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Chapter: Psychiatric Mental Health Nursing : Eating Disorders

Bulimia - Eating Disorders

Bulimia nervosa usually begins in late adolescence or early adulthood; 18 or 19 years is the typical age of onset.



Onset and Clinical Course


Bulimia nervosa usually begins in late adolescence or early adulthood; 18 or 19 years is the typical age of onset. Binge eating frequently begins during or after dieting. Between binging and purging episodes, clients may eat restrictively, choosing salads and other low-calorie foods. This restric-tive eating effectively sets them up for the next episode of binging and purging, and the cycle continues.


Clients with bulimia are aware that their eating behav-ior is pathologic and go to great lengths to hide it from others. They may store food in their cars, desks, or secret locations around the house. They may drive from one fast-food restaurant to another, ordering a normal amount of food at each but stopping at six places in 1 or 2 hours. Such patterns may exist for years until family or friends discover the client’s behavior or until medical complica-tions develop for which the client seeks treatment.


Follow-up studies with clients with bulimia show that 10 years after treatment, 30% continued to engage in recurrent binge eating and purging behaviors, whereas 38% to 47% were fully recovered (Anderson & Yager, 2005). One third of fully recovered clients relapse. Clients with a comorbid personality disorder tend to have poorer outcomes than those without.

The death rate from bulimia is estimated at 3% or less.


Most clients with bulimia are treated on an outpatient basis. Hospital admission is indicated if binging and purg-ing behaviors are out of control and the client’s medical status is compromised. Most clients with bulimia have near-normal weight, which reduces the concern about severe malnutrition—a factor in clients with anorexia nervosa.


Treatment and Prognosis


Cognitive–Behavioral Therapy


CBT has been found to be the most effective treatment for bulimia. This outpatient approach often requires a detailed manual to guide treatment. Strategies designed to change the client’s thinking (cognition) and actions (behavior) about food focus on interrupting the cycle of dieting, bing-ing, and purging and altering dysfunctional thoughts and beliefs about food, weight, body image, and overall self-concept. CBT enhanced with assertiveness training and self-esteem enhancement has produced positive results (Schmidt et al., 2007).



Since the 1980s, several controlled studies have been conducted to evaluate the effectiveness of antidepres-sants to treat bulimia. Drugs, such as desipramine (Nor-pramin), imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluox-etine (Prozac) were prescribed in the same dosages used to treat depression . In all the studies, the antidepressants were more effective than were the place-bos in reducing binge eating. They also improved mood and reduced preoccupation with shape and weight. Most of the positive results, however, were short term, with about one third of clients relapsing within a 2-year period (Agras, 2006).


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