Bulimia Nervosa is an eating disorder in which consuming more than the amount of food that can normally be consumed in a short time and then compensatory behavior is exhibited (DSM-5, 2013). The eating habit starts with an attack and is unconscious and unstoppable (DSM-5, 2013). During an eating attack, patients function as if they choke and binge, and the patient is ashamed of the attack, so they feel the need to eat in more secret places (Öztürk & Uluşahin, 2014). Patients aim to get rid of these calories by eating in an environment where they are alone, consuming food by hiding, not being able to stop even though they know that they should stop, eating the food in the form of an attack and then using laxatives, vomiting, and exercising excessively (Öztürk & Uluşahin, 2014). Observation of compensatory behaviors such as vomiting, fasting, resorting to different drugs, and using drugs continuously within three months, provided that they occur at least once a week, is necessary for diagnosis (DSM-5, 2013). Even if the person does not want to eat the food, he cannot help himself and the hygiene and appearance of the food is not important, and the patient may even vomit what he ate and continue to eat (Öztürk & Uluşahin, 2014). After the attack is over, the person is disgusted with himself, and sometimes he may develop panics that he will not be able to find food and drink and may need to hide his food (Öztürk & Uluşahin, 2014). When considered fundamentally, it is the inability to stop the binge behavior and the subsequent effort to get rid of it (Öztürk & Uluşahin, 2014). Although no results can be obtained after long-term diets, bulimia may occur and the person is prone to depression (Ercan, 2014). However, it does not show the symptoms that would be diagnosed with AN, if it has an environmental reaction after the binge attack, self-closing and eating alone behavior is observed (Ercan, 2014). Attack moments last 1-2 hours on average and due to vomiting; Decays in tooth enamel functions and bone changes are seen in the hand and back (Ercan, 2014). The course of weight is fluctuating, some of the cases vomit and some of them show laxative use behavior (Ercan, 2014). There is a decrease in the feeling of satiety, compensatory behaviors appear with regret after the attack (Ercan, 2014). Abdominal pain in cases showing removal behavior , esophageal injury, tooth enamel erosion, parotid enlargement, heart ailments may be encountered (Ercan, 2014). According to the frequency of the compromising behavior; mild, moderate, severe, and extreme levels (Öztürk & Uluşahin, 2014). Physiologically, the disease is not understood physically, it is seen that they are at the expected weight and sometimes even above the expected weight (Öztürk & Uluşahin, 2014). In most of the female patients, disruption in the menstrual cycle or inability to menstruate is observed, and a significant decrease in hormonal LH levels has been detected in accordance with the studies conducted (Öztürk and Uluşahin, 2014). When the brain imaging was examined, it was determined that there was a hollow gray and white matter, shrinkage in the brain structure and ventricular enlargement (Öztürk and Uluşahin, 2014). The incidence in women is generally 10 times that of men in all societies, and the group with the highest incidence in these female cases is university students (Öztürk and Uluşahin, 2014). Denial is at the forefront in the illness that spreads over a long period of time, and the patient does not accept it, he experiences attacks from time to time, it can trigger other pathological diseases, lead to smoking, alcohol and substance use, and in such cases, depression is observed (Öztürk and Uluşahin, 2014). Although how bulimia nervosa is triggered and the cause of its emergence has not been determined, some experts argue that it may be recurrent atypical depression (Öztürk & Uluşahin, 2014). It is one of the hypotheses put forward that the hypothalamus in the brain structure could not maintain the balance of hunger and satiety. There are also those who suffer from ailment as a result of sexual assault or encountering a traumatic situation (Öztürk & Uluşahin, 2014). In many cases, flashbacks are experienced during treatment, and there are drug and psychotherapy treatments (Öztürk & Uluşahin, 2014).
