Bulimia Nervosa

Eating disorder (Bulimia Nervosa), Binge Eating

1. Presentation on Bulimia nervosa Presented by- Amit newton M.Sc. Final Year

2. Eating disorders Eating disorders refer to a group of conditions defined by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individual's physical and mental health.

3. Classification of eating disorders Diabulimia Pica Night eating disorder Compulsive overeating Purging disorder Rumination Binge eating disorder Bulimea nervosa Anorexia nervosa Orthorexia

4. Bulimia nervosa is an episodic ,uncontrolled ,compulsive ,rapid ingestion of large quantity of food over a short period of time(bingeing), followed by inappropriate compensatory behaviors to rid the body of the excess calories.

5. Epidemiology

6. Prevalence Lifetime prevalence of BN = 1.5% in women and 0.5% in men.    The average lifetime duration of BN is found to be approximately 8.3 year. 4% of females in the US have bulimia during their lifetime, 3.9% of these die. Of those only 6% obtain treatment In a survey of 11–16 year-olds, 10% of normal-weight children reported being bullied, compared to 15% of overweight and 23% of obese children     

7. Project EAT      - More than 1/2 of girls and 1/3 of boys engage in unhealthy weight control behaviors control appetite)      - Higher weight and overweight teens are more likely to engage in both binge-eating and unhealthy weight control than normal weight teens

8. Continuum of eating regulation response

9. Binge & purge cycle

10. Categories of bulimia Purging Regularly self induced vomiting or misuse of laxatives, diuretics, enemas after binging.

11. Non purging other methods to reduce the weight For example Over exercising Fasting Strict dieting

12. Etiology

13. Etiology Being female Girls and women are more prone . Age. late teens or early adulthood. Biological factors Acc to DSM4 -increased frequency in first degree relatives. Specific areas of chromosomes 10p linked to families with history of bulimia. Altered serotonin level in brain . .

14. Psychological and emotional issues . Low self-esteem Perfectionism Impulsive behavior Anger management problems Depression Anxiety disorders Obsessive-compulsive disorder. Alcohol dependence Shoplifting Societal pressure Peer pressure Effect of media Neglectful and rejecting parents. Family disturbances and conflicts Performance pressure in sports encouraging young athletes to lose weight, maintain a low weight restrict eating for better performance. .

15. Symptoms

16. Clinical features Preoccupation with body weight and shape. Eating in secret . Chronic sore throat. Dental problems. Misusing of laxatives , diuretics or enemas after eating 100% Binge eating

17. Contd ………… Oral trauma Withdrawal from friends and usual activity Fluid and electrolyte imbalance Intestinal problem Irregular menstrual problems Depression and mood swings

18. SCOFF mnemonic questionnaire SCOFF questionnaire includes 5 questions: Do you make yourself S ick because you feel uncomfortably full? Do you worry you have lost C ontrol over how much you eat? Have you recently lost more than O ne stone (about 14 lbs or 6.35 kg) in a 3-month period? Do you believe yourself to be F at when others say you are too thin? Would you say that F ood dominates your life

19. Eating Disorder Screen for Primary Care The Eating Disorder Screen for Primary Care (ESP) questionnaire contains 5 questions: Eating Attitudes Test (EAT) is a self-report population-based screening instrument that patients can complete in the waiting room prior to seeing the health care provider.

20. Co-morbidities Associated ADHD=34.9% Impulse control disorders=17.6% illicit drug abuse=26% Alcohol abuse =33.7% PTSD =45.4% GAD=11.8% social phobia=41.3% OCD =17.4% BPAD =17.7%. MDD=50% panic disorder= 16.2%

21. Diagnostic Evaluation

22. Diagnostic criteria according to DSM-5(307.51) A . Recurrent episodes of binge eating. Each of which is characterized by: Eating in a discrete period of time A sense of lack of control over eating during the episodes B . Recurrent inappropriate compensatory behaviors in order to prevent weight gain such as self induced vomiting, misuse of laxatives ,diuretics and other medications, fasting and excessive exercise. C . Binge eating and inappropriate compensatory behaviors both occur ,on an average for once a week for 3 months. D .Self evaluation is unduely influenced by body shape and weight

23. Diagnostic criteria according to Clinical evaluation A complete physical examination 2. Blood chemistry : To rule out occult metabolic complications of bulimia. hypokalemic metabolic alkalosis (may cause due to vomiting). normokalemic metabolic acidosis ( may be due laxative abuse). Hyponatremia , hypocalcemia , hypophosphatemia , and hypomagnesemia Elevated blood urea nitrogen levels (significant in intravascular depletion) Complete blood cell count ( to exclude anemia ) Hyperamylasemia (significant vomiting because of hypersecretion from the salivary glands)

24. 3 . Urinalysis Urine specific gravity may reflect the state of hydration. Urine toxicology- Comorbid substance abuse should be ruled out with a urine toxicology screen. 4. Pregnancy test This should always be obtained to rule out pregnancy in female patients presenting with amenorrhea 5. X-ray -- to check for broken bones, pneumonia or heart problems 6. Electrocardiogram (EKG)-- to look for heart irregularities. 7. Medical evaluation to rule out upper gastro intestinal disorder. 8. Psychological evaluation -- a discussion of your eating habits and attitude toward food and beck depression inventory(for MDD).

