Page 74 nursing.elitecme.com Complete Your CE Test Online - Click Here Diagnostic criteria The following statements summarize the diagnostic criteria for bulimia nervosa as identified in the DSM-5[1] : ● ● Recurrent episodes of binge eating. Binge eating is described as eating in a specific period of time, an amount of food that is definitely larger than most people would eat in a similar time period under similar circumstances. There must also be a feeling of a lack of control over eating during the binging episode. ● ● Recurrent inappropriate compensatory behaviors in order to prevent weight gain. Examples of inappropriate behaviors include self-induced vomiting, abuse of laxatives, diuretics, or other medications, fasting, and/or 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. As part of the diagnosis, it should be specified if the affected person is in[1] : ● ● Partial remission: After full criteria for bulimia nervosa were met, some but not all of the criteria have been met for a sustained period of time. ● ● Full remission: After full criteria for bulimia nervosa were met, none of the criteria have been met for a sustained period of time. The severity of the disorder should also be documented. The following are the criteria for classifying the severity of bulimia nervosa[1] : ● ● Mild: An average of 1-3 episodes of inappropriate compensatory behaviors occurs per week. ● ● Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors occurs per week. ● ● Severe: An average of 8-13 episodes of inappropriate compensatory behaviors occurs per week. ● ● Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors occurs per week. Treatment interventions for bulimia nervosa Most persons who are affected by bulimia nervosa are treated in outpatient settings. Since most clients have normal or almost-normal weight, the concerns about severe malnutrition are reduced. This is in contrast to persons suffering from anorexia nervosa, who are generally suffering from significant malnutrition[2,9,12,18] . Nursing consideration: Hospitalization is indicated for persons whose binging and purging behaviors are out of control and/or if the medical status is compromised[12,18] . For example, hospitalization is indicated for severe fluid and electrolyte imbalance, cardiac compromise, and danger from potential hemorrhage due to gastric or esophageal tears or rupture. Research indicates that the most effective treatment for bulimia nervosa is cognitive behavioral therapy (CBT). This is an outpatient treatment intervention and requires a detailed strategy to guide treatment. Research indicates the need for highly detailed, manual guided treatments for 18 to 20 sessions over a period of five to six months, and should be conducted by a therapist who is an expert in CBT and who has experience treating persons with bulimia nervosa[9,12,18] . 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[16,18] . Therapy is designed to stop the client’s focus on food and to interrupt the cycle of dieting, binging, and purging[12] . Other possible forms of psychotherapy that may be part of the treatment regimen include[16,18] : ● ● Interpersonal psychotherapy: Helps affected persons deal with interpersonal problems and improve communication and problem- solving skills. ● ● Dialectical behavior therapy: This therapy is designed to help affected persons learn ways to tolerate stress, control emotions, and enhance interpersonal relationships. Affected persons also learn to recognize stressors that trigger binging and purging and learn coping strategies to deal with such stressors. ● ● 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. Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat depression and even if depression has not been diagnosed[16,18] . Findings from research indicate 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 within a two- year period[12] . Nursing 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[18] . 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[16,18] . Some alternative medicine interventions may be helpful to reduce the signs and symptoms of bulimia nervosa. Examples of such interventions include[16,18] : ● ● Massage and therapeutic touch: These can help to reduce anxiety and alleviate stress associated with eating disorders. ● ● Mind-body therapies: These include meditation, yoga, and biofeedback. Such interventions are designed to facilitate relaxation, reduce stress, and increase a sense of well-being. ● ● Acupuncture: Acupuncture may help to alleviate anxiety and depression. Research is being conducted to determine its effectiveness. ● ● If clients are also abusing alcohol or other drugs, they may need to participate in a drug rehabilitation program. Self-help and support groups may also be of benefit[9] . Nursing consideration: Most people with bulimia nervosa recover, but some find that symptoms do not go away permanently. Episodes of binging and purging may recur throughout the person’s lifetime, particularly during periods of stress or anxiety[2,12,16,18] . Clients and families must be educated about the possibility of recurrence and to seek immediate medical help if this occurs. The effectiveness of treatment varies according to the ability of the client to recognize what triggers binging and purging and her/his ability to deal with these issues. Some people recover completely, while others relapse. It is important that healthcare professionals realize that some people with bulimia nervosa need life-long monitoring. Moreover, it is important that persons affected by bulimia nervosa and other eating disorders receive objective, supportive care. Healthcare professionals must not show disgust or amusement, nor should they behave in a judgmental fashion. Objectivity and empathy must be part of the healthcare professional’s demeanor. Nursing interventions It is important to be able to provide nursing interventions that are necessary for improvements in client care and enhancing client outcomes, as well as to add to the body of knowledge that is nursing. Eating disorders are not easily understood. Society emphasizes the importance of being attractive, and being attractive often means being thin. This is the message sent by role models in the popular media.