Bulimia nervosa

Introduction:
Bulimia nervosa is an eating disorder in which a person binges and purges. The person may eat a lot of food at once and then try to get rid of the food by vomiting, using laxatives, or sometimes over-exercising. People with bulimia are preoccupied with their weight and body image. Bulimia is associated with depression and other psychiatric disorders. It shares some symptoms with anorexia nervosa, another major eating disorder. Because many people with bulimia can maintain a normal weight, they may be able to keep their condition a secret for years. If not treated, bulimia can lead to nutritional deficiencies and even fatal complications.

Signs and Symptoms:

People with bulimia may have the following signs and symptoms:
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Binge eating of high-carbohydrate foods, usually in secret Exercising for hours Eating until painfully full Going to the bathroom during meals Loss of control over eating, with guilt and shame Body weight that goes up and down Constipation, diarrhea, nausea, gas, abdominal pain Dehydration Missed periods or lack of menstrual periods Damaged tooth enamel Bad breath Sore throat or mouth sores Depression

What Causes It?:

No one knows what causes bulimia, although there are several theories. Genes may play a part -there is some evidence that women who have a sister or mother with bulimia are at higher risk of developing the condition. Families may put an too much emphasis on achievement, or may be overly critical. Psychological factors may also play a part including having low self-esteem, not being able to control impulsive behaviors, and having trouble expressing anger. Some people with bulimia may have a history of sexual abuse. People with bulimia may also experience depression, self-mutilation, substance abuse, and obsessive-compulsive behavior. Cultural pressures to look thin can also play a part, particularly among dancers and athletes.

Who's Most At Risk?:

People with the following conditions or characteristics are at higher risk for developing bulimia:

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White, middle-class women (mostly teenagers and college students) People with a family history of mood disorders and substance abuse People with low self-esteem

What to Expect at Your Provider's Office:

Often, people with bulimia are ashamed of their condition and do not ask for help for many years. By then, their habits are harder to change. If you have symptoms of bulimia, you should talk to your doctor as soon as possible. The doctor should check for physical signs such as eroded tooth enamel and enlargement of the salivary glands, as well as signs of depression. Laboratory tests may show chemical changes caused by bingeing and purging. Your doctor or a mental health practitioner will do a psychological exam and ask about your feelings and your eating habits.

Treatment:

Treatment Plan
The most successful treatment combines psychotherapy, family therapy, and medication. It is important for the person with bulimia to be actively involved in their treatment.

Drug Therapies
Antidepressants are often prescribed for bulimia. The most common antidepressants prescribed are selective serotonin reuptake inhibitors (SSRIs). They include:
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Fluoxetine (Prozac) Sertraline (Zoloft) Paroxetine (Paxil) Fluvoxamine (Luvox)

Prozac is the only antidepressant approved by the Food and Drug Administration to treat bulimia, although some studies suggest that other SSRIs, such as Luvox, may be even more effective. Some studies indicate that Prozac and other antidepressants may cause some children and teenagers to have suicidal thoughts. Children who are taking these drugs should be monitored very carefully for signs of suicidal behavior. People with bulimia may not be getting the nutrients their bodies need. Your health care provider may prescribe potassium or iron supplements, or other supplements to make up for any deficiency.

Complementary and Alternative Therapies

Psychotherapy is a cornerstone of bulimia treatment. Cognitive behavioral therapy, which teaches you to replace negative thoughts and behaviors with healthy ones, is a common treatment method. Other mind-body and stress-reduction techniques, such as yoga, tai chi, and meditation, may help you become more aware of your body and have a more positive body image. A 6-week clinical trial showed that guided imagery helped people with bulimia reduce bingeing and vomiting, feel more able to comfort themselves, and improved feelings about their bodies and eating. More studies are needed to see if guided imagery has long-term benefits. Always tell your health care provider about the herbs and supplements you are using or considering using.

