Most patients with bulimia nervosa can be treated effectively as outpatients. Indications for hospitalization fall into two categories: medical and psychological. Medical hospitalizations usually result from the consequences of purging activities, such as frequent vomiting and abuse of laxatives and diuretics, which can create serious electrolyte imbalances and dehydration. These patients may present with complaints of weakness and lethargy and are at risk for developing cardiac arrhythmias. Cardiac arrest may occur during an arrhythmic episode. If the patient’s serum potassium falls below 2.5 mEq/L, the patient should be hospitalized (Halmi 1985b).
Other situations can present as medical emergencies and require hospitalization. Severe abdominal pain in a bulimic patient is a warning for possible gastric dilatation and the need for nasogastric suction, X rays, and surgical consultation. The most serious consequence of gastric dilatation is a potentially fatal gastric rupture (Mitikainen 1979). Esophageal tears caused by self-induced vomiting can produce shock (Mitchell et al. 1982).
Cardiac failure caused by cardiomyopathy from ipecac intoxication is a medical emergency that is being reported more frequently and may result in death. Symptoms of precordial pain, dyspnea, and generalized muscle weakness associated with hypotension, tachycardia, and electrocardiogram abnormalities should alert the clinician to possible ipecac intoxication.
Psychological symptomatology requiring hospitalization for bulimia is severe depression. One-third of bulimic patients may be experiencing symptoms of major depression, and reports of suicidal ideation are not unusual (Braun et al. 1994). Hospitalization is necessary for those patients who have an actual suicide plan and who state that they intend to carry it out or have actually made a suicide attempt. Repeated self-injury, such as cutting, also is an indication for hospitalization.
Severe functional impairment from persistent bingeing and purging may occur in some bulimic patients. Bulimic patients who are no longer able to function at work or at school, who experience a marked deterioration in their social relationships, and who have failed previous outpatient treatment programs should benefit from hospitalization.
For most patients, managed care dictates the terms of hospitalization. Within these constraints, the Cornell Eating Disorders Program has designed criteria for hospital admission of patients with bulimia nervosa. The following criteria are for a brief hospitalization between 7 and 14 days:
- An unstable medical condition defined as serum potassium below 3 mEq/L with an abnormal electrocardiogram or serum potassium below 2.5 mEq/L, a metabolic alkalosis, or dehydration
- Major depression with suicidal ideation
- Inability to function at work, at school, or in family responsibilities
- Comorbid problems that severely impair the patient’s functioning-for example, severe personality disorder issues or substance abuse that is out of control
Treatment for this brief hospitalization includes 1) 24-hour surveillance for response-prevention of bingeing and purging; 2) multiple group therapy sessions, which include groups for body image and eating behavior issues; self-esteem, self-efficacy, and assertiveness problems; and specific female issues; and 3) appropriate medical treatment.
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The discharge criteria from this brief hospitalization include 1) medical stability (e.g., a normal electrocardiogram and serum electrolytes), 2) no suicide risk, and 3) ability to eat foods in family-style servings without bingeing and to use bathroom privileges without purging.
The first aim of inpatient treatment should be to stop the patient’s bingeing and purging behavior. This not only helps to correct electrolyte imbalances and dehydration but also is the first step toward reestablishing normal eating behavior. Another immediate aim is to correct medical problems. Elevations of serum amylase are usually indicative of vomiting behavior. Because bulimic patients are often unreliable, a urine drug screen is necessary to check for both illicit and prescription drug use.
The binge-purge behavior must be stopped to treat the medical abnormalities. The opportunity to binge must be removed, with access to food restricted to mealtimes and supervised snacks. The bulimic patient should receive balanced meals of sufficient calories to maintain weight within a normal range. Patients should be observed during meals and for at least several hours after meals. Access to bathrooms should be restricted and supervised to prevent surreptitious vomiting. Stool examinations may be required to monitor laxative abuse. By substituting alternative behaviors for the urge to binge, the bulimic patient may work toward extinguishing the binge-purge behavior. Frequent substitution behaviors include exercising, using relaxation techniques, or engaging in a favorite activity.
Although interruption of the binge-purge cycle often restores a sense of well-being and a lessening of hopelessness, additional treatment for depression is often necessary. Along with individual and group therapies, antidepressant medications may be indicated to alleviate depression and to aid in the patient’s control of the urge to binge and purge (Walsh and Delvin 1992).
Of those psychotherapies that have been rigorously studied, cognitive therapy has been shown to be the most effective form of therapy for patients with bulimia nervosa (Fairburn et al. 1986). This form of psychotherapy can be easily used in an inpatient setting for the individual patient. The therapy should focus on personal psychological issues, interpersonal relationships, and the development of social skills. Many bulimic patients have isolated themselves from their family and friends for such a long time that they must relearn how to interact with others. Group therapy and therapeutic activities are especially helpful in this process. Common themes for individual psychological issues include inability to express anger appropriately as well as dependency, control, and a perfectionistic, overcritical attitude with an inability to give to oneself. Problems related to past physical and sexual abuse also may be present.
Bulimic patients who are hospitalized often have involved family members who can benefit from family counseling or therapy. At times, physical and sexual abuse issues must be dealt with in the family therapy format.
The bulimic patient often comes to the hospital with no structure in his or her life except for the bulimia. Jobs are often in jeopardy, or school performance is seriously deteriorating. Vocational assessment and training or counseling can be an important part of the hospital treatment program during this time.
Bulimic patients often have high levels of impulsivity, engage in a range of antisocial acts (such as lying and stealing), have substance abuse problems, show prominent mood lability and poor self-esteem, and have interpersonal difficulties. For these patients, food often serves as an escape from the discomfort they feel in social situations and becomes a mechanism for coping with distressing personal events. These personality traits bear significantly on the management and treatment of bulimia, influencing not only the goals of treatment but also the treatment process by compromising the patient’s motivation, participation, and follow-through with treatment. The contained and structured hospital environment helps promote greater control by offering fewer opportunities for “acting out.” Patients may rebel against this structure and feel a greater urgency to act out in some way because they are much less able to act out with food. Thus, components of the treatment program that directly target the issues that are common to patients with borderline personality disorder should be set in place.
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For example, skills training groups (adapted from Linehan 1993) are useful for enhancing competence in affect regulation, problem solving, distress tolerance, and interpersonal effectiveness. In addition, the therapeutic milieu and community can be used effectively to help these patients “to take responsibilities for their behaviors and learn about their effects and actions on others” (Linehan 1993, p. 5). Reactions from peers and consequences to the community of the patients’ acting-out behaviors are often very powerful in effecting insight and behavior change.
Arrangements for a continuing outpatient program are crucial. Often, patients are not ready to live on their own, and placement in a structured living situation, such as a halfway house, can be an effective transition to an independent living arrangement. The structure provided by such a setting is helpful in continuing the gradual increases in responsibilities that begin in the hospital. This stepwise transition into life outside the hospital is often reassuring to the patient and may help to prevent a quick return of symptoms. If the patient lived at home, a return home often is not advisable; rather, a more independent living situation is necessary. After hospitalization, group therapy is often a useful adjunct to individual therapy and in some cases may be in itself sufficient. Discharge planning should include a physician who can be involved in the patient’s outpatient program. Periodic monitoring of the patient’s weight, serum electrolytes, and serum amylase levels may be indicated in the medical aftercare of these patients. Careful attention to establishing a comprehensive posthospitalization treatment plan is likely to prevent rehospitalization.
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Katherine A. Halmi, M.D.
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