Complications of Bulimia Nervosa A number of potential complications can arise with bulimia nervosa: ● Suicide risk: Persons affected by bulimia nervosa have an increased risk of suicide. Clients should be assessed for suicidal ideation as well as the coexistence of other mental health disorders such as depression, obsessive-compulsive disorder, and other anxiety disorders (Mayo Clinic, 2018d). ● Dental erosion: The acidic gastric contents expelled by vomiting destroy tooth enamel. This can lead to severe tooth decay and dental problems (Eating Disorder Hope, 2018b; Videbeck, 2017). ● Esophageal damage leading to esophageal bleeding: Such bleeding can progress to hemorrhage (Eating Disorder Hope, 2018b). Diagnostic Criteria The following statements summarize the diagnostic criteria for bulimia nervosa as identified in the DSM-5 (American Psychiatric Association, 2013): ● Recurrent episodes of binge eating: Binge eating is described as eating in a specific period an amount of food that is definitely larger than most people would eat in a similar time under similar circumstances. There must also be a feeling of a lack of control over eating during the binging episode. ● Recurrent inappropriate compensatory behaviors to prevent weight gain: Examples of inappropriate behaviors are self- induced vomiting; abuse of laxatives, diuretics, or other medications; fasting; and excessive exercise. ● Binging and purging occur on an average of at least once a week for three months. ● Self-evaluation is disproportionately influenced by body shape and weight. ● The binging and purging do not occur exclusively during episodes of anorexia nervosa. Treatment Interventions for Bulimia Nervosa Early treatment of bulimia nervosa is critical because as time goes on, the client’s behavior patterns become more entrenched, and clients become more resistant to change. The earlier clients receive treatment, the more likely they are to fully recover (Gersch et al., 2016). Healthcare consideration : Hospitalization is indicated for persons whose binging and purging behaviors are out of control or if their medical status is compromised (Mayo Clinic, 2018d; Videbeck, 2017). For example, hospitalization is indicated for severe fluid and electrolyte imbalance, cardiac compromise, and danger from potential hemorrhage because of gastric or esophageal tears or rupture. Research has suggested that the most effective treatment for bulimia nervosa is cognitive behavioral therapy (CBT). This is an outpatient treatment intervention requiring a detailed strategy to guide treatment. Research has suggested the need for highly detailed, manual-guided treatments for 18 to 20 sessions over a period of 5 to 6 months that should be conducted by a therapist who is an expert in CBT and who has experience treating persons with bulimia nervosa (Gersch et al., 2016; Mayo Clinic, 2018d; Videbeck, 2017). The goal of CBT is to change the client’s cognition (thinking) and behaviors. Emphasis is on helping persons suffering from the disorder to identify unhealthy, negative beliefs, thoughts, and behaviors, and replace them with healthy, positive ones (Gersch et al., 2016; Mayo Clinic, 2018d). Therapy is designed to stop the client’s focus on food and to interrupt the cycle of dieting, binging, and purging (Videbeck, 2017). Other possible forms of psychotherapy may be part of the treatment regimen (Mayo Clinic, 2018d):
● Gastric rupture: The pressure and damage to the gastric area from prolonged episodes of vomiting can lead to significant bleeding, hemorrhage, and peritoneal infection because of the release of gastric contents following rupture (Eating Disorder Hope, 2018b; Videbeck, 2017). ● Cardiac problems: Cardiac problems can occur as a result of electrolyte imbalances. Many of these imbalances affect the cardiac system and can cause dangerous, even life- threatening, arrhythmias (Eating Disorder Hope, 2018b; Mayo Clinic, 2018e; Videbeck, 2017). Palpitations, which usually occur immediately after purging, are caused by the stress of purging and volume depletion. Palpitations that occur more frequently need immediate investigation. As part of the diagnosis, it should be specified if the affected person is in one of the following states (American Psychiatric Association, 2013): ● Partial remission: After full criteria for bulimia nervosa were met, some but not all of the criteria have been met for a sustained period. ● Full remission: After full criteria for bulimia nervosa were met, none of the criteria have been met for a sustained period. The severity of the disorder should also be documented. The following are the criteria for classifying the severity of bulimia nervosa (American Psychiatric Association, 2013): ● Mild: An average of 1 to 3 episodes of inappropriate compensatory behaviors occur per week. ● Moderate: An average of 4 to 7 episodes of inappropriate compensatory behaviors occurs per week. ● Severe: An average of 8 to 13 episodes of inappropriate compensatory behaviors occurs per week. ● Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors occurs per week. ● Interpersonal psychotherapy: This helps affected persons deal with interpersonal problems and improve communication and problem-solving skills. ● Family-based therapy: Family therapy focuses on helping the family unit to intervene to stop the pattern of binging and purging and regain control, stop unhealthy family interactions, and enhance interpersonal relationships among family members. ● Medication therapy: Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are sometimes prescribed to clients who are not pregnant to treat depression even if depression has not been diagnosed (Mayo Clinic, 2018d). Findings from research have suggested that antidepressants were more effective than placebos in reducing the occurrence of binge eating. These drugs also improved mood and reduced fixation on body shape and weight. However, these positive outcomes were short term; about 33% of clients relapsed (Videbeck, 2017). Healthcare consideration : Fluoxetine (Prozac) is the only FDA-approved antidepressant specifically approved for the treatment of bulimia. It has been shown to help clients even if depression is not present (Mayo Clinic, 2018d) Education regarding nutrition and achieving and maintaining a healthy weight in healthy ways is also part of the treatment for bulimia nervosa. Dieticians must be part of the healthcare team and have active input into the treatment regimen focusing on how to achieve a healthy weight, develop normal eating habits, and recognize the components of a healthy diet (Mayo Clinic, 2018d).
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