Nutrition and Supplements

People with bulimia are more likely to have vitamin and mineral deficiencies, which can affect their health. Getting enough vitamins and minerals in your diet or through supplements can correct the problems. Some natural therapies, including dietary supplements, may help general health and well-being. Following these nutritional tips may help reduce symptoms:
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Avoid caffeine, alcohol, and tobacco. Drink 6 - 8 glasses of filtered water daily. Use quality protein sources -- such as lean meat and eggs, whey, and vegetable protein shakes -- as part of a balanced program to gain muscle mass and preventing wasting. Avoid refined sugars, such as candy and soft drinks.

If you aren' t getting enough of some nutrients, your doctor may suggest the following supplements:
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A daily multivitamin, containing the antioxidant vitamins A, C, E, the B-vitamins, and trace minerals, such as magnesium, calcium, zinc, phosphorus, copper, and selenium. Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil two to three times daily, to help decrease inflammation and improve immunity. Cold-water fish, such as salmon or halibut, are good sources; eat two servings of fish per week. Fish oil can increase the risk of bleeding, so ask your doctor before taking it. Eating fish doesn' t cause the same problem. Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support. Creatine, 5 - 7 grams daily, when needed for muscle weakness and wasting. In high doses, creatine may harm the kidneys. People with kidney problems should not take creatine. People with bulimia should ask their doctor before taking creatine, and their doctor should check their kidney function.

Probiotic supplement (containing Lactobacillus acidophilus among other strains), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. Refrigerate probiotic supplements for best results.

Herbs
Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted. These herbs are not used to treat bulimia specifically, but may be good for general overall health:
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Ashwagandha (Withania somniferum) standardized extract, 450 mg one to two times daily, for general health benefits and stress. Pregnant and breast-feeding women should not take ashwaganda. Ashwaganda can interact with some prescription medications, so ask your doctor before taking it. Holy basil (Ocimum sanctum) standardized extract, 400 mg daily, for stress. You can also prepare teas from the plant. Holy basil may make the effects of blood thinners, such as warfarin (Coumadin) and aspirin, stronger. Holy basil also interacts with pentobarbital (Nembutal), a sedative. Grape seed (Vitis vinifera) standardized extract, 100 - 200 mg three times daily, for antioxidant effects, and heart and blood vessel protection. Pregnant women should not take grape seed. Grape seed may increase the risk of bleeding, especially if you also take blood thinners such as warfarin (Coumadin). Ask your doctor before taking grape seed if you take blood thinning medication. Catnip (Nepeta spp.), as a tea two to three times per day, to calm the nerves and soothe the digestive system. Pregnant and breast-feeding women and women with pelvic inflammatory disease should ask their doctors before taking catnip. Stop taking catnip at least 2 weeks before surgery. Catnip may interact with lithium and sedative medications.

Homeopathy
There are no scientific studies that support using homeopathy to treat bulimia. However, an experienced homeopath will consider your individual case and may recommend treatments to address both your underlying condition and any current symptoms.

Acupuncture
There are no scientific studies that support using acupuncture to treat bulimia. However, a trained acupuncturist may be able to recommend acupuncture treatments to support your overall health. Many inpatient treatment centers for eating disorders include acupuncture in their overall

treatment plan. Studies have found that acupuncture can be helpful in treating addictive behaviors and anxiety in general, which can help people with bulimia who are in recovery.

Massage
Therapeutic massage can be an effective part of a bulimia treatment plan. In one study, teen girls with bulimia got massage therapy for 5 weeks or were in a control group that didn' t get massage therapy. The 24 girls receiving massage improved, while the control group did not improve. Women in the massage group were less anxious and depressed right after their first massages. They also had better scores on the Eating Disorder Inventory, which helps health care providers assess psychological and behavioral traits in eating disorders.

Prognosis/Possible Complications:
Many people with bulimia relapse after treatment and need long-term care. Possible complications from repeated bingeing and purging include problems with the esophagus, stomach, heart, lungs, muscles, or pancreas. People with suicidal thoughts or severe symptoms may need to be hospitalized. Women with bulimia may find pregnancy emotionally difficult because of the changes in their body shape. The mother's poor nutritional health can affect the baby. Women who have stopped having periods because of bulimia will be unable to become pregnant.

