Abstract
Bulimia nervosa (BN) is the most common eating disorder noted in the female adolescent and college-age population. BN develops like other self-destructive substance addictions and often runs a chronic and relapsing course. The potentially irrevocable effects, including death, of BN on the growth and development of adolescents emphasize the importance of providing appropriate nursing interventions for this population. This proposed nursing plan of care for female adolescent suffering with BN is guided by Roy's Adaptation Model and incorporates aspects of addiction, nutritional, cognitive-behavioral, relapse prevention, and family therapy techniques and models. This group plan was developed to provide a framework or foundation for nurses working with this population. Future practice and research recommendations are also presented.
Bulimia nervosa (BN) develops like other self-destructive substance addictions. The bulimic behavior may begin with a specialized trigger (dieting-binging-purging), but the trigger tends to broaden gradually to encompass other emotional or social stimuli (e.g., feeling depressed or anxious). This results not only because of physiologic effects on the body, but also secondary to learned responses (Riley, 1991). The framework for this proposed nursing plan of care for adolescents suffering with BN, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994), is guided by Roy's Adaptation Model (1984). This outpatient group plan incorporates many aspects of addiction, nutritional, cognitive-behavioral, relapse prevention, and family therapy techniques and models. The plan outlined in this article is offered as a foundation for nursing practice and research development.
Within an addiction model, BN is viewed as a primary, chronic, and progressive illness from which individuals can be helped to physical, psychological, and spiritual recovery. Key to the addiction model is the disease concept. This concept defines BN as an involuntary, biopsychological state and lifts from the person the responsibility and guilt for the development of the disease, but emphasizes the need for responsible management of the problem once it exists. Because many bulimics are embarrassed by their inabilities to control food intake, the disease concept helps break through the denial surrounding the illness. Denial perpetuates the disease and associated feelings of depression, shame, and powerlessness (Riley, 1991).
The group context provides a safe, supportive, and empathetic environment in which group members are guided to challenge each other's denial, magical thinking, and other cognitive and behavior mal-adaptations (Riley, 1991). Adolescents place special importance on what their peers think is acceptable, thereby learning that their problems, including bulimia, are not unique fosters sharing with less denial (Cramer-Azima, 1992). Finding out they are not alone produces a tremendous sense of relief and instills hope (Riley, 1991).
Group therapists working with adolescents must be active in setting boundaries and rules, and initially are more directive. This directiveness should lessen as the group matures and its climate begins to favor self-closure and problem solving (Cramer-Azima, 1992). Therapists must also be aware of the potential for group members' sharing of maladaptive behaviors, such as purging methods and stealing techniques (Pilote, 1998). These behaviors should be immediately confronted within the group.