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Presentation
on
Bulimia nervosa
Presented by-
Amit newton
M.Sc. Final Year
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.
Classification
of eating
disorders
Diabulimia
Pica
Night
eating
disorder
Compulsive
overeating
Purging
disorder
Ruminatio
n
Binge
eating
disorder
Bulimea
nervosa
Anorexia
nervosa
Orthorexia
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.
Epidemiology
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
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
Continuum of eating regulation
response
Tension and
craving
Binge eating
Weight
gain
Anxiety about
fatness
Purging
Guilt and
self dislike
Strict dieting
Binge & purge
cycle
Categories of bulimia
Purging
Regularly self induced vomiting or misuse of laxatives, diuretics,
enemas after binging.
Non purging
other methods to reduce the weight
For example
Over exercising
Fasting
Strict dieting
Etiology
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.
•.
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.
•.
Symptoms
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
Contd…………
Oral trauma
Withdrawal from friends and
usual activity
Fluid and electrolyte
imbalance
Intestinal problem
Irregular menstrual problems
Depression and mood swings
SCOFF mnemonic questionnaire
SCOFF questionnaire includes 5 questions:
• Do you make yourself Sick because you feel
uncomfortably full?
• Do you worry you have lost Control over how
much you eat?
• Have you recently lost more than One stone
(about 14 lbs or 6.35 kg) in a 3-month period?
• Do you believe yourself to be Fat when others say
you are too thin?
• Would you say that Food dominates your life
• 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.
Co-morbidities
Associated
ADHD=34.9%
Impulse
control
disorders=1
7.6%
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%
Diagnostic
Evaluation
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
Diagnostic criteria according to
Clinical evaluation
1. 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)
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).
Complications
• 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.
Management
Management includes:
• Pharmacological
• Psychological
• Nursing
• Dietary approach
Pharmacotherapy
• Antidepressants may help reduce the
symptoms of bulimia
• Selective serotonin reuptake inhibitor --
fluoxetine (Prozac)
• TCA’s
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.
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.
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.
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
Prevention
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
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
Nursing
Management
Nursing diagnosis
• Imbalanced nutrition less than body
requirement
• Deficient fluid volume
• Ineffective denial
• Disturbed body image ,low self esteem
• Anxiety (moderate to severe)
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.
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.
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 .
Summary
Conclusion
Evaluation
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;5th ed;ISBN;Arlington.USA;2013;PG-345-349.
• 7.Sadock.BJ,Sadock.VA;Synopsis of Psychiatry;9th ed;William and
Wilkins;USA;1972;PG-746-750.
• 8. Shreevani.R;A Guide to mental health and psychiatric nursing;3rd
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;7th ed;F.A.Davis
company;Philadelphia;2012;pg-738-759.

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Spearman's correlation,Formula,Advantages,
 

Bulimia Nervosa

  • 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.
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  • 5. 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.
  • 7. 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
  • 8. 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
  • 9. Continuum of eating regulation response
  • 10. Tension and craving Binge eating Weight gain Anxiety about fatness Purging Guilt and self dislike Strict dieting Binge & purge cycle
  • 11. Categories of bulimia Purging Regularly self induced vomiting or misuse of laxatives, diuretics, enemas after binging.
  • 12. Non purging other methods to reduce the weight For example Over exercising Fasting Strict dieting
  • 14. 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. •.
  • 15. 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. •.
  • 17. 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
  • 18. Contd………… Oral trauma Withdrawal from friends and usual activity Fluid and electrolyte imbalance Intestinal problem Irregular menstrual problems Depression and mood swings
  • 19. SCOFF mnemonic questionnaire SCOFF questionnaire includes 5 questions: • Do you make yourself Sick because you feel uncomfortably full? • Do you worry you have lost Control over how much you eat? • Have you recently lost more than One stone (about 14 lbs or 6.35 kg) in a 3-month period? • Do you believe yourself to be Fat when others say you are too thin? • Would you say that Food dominates your life
  • 20. • 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.
  • 23. 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
  • 24. Diagnostic criteria according to Clinical evaluation 1. 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)
  • 25. 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).
  • 27. • 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.
  • 29. Management includes: • Pharmacological • Psychological • Nursing • Dietary approach
  • 30. Pharmacotherapy • Antidepressants may help reduce the symptoms of bulimia • Selective serotonin reuptake inhibitor -- fluoxetine (Prozac) • TCA’s
  • 31. 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.
  • 32. 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.
  • 33. 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.
  • 34. 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
  • 36. 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
  • 37. 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
  • 39. Nursing diagnosis • Imbalanced nutrition less than body requirement • Deficient fluid volume • Ineffective denial • Disturbed body image ,low self esteem • Anxiety (moderate to severe)
  • 40. 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.
  • 41. 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.
  • 42. 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 .
  • 46. 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;5th ed;ISBN;Arlington.USA;2013;PG-345-349. • 7.Sadock.BJ,Sadock.VA;Synopsis of Psychiatry;9th ed;William and Wilkins;USA;1972;PG-746-750. • 8. Shreevani.R;A Guide to mental health and psychiatric nursing;3rd 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;7th ed;F.A.Davis company;Philadelphia;2012;pg-738-759.