Following Up:
Because bulimia is usually a long-term disease, a health care provider will need to check the person's weight, exercise habits, and physical and mental health from time to time. ROLE OF THE NURSE Having knowledge and understanding will enable nurses to monitor food intake and observe for potential eating disorders. Treatment will depend on an individual's symptoms and relate specifically to the individual problem. Patients may be cared for: in primary or secondary care environments; at home; as inpatients in a hospital, nursing or residential home; at a private clinic; or at an outpatient clinic. Nurses must remember that many patients may also be receiving treatment for other psychological or physical conditions and that the eating disorder may have a major impact on their overall condition. It is essential to observe patients' nutritional status as eating disorders can be life threatening. It is also important to ensure they maintain adequate nutrition and electrolyte balance. If an eating disorder has been identified, the nurse must monitor weight on a regular basis. This can be achieved by encouraging the supervision of patients during and after mealtimes in order to prevent vomiting after eating. Setting time limits for each meal will help to set realistic expectations and encourage a relaxed atmosphere at mealtimes that will, in turn, help to reduce stress and anxiety.

It is essential to monitor patients' elimination pattern as excessive use of diuretics and laxatives is common among patients with eating disorders. As a consequence, patients may require intervention to treat constipation. Monitoring skin condition for breakdown and poor healing is an important part of the nurse's role. A lack of protein, needed to aid tissue repair, makes the skin more likely to break down. In addition, it is vital that good oral hygiene is achieved as recurrent vomiting may cause dental problems. Finally, it is important to monitor patients' activity levels. With anorexia they may undertake excessive exercise that can be detrimental to their physiological state. Additionally, if they also have a physical illness, excessive exercise could slow their recovery. PSYCHOLOGICAL CARE Nurses must be non-judgemental and accepting of patients with eating disorders. This can be achieved by building a trusting relationship and by encouraging patients to talk about their concerns. An important part of the nurse's role is to educate family and carers about a patient's eating disorder. The family can then be encouraged to participate in the patient's care and provide support. Observing for potential suicide risk must also be considered. Within mental health settings, behaviour modification approaches are used to reward patients for weight gain. This positive reinforcement helps to encourage the desired behaviour. It is important to ensure that patients take some responsibility for treatment of their condition. This can be achieved by establishing a contract with them over the amount and type of food to be eaten at each meal. By ensuring that positive feedback is given, compliance with the eating regimen can be maintained and patients' self-esteem promoted. The National Collaborating Centre for Mental Health developed a clinical guideline in relation to eating disorders for NICE (NICE, 2004). It produced core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. The following priorities were identified for patients with anorexia nervosa: - Most people with anorexia are managed as outpatients and should be able to access specialised care; - When requiring inpatient admission, people with anorexia will receive skilled implementation of refeeding with physical monitoring and psychological interventions; - Appropriate family interventions will be provided for children and adolescents with anorexia nervosa.

The following core interventions are noted for care of those with bulimia nervosa: - Patients diagnosed with bulimia nervosa will be encouraged to follow an evidence-based selfhelp programme; - Adults with bulimia may also be offered a trial of an antidepressant drug; - Cognitive behaviour therapy (CBT) programmes of 16-20 sessions over four or five months can be offered to adults with bulimia nervosa. Adolescents with bulimia can also be treated with CBT suitable for their age and circumstances. If possible, the family will be included as part of the individual's treatment. It is important that all nurses are knowledgeable about eating disorders and that they have appropriate understanding of the nursing care provided for vulnerable patients with eating disorders that often go unrecognised and undiagnosed. Nurses have an important role to play in supporting patients with eating disorders and in ensuring that they can and do access the treatment and support that is required. LEARNING OBJECTIVES - Understand the various causes of eating disorders - Recognise the signs and symptoms of anorexia nervosa - Recognise the signs and symptoms of bulimia nervosa - Be aware of the nurse's role in managing eating disorders GUIDED LEARNING - Identify signs and symptoms of eating disorders - List factors that contribute to the development of these disorders - Describe psychological aspects of care for people with eating disorders - Outline physical problems resulting from eating disorders This article has been double-blind peer-reviewed.