Bulimia Nervosa
__% population
Stats likely the tip of the iceberg as this disorder is very ___
Onset adolescence?
Onset slightly ___ than AN
Persists at all ages
2-4% population
Secretive
Early adulthood
Later
DSM-5: Bulimia Nervosa?
• BMI may be subnormal, normal or >25 (obese)
• Binge eating alternating with purging
• May involve intense exercise
• Feelings of a lack of control over the cycles
• Episodes once a week minimum for 3 months
• Severity is based upon number of episodes a week-p. 191 text
• Distorted body image
• Tension which is followed by guilt and shame
Co-occurring with Binge Eating?
Bipolar, Depression, Anxiety, SUD, Personality Disorders
Nursing Process Example: Binge?
Ineffective denial: refuses to acknowledge impact of obesity on health R/T lack of motivation to change AEB patient continues to sneak food onto unit, has refused to participate in planning a weight management program.
- Goal: At discharge, client will be able to explain health risks due to obesity
Nursing Actions:
1. Provide education on causes and consequences of obesity in group therapy
2. Dietician referral
3. Establish a therapeutic relationship with focus on encouraging client to express feelings about how obesity impacts her achieving her goals
4. Prepare for discharge by helping client to identify triggers, when she binges, how to substitute healthy coping mechanisms
Co-occuring?
- Depression, SUD, impulsivity, anxiety disorders
Nursing process Example?
Low self esteem R/T disturbed body image AEB patient reports she feels shame about her bulimia and feels like a failure in school
Goal:
1) Beth’s Journal will indicate positive affirmations (replace cognitive distortions) and acknowledge her ability to reach her goals
Nursing Actions:
1. Beth will work with IDT and School liaison to establish goals for completing her school coursework (refocus from food to academic achievement
2. Beth to journal twice daily with a focus on accomplishments and positive affirmations
3. Individual therapy participation daily
4. Group therapy twice a week with the Eating Disorder Team
5. Beth to set short term goals that she can reach daily
6. Explore CAM therapy preferences and make referrals
Binge strongly associated with obesity: ___% prevalence in an obese population
42%
Binge: __% women, __% men –lifetime prevalence, general population
3.5% women, 2% men –lifetime prevalence, general population
___% of people with Bulimia Nervosa have considered suicide
25-33%
Bulimia Nervosa: Theories of etiology?
Predisposing factors Similar to AN
Genetic/Neurobiology: Documented neurotransmitter and endocrine abnormality but different than AN
DSM5 Binge Eating?
• Recurrent and persistent episodes of binge eating
• Binge eating episodes are associated with 3(or more) of the following:
• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of being embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed, or very guilty after overeating
• Marked distress regarding binge eating
• Absence of regular compensatory behaviors (such as purging).
• Screening Tool Binge Eating Scale
___% in an obese population seeking weight loss treatment
7.5% -30%
Bulimia Nervosa: death by suicide ___ than general population
Higher
Bulimia Nervosa: Interventions?
Similar to AN General List
Physiological stability priority
• Relationship with healthcare providers may be more easily established because he client is more likely to want to change; client is often ashamed of the cycle of binging and purging
• Psychotherapy including CBT to explore triggers (cognitive distortions) for the binge that starts the cycle
• Prevent purging by removing access to any OTC medication, stimulants, teas, energy drinks with caffeine
• Prevent purging by 1:1 or line of sight for 2 hours after meals
• Education on disease process and possible etiologies
• Alternative therapies for coping
• Encourage expression of feelings
• Prozac /fluoxetine for control of urge to binge
• FDA Approved in 2015 for BED (may be effective due to increase in dopamine –Vyvanse, off label for Bulimia
Binge Eating: Nursing Process?
• Assessment similar to AN and BN
• Treat as a compulsion/addiction
• Physiological need priorities may include diabetes, cardiac or respiratory insufficiency, skin alterations, joint pain
• Recovery philosophy
• Reduce focus on controlling food and increase focus on other areas of assertiveness, decision making for increasing self esteem
• Promote expression of feelings, develop coping skills
• Provide compassion, limit setting, recognize achievements
• Dieting not always in the history of the individual
• Assessment of Depression, SUD, Suicidal ideations
• Intervention may include treatment of mood disorder with SSRIs
Non-pharm for BED?
• Individual Therapies-CBT common
• Group therapy
• Over Eaters Anonymous and other RECOVERY models
Tension builds during binge and vomiting relieves the tension which is followed by guilt and shame?
Psychological mechanism
Bulimia Nervosa: Nursing Diagnoses?
- Disturbed body image/ Describes, draws, body consistent with image
- Ineffective coping/No purging
- Chronic low self esteem/ Names, draws 3 positive traits or stengths in the journal weekly
- Risk of harm: ruptured esophagus with hemorrhage/No injury due to hemorrhage
- Risk of self harm: suicide/No suicide ideations or attempts
- Risk of electrolyte imbalance d/t self-induced vomiting/ Electrolytes within normal values
Binge Eating: Untreated?
• Discrimination in workplace
• Shame
• Cardiovascular disease: hypertension, atherosclerosis, hyperlipidemia
• Diabetes
• Respiratory insufficiency
• Osteoarthritis
• Immobility
• Skin breakdown
• Death by suicide
Off label and Trial Pharmacologics for BED, Obesity?
• Prozac-reduction of CHO craving
• Topamax-reduction of binge eating
• SSRIs to reduce bulimia
• Beluq, Qymia-effect hypothamus to induce appetite loss