Page 72 Complete Your CE Test Online - Click Here These low calorie choices look as though the client is merely following a sensible, low calorie diet. In reality, the person with bulimia nervosa is preparing herself for the next cycle of binging and purging[12] . Clients become quite adept at hiding quantities of food in various locations such as in their cars, desks, purses, briefcases, school lockers, and unusual places in their homes. They may drive from one restaurant (especially fast-food restaurants) to another, purchasing “normal” size meals at each but stopping at many restaurants in just a few hours so that they can binge without discovery[12] . Nursing consideration: Cycles of binging and purging alternating with cycles of symptom remission may occur for years without discovery. Behaviors may be discovered by accident, by unexpectedly coming upon the client when she/he is binging or purging, or when medical complications of the disease occur[1,12] . Nurses must be alert to behaviors that suggest clients are binging and purging. Long-term follow-up studies show that[12] : ● ● 10 years after treatment, 30% of clients still engaged in repeated episodes of binging and purging. ● ● 10 years after treatment, 38% to 47% of affected persons were fully recovered. ● ● One-third of those persons who were fully recovered relapsed. Nursing consideration: Clients who have a “co-morbid personality disorder tend to have poorer outcomes than those without[12] .” Nurses must be aware of co-existing conditions when caring for clients with bulimia. Essential features of bulimia nervosa The DSM-5 describes the following essential features of bulimia nervosa[1] : ● ● Recurrent episodes of binging and purging. ● ● Recurrent inappropriate compensatory behaviors in order to prevent weight gain. ● ● Binging and purging behaviors occur, on average, at least once a week for three months. ● ● Self-evaluation is unduly influenced by body shape and weight. ● ● The disturbance does not occur exclusively during episodes of anorexia nervosa. The previous features must be present to support a diagnosis of bulimia nervosa. Remember that anorexia nervosa and bulimia nervosa can co-exist. But in order to qualify for a diagnosis of bulimia nervosa, the binging and purging behaviors must NOT occur only during episodes of anorexia nervosa[1] . Mental health and neurological disorders and bulimia nervosa Several mental health and neurological disorders are associated with bulimia nervosa. Here is some information to help nurses and other healthcare professionals distinguish between these disorders and bulimia nervosa. ● ● Anorexia nervosa, binge-purging type: Persons whose binging and purging occur only during episodes of anorexia nervosa are given the diagnosis of anorexia nervosa: Binge-eating/purging type. They should not be given the co-existing diagnosis of bulimia nervosa. An additional diagnosis of bulimia nervosa is made only when all of the diagnostic criteria for bulimia nervosa have been met for at least three months[1] . ● ● Binge-eating disorder: Persons who binge but do not purge do not meet the criteria for bulimia nervosa. These people may meet the criteria for binge-eating disorders. ● ● Borderline personality disorder: Borderline personality disorder is characterized by a consistent pattern of unstable interpersonal relationships, self-image, and affect. Persons affected by this disorder also display significant impulsivity[12] . Binge-eating behaviors are included as part of the impulsivity criteria for borderline personality disorder. If criteria for both disorders are met, a diagnosis of bulimia nervosa, as well as borderline personality disorder should be given[1] . ● ● Kleine-Levin Syndrome: Disturbed eating behaviors are part of certain neurological conditions, such as Kleine-Levin Syndrome. Kleine-Levin Syndrome is a rare disorder characterized by recurring, but reversible, periods of excessive sleep and irritability, excessive food intake, childishness, and abnormally uninhibited sex drive[17] . However, the abnormal concern with body shape and weight are not present in these neurological conditions[1] . ● ● Major depressive disorder with atypical features: Overeating behaviors are often seen in persons with major depressive disorder with atypical features. However, purging behaviors are not part of the characteristics of major depressive disorder with atypical features, nor is excessive concern with body shape and weight gain present that is part of the criteria for bulimia nervosa. If criteria for both disorders are present, both diagnoses (bulimia nervosa and major depressive disorder with atypical features) should be given[1] . Generalized signs and symptoms of bulimia nervosa include[9,12,16] : ● ● Recurrent episodes of binge eating and purging occur. Since clients often hide these behaviors from even their closest family members and friends, it is important to recognize other warning signs and symptoms, even if binging and purging are not observed. ● ● Large supplies of laxatives and diuretics are found in the medicine chest of persons suspected of having the disorder. Clients abuse laxatives, diuretics, and the use of enemas in their purging attempts. ● ● The breath of affected persons may have a strong odor of mouthwash or breath mints as they attempt to cover the bad breath smell from vomiting. ● ● Affected persons may eat to the point of discomfort and epigastric pain. They may eat rapidly during periods of binging. ● ● Affected persons may exercise excessively. ● ● Affected persons seem to spend an unusual amount of time in the bathroom, especially after meals. ● ● Affected persons are preoccupied with body shape and weight. ● ● Affected persons are obsessed with and fearful of the idea of gaining weight. ● ● Affected persons often eat abnormally large amounts of food at a time, especially high-fat, high-calorie foods. The foods are often soft in consistency since these kinds of food do not irritate a throat that may already be injured due to self-induced vomiting. ● ● Affected persons may dislike and avoid eating in public or in front of other people. ● ● Affected persons may abuse alcohol and/or other drugs. Physical assessment reveals normal weight or slightly above normal weight. This characteristic helps to distinguish bulimia nervosa from anorexia nervosa. Symptoms of anxiety or depression may be evident. Clients may also frustrate easily, behave impulsively, and have difficulty functioning in social settings, at school, or at work[9,12] . Menstrual irregularities, including amenorrhea, may occur[9] . Repeated episodes of vomiting may lead to painless enlargement of the salivary glands, hoarseness, sore throat, lacerations of the throat, and esophageal tears. Dental examination shows a loss of dental enamel, and teeth are chipped, ragged, or moth-eaten in appearance[9,12] . Examination of the client’s hands reveals calluses on the knuckles or abrasions and scars on the backs of the hands due to tooth injury as the client self-induced vomiting by sticking her/his fingers down the throat[9,12] . Nursing consideration: Many persons with bulimia nervosa induce vomiting by ingesting ipecac[9] . Therefore, injuries to the hands and knuckles would not be evident. Persons with bulimia nervosa are commonly perceived by others to have the “perfect” life. They may be thought to be the perfect student, perfect spouse, perfect career woman, and/or the perfect parent. Adolescents may excel at competitive activities such as sports or academic test scores. However, psychosocial assessment may reveal symptoms of depression or anxiety disorders, feelings of guilt, and/or childhood trauma such as sexual abuse[9] .