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Bulimia Nervosa
Kelsey Maw
DSU
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Bulimia Nervosa
Introduction
A 45 year old female patient presented to her primary care provider’s office for a checkup. She reports that she has been feeling more tired than usual and experiences dizzy spells.
Upon review of health history the nurse discovers the woman has been having irregular
menstrual periods and having difficulty sleeping. The nurse begins her physical assessment.
Upon inspection of the oral cavity the nurse notes deterioration of enamel of the patient’s
teeth. Mucous membranes and skin of the face and hands are dry. The parotid gland appears
enlarged. The patient’s blood pressure is 95/55 with a resting heart rate of 58. The nurse also
notes abdominal bloating and some tenderness upon palpation. She also has bilateral lower
extremity edema. Blood work reveals hypokalemia and increased BUN. The nurse suspects the
patient is suffering from an eating disorder. After reviewing findings with the patient, she
reluctantly reports that since her divorce 9 months ago she has been binge-eating and
vomiting. Nursing diagnoses and implications for this patient include disturbed thought
processes related to poor body image, indicators of depression and insomnia; imbalanced
nutrition related to inadequate nutrition and self-induced vomiting; fluid volume deficit related
to electrolyte imbalances caused by self-induced vomiting; and impaired skin integrity as
evidenced by dry skin and mucous membranes; and lower extremity edema.
History
Bulimia nervosa (BN) is considered a relatively new disease. It was recognized in 1979
by Gerald Russell. Until recently there was not much research of information available about
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bulimia. Authors Van den Eynde & Schmidt (2008) attribute “celebrity cases” as well as
increasing prevalence of this disorder on the research that has been done.
Diagnosis
According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 2000)
there must be behavior and cognitive symptoms present for a diagnosis of bulimia nervosa to
accurately be made. Additional criteria includes experiencing recurrent episodes of eating large
amounts of food, or binge eating twice a week for three consecutive months followed by
behaviors that reduce or prevent weight gain such as: excessive exercise, vomiting, fasting,
abusing medications, laxatives, diuretics, or enemas. Cognitive symptoms must also be present
and are described as having “undue influence of body weight or shape on self-evaluation”
(Williams, Watts, & Wade, 2012) which is generally related to self-worth .
Labs & Imaging
In most cases a “complete blood cell count, erythrocyte sedimentation rate, urinalysis,
and measurements of liver function, electrolytes, and thyroid-stimulating hormone” tests
should be ordered (Williams & Goodie, 2007, p. 19). In addition, if a patient presents with
bradycardia or electrolyte abnormalities they should have an electrocardiogram (Williams &
Goodie, 2007).
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Treatment Options
The exact cause of bulimia nervosa is still unclear, which is one of the reasons it is so
difficult to predict and treat. Despite these reasons, there are some options available that have
shown to have good outcomes. Psychological treatment is one option. There are different
types of therapy such as cognitive behavioral therapy or interpersonal therapy that may be
helpful. Cognitive behavior therapy is provided by a trained mental health professional, which
can often be an impracticable option for some patients, “with a recommended course of
treatment of twenty 50-minute sessions over 4 to 5 months.” Self-help and guided self- help
are another option discussed by Van den Eynde & Schmidt (2008). The last treatment option is
pharmacological. Anti-depressants, specifically SSRI’s and have been used in cases of bulimia
nervosa. There is still a lot of research to be completed in this area, especially in regards to the
combination of treatment options and determining success.
Pharmacological Treatment of Bulimia Nervosa
Antidepressants are the main class of medications prescribed in the treatment of
bulimia nervosa.
“The rationale for this was high comorbidity between BN and affective disorders, and
findings of serotonin system dysfunctions in BN. According to some authors
antidepressants have antibulimic properties regardless of the presence of mood
symptoms, but according to others it remains unclear whether this effect is direct or
indirect by lowering depressive symptoms” (Eynde & Schmidt, 2008).
