Bulimia Nervosa

Key Points

• Bulimia nervosa features recurrent binge episodes with compensatory behaviors such as vomiting, laxative misuse, or overexercise.
• Life-threatening complications include electrolyte disturbances, arrhythmias, esophageal injury, and suicide risk.
• Bulimia may occur at normal or high body weight, so screening cannot rely on appearance alone.
• Effective care integrates psychotherapy, safety monitoring, and symptom-targeted medication.

Pathophysiology

Bulimia nervosa is maintained by a binge-compensation cycle linked to emotion dysregulation, impulsivity, and maladaptive beliefs about weight and control. Purging or compensatory behavior transiently relieves distress, reinforcing recurrence.

Repeated vomiting and laxative or diuretic misuse produce fluid-electrolyte imbalance and acid-base disturbance. Cardiac electrophysiologic instability, especially with hypokalemia, increases mortality risk.

Classification

• Purging pattern: Self-induced vomiting, laxatives, diuretics, or enemas.
• Nonpurging pattern: Fasting, excessive exercise, or other compensatory behaviors.
• Complicated bulimia: Bulimia with acute medical instability or high suicide risk.

Nursing Assessment

NCLEX Focus

Assess purge-related medical instability and suicide risk every shift in acute care.

• Assess binge frequency, compensatory methods, and trigger patterns.
• Assess orthostatic changes, dehydration, electrolyte risk, and ECG concerns.
• Assess oral and dental findings from recurrent emesis.
• Assess depression, impulsivity, shame burden, and suicidal ideation.
• Assess comorbid diabetes and unsafe insulin manipulation behaviors.

Nursing Interventions

• Stabilize fluids/electrolytes and monitor for arrhythmia warning signs.
• Implement structured meal support and interrupt purge opportunity windows.
• Provide suicide precautions and crisis planning as indicated.
• Use CBT/IPT-aligned communication to challenge maladaptive patterns.
• Coordinate multidisciplinary care with psychiatry, nutrition, and medical specialists.

Cardiac Risk

Repeated purging can cause severe hypokalemia and QT-related arrhythmias requiring urgent intervention.

Pharmacology

Fluoxetine is the primary FDA-approved pharmacologic option for bulimia and can reduce binge-purge frequency. Other medications may target comorbid mood or anxiety symptoms.

Nurses monitor adherence, side effects, suicidality warning signals, and seizure-risk cautions with contraindicated agents.

Clinical Judgment Application

Clinical Scenario

A client reports nightly binge episodes followed by self-induced vomiting and presents with dizziness, palpitations, and shame.

Recognize Cues: Active binge-purge cycle, autonomic symptoms, and emotional distress. Analyze Cues: High risk for electrolyte imbalance and self-harm. Prioritize Hypotheses: Medical stabilization and suicide-risk mitigation are immediate priorities. Generate Solutions: Begin monitoring, labs, ECG surveillance, and structured therapeutic support. Take Action: Implement safety plan and coordinate psychiatric and nutritional treatment. Evaluate Outcomes: Confirm physiologic correction and reduced binge-purge frequency.

Related Concepts

• anorexia-nervosa - Overlapping psychopathology with different weight and behavior profiles.
• binge-eating-disorder - Shares binge behavior but lacks regular compensation.
• eating-disorder-risk-factors - Upstream personality, social, and biologic vulnerabilities.
• self-harm-and-suicide - Major risk pathway requiring active screening.
• therapeutic-communication-and-relationships - Essential for reducing shame and dropout.