BULIMIA NERVOSA

often simply called bulimia, is an eating disorder characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate compensatory behaviours to avoid weight gain such as purging (self-induced vomiting or use of laxatives, diuretics, enemas, or emetics), fasting, or excessively exercising (APA, 2000). The amount of food consumed during a binge episode is much larger than a person would normally eat.

Usually begins in late adolescence or early adulthood; 18- 19 years is the typical age of onset. Binge eating frequently begins during or after eating. Between binging and purging episodes, clients may eat restrictively, choosing salads and other low calorie foods. These restrictive eating effectively sets them up for the next episodes of binging and purging and the cycle continues.

Clients with bulimia are aware that their eating behavior is pathologic and go to great lengths to hide it from the others. They may store food in their cars, desks, or secret location around the house. They may drive from one fast-food restaurant to another, ordering in normal amount of food at each but stopping at 6 places in one or two hours.

Such patterns may exist for years until family or friends discover the clients behavior or until medical complications develop for which the client seeks treatment. Follow up studies with clients with bulimia show that 10 years after the treatment, 30% continued to engage in recurrent binge eating and purging behaviors, whereas 38% to 47% were fully recovered. Anderson and Yager (2005)

Clients with comorbid personality disorder tend to have poorer outcomes than those without. The death rate from bulimia is estimated at 3% or less. Most client with bulimia are treated on an outpatient basis.

The client often engages in binge eating secretly. Between binges, the client may eat low-calorie foods or fast. Binging or purging episodes are often precipitated by strong emotions and followed by guilt, remorse, shame, or self-contempt.

See in Table 18-1

Cognitive-behavioural therapy has been found to be the most effective treatment for bulimia. This out- patient approach often requires a detailed manual to guide treatment. Strategies designed to change the clients thinking (cognition) and actions (behaviour) about food focus on interrupting the cycle of dieting, binging, and purging, and altering dysfunctional thoughts and beliefs about food, weight, body image, and overall self-concept (Halmi, 2000)

desipramine (Norpramin), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine (Prozac)

ASSESSMENT-Several specialized test have been developed for eating disorders. An assessment tool such as the Eating Attitudes Test often is used in studies of anorexia and bulimia.

Family members often describe clients with anorexia nervosa as perfectionists with above-average intelligence, achievement-oriented, dependable, eager to please, and seeking approval before their condition began. Parents describe clients as being good, causing us no trouble until the onset of anorexia. Likewise, clients with bulimia often are focused on pleasing others and avoiding conflict. Clients with bulimia, however, often have a history of impulsive behavior such as substance abuse and shoplifting as well as anx- iety, depression, and personality disorders (Schultz & Videbeck, 2002).

Clients with anorexia appear slow, lethargic, and fatigued; they may be emaciated, depending on the amount of weight loss. They may be slow to respond to questions and have difficulty deciding what to say. They are often reluctant to answer questions fully because they do not wanting to acknowledge any problem. They often wear loose-fitting clothes in layers, regardless of the weather both to hide weight loss and to keep warm (clients with anorexia are generally cold). Eye contact may be limited. Clients may turn away from the nurse, indicating their unwillingness to discuss problems or to enter treatment.

Clients with bulimia may be underweight or over- weight but are generally close to expected body weight for age and size. General appearance is not unusual, and they appear open and willing to talk.

Clients with eating disorders have labile moods that usually correspond to their eating or dieting behaviours. Avoiding bad or fattening foods gives them a sense of power and control over their bodies, whereas eating, binging, or purging leads to anxiety, depression, and feeling out of control. Clients with eating disorders often seem sad, anxious, and worried. Those with anorexia seldom smile, laugh, or enjoy any at- tempts at humor; they are somber and serious most of the time. In contrast, clients with bulimia are initially pleasant and cheerful as though nothing is wrong. The pleasant faade usually disappears when they begin describing binge eating and purging; they may express intense guilt, shame, and embarrassment.

It is important to ask clients with eating disorders about thoughts of self-harm or suicide. It is not un- common for these clients to engage in self-mutilating behaviors such as cutting. Concern about self-harm and suicidal behavior should increase when clients have a history of sexual abuse (see Chaps. 11 and 15).

Clients with eating disorders spend most of the time thinking about dieting, food, and food-related behavior. They are preoccupied with their attempts to avoid eating or eating bad or wrong foods. Clients can- not think about themselves without thinking about weight and food.

The body image disturbance can be almost delusional; even if clients are severely under- weight, they can point to areas on their buttocks or thighs that are still fat, thereby, fueling their need to continue dieting.

Generally clients with eating disorders are alert and oriented; their intellectual functions are intact. The exception is clients with anorexia who are severely malnourished and showing signs of starvation such as mild confusion, slowed mental processes, and difficulty with concentration and attention.

Clients with anorexia have very limited insight and poor judgment about their health status. They do not believe that they have a problem; rather they think that others are trying to interfere with their ability to lose weight and to achieve the desired body image. Facts about failing health status are not enough to convince these clients of their true problems. Clients with anorexia continue to restrict food intake or to engage in purging despite the negative effect on health

Low self-esteem is prominent in clients with eating disorders. They see themselves only in terms of their ability to control their food intake and weight. They tend to judge themselves harshly and see themselves as bad if they eat certain foods or fail to lose weight.

Eating disorders interfere with the ability to fulfill roles and to have satisfying relationships. Clients with anorexia may begin to fail at school, which is in sharp contrast to previously successful academic performance. They withdraw from peers and pay little attention to friendships. They believe that others will not understand or fear that they will begin out-of- control eating with others.

The health status of clients with eating disorders relates directly to the severity of self-starvation, purging behaviours, or both (see Table 18-1). In addition, clients may exercise excessively, almost to the point of exhaustion, in an effort to control weight. Many clients have sleep disturbances such as insomnia, reduced sleep time, and earlymorning wakening.

Eating disorders usually first diagnosed in infancy and childhood include rumination disorder, pica, and feeding disorder (see Chap. 20).