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SSRI’s are typically the first choice in the treatment of BN. Fluoxetine is approved by the FDA
for treatment of bulimia nervosa and has been the most effective up to this point. In general, a
higher dose of 60 mg would be prescribed for a patient diagnosed with bulimia nervosa. Other
medications, including mood stabilizers and medications such as ondansetron have had positive
results in some studies. A major factor with some psychotropics and feasibility of treatment is
the fact that they require administration more than once a day and can be very expensive.
Outcomes
Bulimia nervosa can be a difficult disorder to treat and there are many variables that will
affect the outcome. Authors Williams, Watts, & Wade (2012) use the terms remission, recovery
and relapse as the best indicators of how effective treatment has been. In many cases a person
never fully overcomes bulimia nervosa but simply displays fewer behaviors or has less frequent
episodes. Because each person will exhibit different symptoms, treatment can be a long
process and it’s difficult to achieve true remission. A problem that has been identified is when
focus is only placed on the absence of behavior symptoms when underlying cognitive aspects
are still present (Williams, Watts, & Wade, 2012).
Plan of Care
The most likely course of care for this patient would be to provide a referral for
outpatient cognitive behavioral therapy in addition to the administration of fluoxetine. In
addition to the physician, a therapist and dietician should be involved in planning care of this
patient. The initial goal would be focused on establishing and maintaining a healthy weight.
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Williams & Goodie (2007) suggest focusing on educating the patient about healthy eating habits
and consequences of binging and purging. They also discuss the need to establish “selfmonitoring of eating, reducing overeating and eliminating dieting” (Williams & Goodie, 2007, p.
19). This patient would most likely benefit from support about self-perception and
interpersonal therapy (Williams & Goodie, 2007).
Conclusion
Eating disorders have become more common, affecting both women and men.
Environmental, psychological and genetic factors can all contribute to the development of an
eating disorder like bulimia nervosa. Nurses and health care workers play important roles in
helping identify eating disorders. We should work to build trusting relationships with our
patients and be alert to signs and symptoms of bulimia nervosa and diagnostic criteria such as
recurrent binge eating, compensatory behaviors, and the way the body shape and weight is
viewed by the patient. Treatment can be a very long process that often involves behavior and
cognitive therapies that may be combined with pharmacological interventions. Patients often
experience many relapses and nurses can play a large supporting role. Nurses can not only
work to treat physical symptoms, but can help the patient develop a positive body image and
improve self-esteem.
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References
Sedghizadeh, P. P. (2013). Bulimia Nervosa. The New England Journal of Medicine, 368(13),
1238. Retrieved from
http://search.proquest.com.libproxy.dixie.edu/nursing/docview/1321934798/abstract/
81106D510F8245D9PQ/1?accountid=27045
Van den Eynde, F., & Schmidt, U. (2008). Treatment of bulimia nervosa and binge eating
disorder. Psychiatry, 7(4), 161-166. http://dx.doi.org/doi:10.1016/j.mppsy.2008.02.001
Walsh, T. B., Fairburn, C. G., Mickley, D., Sysko, R., & Parides, M. K. (2004). Treatment of Bulimia
Nervosa in a Primary Care Setting. The American Journal of Psychiatry, 161(3), 556-561.
Retrieved from
http://search.proquest.com.libproxy.dixie.edu/nursing/docview/220476870/AE98D861
F4F946E3PQ/27?accountid=27045
Williams, P. M., & Goodie, J. (2007). Identifying and treating eating disorders. Family Practice
Recertification, 29(8), 16-23. Retrieved from
http://web.b.ebscohost.com.libproxy.dixie.edu/ehost/pdfviewer/pdfviewer?sid=6af9a4
ce-650b-4131-9783-1001236c689a%40sessionmgr115&vid=0&hid=128
Willimas, S. E., Watts, T. K., & Wade, T. D. (2012). A review of the definitions of outcome used in
the treatment of bulimia nervosa. Clinical Psychology Review, 32(), 292-300. Retrieved
from doi:10.1016/j.cpr.2012.01.006