According to cognitive behavioral therapy, the factor affecting our behavior is thoughts (Özcan and Çelik, 2017). It takes its theoretical foundations from cognitive psychology and learning, problem solving mountain (Özcan and Çelik, 2017). It focuses on the thoughts and reflected behaviors of the person who includes the social environment and developmental course (Özcan & Çelik, 2017). The treatment method, behavioralism, was put forward by the cognitive theorists Ellis and Beck in 1970, with the classical conditioning of which Pavlov formed the basis in the 1960s (Özcan and Çelik, 2017). It was started to be applied by Beck in order to relieve the patient's problems. For Beck, understanding the events is multifactorial (Öztürk & Uluşahin, 2014). It puts the emotion on four bases; sadness, anxiety, joy and anger (Öztürk & Uluşahin, 2014). The diseases that he sees as a pathological reaction are caused by the deterioration of four emotions, for him, psychological disorders are the confusion of emotions in an individual's anxiety about the future (Öztürk & Uluşahin, 2014). It has cognitive schemas that it creates, and the schemas in the theory begin to form in childhood, and people are not aware of the schemas, and they face it as they experience events (Öztürk & Uluşahin, 2014). CBT consists of three phases; the initial stage is the first stage and the patient's symptoms are determined, the therapy process is shared with the patient, the patient's cognitive and emotional states are determined, then the middle stage is the second stage, the treatment process to reduce the patient's symptoms begins, the patient is observed (Özcan and Çelik, 2017). The case is prepared against repetition and repetition. It is the third stage, the interviews are reduced and the responsibility is started on the patient, additional sessions can be added (Özcan & Çelik, 2017). In the therapy method, the therapist is active with the case and tries to establish a positive relationship, with the aim of making the case realize the negativities (Öztürk & Uluşahin, 2014). It is tried to provide a view from different perspectives, childhood stories are taken so that the schema formations of the person are tried to be understood (Öztürk & Uluşahin, 2014). Daily routine life is rested, determinations are made on the points that he likes and dislikes, homework is started to be given to the case, and generalizations are studied (Öztürk & Uluşahin, 2014). Allocating time for homework in outpatients Interviews are made once or twice a week for bedridden patients almost every day (Özcan & Çelik, 2017). The most commonly used method in CBT is homework. While the aim here is to understand the lifestyle of the case at first and to recognize the case, it is expected to affect the person's life and affect his/her daily life in the following days (Soylu & Topaloğlu, 2015). In homework, the patient observes his/her own condition; activity course, noting thoughts in daily life and confrontation with oneself can be seen (Soylu & Topaloğlu, 2015). It is a positive therapy method, if the patient fulfills his homework as required, recovery is faster than those who do not (Soylu & Topaloğlu, 2015).
At the point of treatment for bulimia, it should first be aimed at changing the patient's compensatory behaviors, abnormal eating habits, and body image perception (Erol and Yazıcı, 1999). First of all, the therapist-patient relationship should be positive and awareness should be raised to the patient (Erol and Yazıcı, 1999). At the treatment point, the focus is on the present and the future, and the treatment course of the disease should be explained to the case at first (Erol and Yazıcı, 1999). The current and future-oriented treatment point is semi-structured, it can take up to 20 interviews and can last up to 6 months (Maner and Aydın, 2007). Cognitive planning of the person is aimed and it is aimed to gain awareness on self-related points in the homework given (Maner & Aydın, 2007). The situation between eating and disorder is explained to the patient, information is obtained from the patients about the moment of the attack, and a record is kept (Erol and Yazıcı, 1999). Next comes cognitive focus; Alternative coping methods are developed to resist binge eating and to put an end to compulsive diets (Erol and Yazıcı, 1999). Examples of given homework; Postponing the behavior of vomiting as much as possible and writing down the development of this process, noting the time when he/she has this thought about which subjects he/she behaves as a perfectionist in his/her social environment and the tendency to get approval in his/her social environment, what he/she feels after the binge eating attack occurs, and in which situations this attack occurs. Homework is given to bulimia patients, such as creating a daily eating schedule, noting the desire to eat or remove in mood changes, and it is tried to raise awareness (Okumuş, et al., 2018). The case is asked to focus on the event in order to evaluate the attack moments, weight and body posture, and to change the mentality (Erol & Yazıcı, 1999). When awareness is gained, it is aimed to maintain the state of well-being and prevent attacks (Erol & Yazıcı, 1999). Studies are carried out to prevent it from being repeated when weight gain and eating habits become normal in the later course (Okumuş, et al., 2018). This therapy method is at least as effective as drugs, and if the patient follows the course determined by the therapist, changes in weight, attitude and physical appearance are observed (Erol and Yazıcı, 1999).
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