan progressive exercise program tailored to individual goals and choice. Exercise may enhance weight loss by burning calories and reducing appetite, increasing energy, toning muscles, and enhancing sense of well-being and accomplishment. Walking is an excellent choice for overweight individuals.

6. Discuss the probability of reaching plateaus when weight remains stable for extended periods. Client should know that this is likely to happen as changes in metabolism occur. Plateaus cause frustration, and client may need additional support during these times to remain on the weight loss program.

7. Provide instruction about medications to assist with weight loss if ordered by the physician. Appetite-suppressant drugs (e.g., sibutramine)may be helpful to someone who is obese. Drugs should be used for this purpose for only a short period while the individual attempts to adjust to the new pattern of eating.

Outcome Criteria

1. Client has established a healthy pattern of eating for weight control  the weight loss progressing toward a desired goal.

2. Client verbalizes plans for future maintenance of weight control.

● DISTURBED BODY IMAGE/LOW SELF-ESTEEM  related to

[Dissatisfaction with appearance]

[Unmet dependency needs]

[Lack of adequate nurturing by maternal figure]

evidenced by

Negative feelings about body (e.g., feelings of helplessness, hopelessness, or powerlessness)

[Verbalization of desire to lose weight]

[Failure to take responsibility for self-care (self-neglect)]

Lack of eye contact

[Expressions of low self-worth]

Goals/Objectives

Short-Term Goal

Client will begin to accept self based on self-attributes rather than on appearance.

Long-Term Goal

Client will pursue loss of weight as desired.

Interventions with Selected Rationales

1. Assess client’s feelings and attitudes about being obese. Obesity and compulsive eating behaviors may have deep-rooted psychological implications, such as compensation for lack of love and nurturing or a defense against intimacy.

2. Ensure that the client has privacy during self-care activities. The obese individual may be sensitive or self-conscious about his or her body.

3. Have client recall coping patterns related to food in family of origin, and explore how these may affect current situation. Parents are role models for their children. Maladaptive eating behaviours are learned within the family system and are supported through positive reinforcement. Food may be substituted by the parent for affection and love, and eating is associated with a feeling of satisfaction, becoming the primary defense.

4. Determine client’s motivation for weight loss and set goals. The individual may harbour repressed feelings of hostility, which may be expressed inward on the self. Because of a poor self-concept, the person often has difficulty with relationships. When the motivation is to lose weight for someone else, successful weight loss is less likely to occur.

5. Help client identify positive self-attributes. Focus on strengths and past accomplishments unrelated to physical appearance. It is important that self-esteem not be tied solely to size of the body.Client needs to recognize that obesity need not interfere with positive feelings regarding self-concept and self-worth

6. Refer client to support or therapy group. Support groups can provide companionship, increase motivation, decrease loneliness and social ostracism, and give practical solutions to common problems.

Group therapy can be helpful in dealing with underlying psychological concerns.⁵

. CONCLUSION:

Prevention will only be possible when specific and reversible factors that lead to the initiation of eating disorders have been identified. However, treatment is often provided on an empirical basis. Here, the most pressing need is an intensive and comprehensive inpatient weight restoration programme for patients with bulimia nervosa  against outpatient supportive care plus access to brief hospitalization for nutritional stabilization.

Discussion    As a health care professional what type of preventive measures can apply to the public

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