25. Complications

26. Dehydration -- kidney failure Heart problems- -irregular heartbeat and heart failure Severe tooth decay and gum disease Amenorrhea Digestive problems- -irregular bowel movements and constipation ,dependence on laxatives to have bowel movements. Anxiety and depression Increased risk of suicide and psychoactive substance use.

27. Management

28. Management includes : Pharmacological Psychological Nursing Dietary approach

29. Pharmacotherapy Antidepressants may help reduce the symptoms of bulimia Selective serotonin reuptake inhibitor -- fluoxetine (Prozac) TCA’s

30. Psychotherapy Cognitive behavioral therapy to help you identify unhealthy, negative beliefs and behaviors and replace them with healthy, positive ones. Interpersonal psychotherapy, which addresses difficulties in your close relationships, helping to improve your communication and problem-solving skills Dialectical behavior therapy to help you learn behavioral skills to tolerate stress, regulate your emotions and improve your relationships with others — all of which can reduce the desire to binge eat. Family-based treatment to help parents intervene to stop their teenager's unhealthy eating behaviors, then to help the teen regain control over his or her own eating, and lastly to help the family deal with problems the bulimia can have on the teen's development and the family.

31. Self help groups Support groups helpful for encouragement, hope and advice on coping. Group members can truly understand what you're going through because they've been there.

32. Nutrition education Dietitians and other health care providers can design an eating plan to help you achieve a healthy weight, normal eating habits and good nutrition. Patient may benefit from medically supervised weight-loss programs.

33. Alternative medicine Massage and therapeutic touch may help to reduce anxiety often associated with eating disorders. Mind-body therapies, such as meditation, yoga, biofeedback and hypnosis, may increase awareness of your body's cues for eating and fullness, as well as promote a sense of well-being and relaxation. Acupuncture shows promise in studies on anxiety and depression, but hasn't been proved effective at this point

34. Prevention

35. For parents Not to waste time trying to figure out why the eating disorder occurred. Ask your child what you can do to help. For example, offer to keep certain trigger foods out of the house. Ask if your teenager would like you to plan family activities after meals to reduce the temptation to purge. Listen. Allow your child to express feelings. Schedule regular family mealtimes. Eating at routine times is important to help reduce binge eating. Let your teenager know any concerns you have. But do this without placing blame. Cultivate and reinforce a healthy body image in your children no matter what their size or shape. Consult pediatrician . Pediatricians may be in a good position to identify early indicators of an eating disorder and help prevent its development

36. Coping and supporting self It may be difficult to cope with bulimia when you're hit with mixed messages by the media, culture, coaches, family, and maybe your own friends or peers. Remind yourself what a healthy weight is for your body. Resist the urge to diet or skip meals, which can trigger binge eating. Don't visit websites that advocate or glorify eating disorders. Identify troublesome situations that are likely to trigger thoughts or behaviors that may contribute to your bulimia and develop a plan to deal with them. Have a plan in place to cope with the emotional distress of setbacks. Look for positive role models who can help boost your self-esteem. Find pleasurable activities and hobbies that can help to distract you from thoughts about bingeing and purging. Build up your self-esteem by forgiving yourself, focusing on the positive, and giving yourself credit and encouragement

37. Nursing Management

38. Nursing diagnosis Imbalanced nutrition less than body requirement Deficient fluid volume Ineffective denial Disturbed body image ,low self esteem Anxiety (moderate to severe)

39. Imbalanced nutrition less than body requirement Determine needed nutritional requirements Explain behavior modification plan Weights and I/O daily Assess skin turgor and mucus membrane daily Stay with client during meals and for 1 hr following meals.

40. Ineffective denial Develop trust relationship Give positive regards Don’t bargain .explain how privelages and consequences are based on compliance with therapy and weight gain Encourage client to verbalise feelings and unresolved issues. Help her understand the negative consequences to current eating behavior.

41. Disturbed body image ,low self esteem Help client develop realistic perception of body image. Allow client independent decision making Give positive feedback Help client accept self Convey knowledge that perfection is unrealistic .

42. Summary

43. Conclusion

44. Evaluation

45. Bibliography 1.http:// edresearch.stanford.edu /eating- disorders.html 2.http:// www.mayoclinic.org /diseases-conditions/bulimia/basics/risk-factors/con-20033050. 3. http://www.indianjpsychiatry.org 4. http://emedicine.medscape.com/article 5. http:// NEDIC.html 6.American nursing association;diagnostic and statistical mannual of mental disorders-5;5 th ed;ISBN;Arlington.USA;2013;PG-345-349. 7.Sadock.BJ,Sadock.VA;Synopsis of Psychiatry;9 th ed;William and Wilkins;USA;1972;PG-746-750. 8. Shreevani.R;A Guide to mental health and psychiatric nursing;3 rd ed;Jaypee publications;New Delhi;2004;pg-217-218. 9. Townsend.C.M;Essentials of psychiatric mental health nursing:concepts of care in evidenced based practice;7 th ed;F.A.Davis company;Philadelphia;2012;pg-738-759.