Eating Disorders

1. Eating Disorders Chapter 24

2. Clinical Course of Anorexia Nervosa • Onset in early adolescence • Chronic condition with relapses characterized by significant weight loss • Often continued to be pre-occupied with food • 10%-25% go on to develop bulimia nervosa • Poor outcome related to initial lower minimum weight, presence of purging, and later age of onset

3. Anorexia Nervosa • Refusal to maintain body weight • Intense fear of gaining weight • Drive for thinness • Disturbance in body image • Undue influence of body weight or shape or denial of current low weight • Absence of three consecutive menstrual cycles • Weight loss of 25 lbs

4. The thinner I got, the happier I felt. It becomes illogical. You’re sixty pounds and you think you’re still fat.... I hate being weighed. That is the worst part of my day. I do the blind weights, where I turn backward, but I’m getting to where I can hear the clicks, and I’m afraid to hear that second click at a hundred. —Erin, 24

5. Types of Anorexia • Restricting -- restrict intake or excessive exercise • Binge eating/purging

6. Conceptual Issues • Body image: the discrepancy between self-perception and others. • Drive for thinness: an intense physical and emotional process that overrides all physiologic body cues, such as hunger and weakness. • Interoceptive awareness: sensory response to emotional and visceral cues, such as hunger.

8. Epidemiology • 0.5%-1% lifetime prevalence • Mostly in 14-16-year old • Female to male ratio 10:1 • Culturally defined body weight expectations • Familial predisposition • Comorbid with depression, dysthymia and obsessive-compulsive disorder and anxiety

9. Etiology: Biologic • Dieting -- a risk factor and etiology • Little evidence to substantiate dysregulations in appetite-satiety systems • No evidence of brain structure changes as a cause • Biopsychosocial model best explains etiology (figure 22.2)

10. Psychological Theories • Psychoanalytic theory • At adolescence child turns to eating as a way of control • Conflict regarding separation & individuation • Feminist theories • Role pressure, trying to please others • Text box 22-3 • Other explanations • Body-image and self-image • Sexuality fears

11. Social Theories • Social Expectations • Societal norms and expectations • Media, fashion industry, peer pressure • See Research Box 22.4 • Body dissatisfaction related to low self-esteem, depression, dieting, bingeing,and purging. Body becomes overvalued. • Family Responses • Enmeshment • Overprotectiveness

12. Risk Factors • Biologic • Dieting • Overweight • Increase in (BMR) • Over-exercising • Concurrent eating disorders • Psychological • Low self-esteem • Body dissatisfaction • Feeling of ineffectiveness • Sexual abuse • Social • Media, fashion industry, and focus on ideal body type • Peer pressure, peer attitudes • Family attitudes

13. Interdisciplinary Treatment • Goals • Initiating nutritional rehabilitation • Resolving conflicts around body image disturbance • Increasing effective coping • Addressing underlying conflicts • Assist family with healthy functioning and communictation • Treatment modalities • Hospitalization usually necessary • Intensive therapies • Pharmacologic management--SSRIs

14. Priority Care Issues • Mortality • Stigma

15. Assessment Evaluation of systems Careful history (patient and family) Determine weight with BMI Menses history Sleep pattern Nursing diagnosis Imbalanced nutrition Sleep disturbance Fatigue Fluid volume deficit Bowel elimination altered Nursing ManagementBiologic Domain

16. Biologic Assessment Vomiting/Laxative Use • Metabolic • Hypokalemia • BUN • Gastrointestinal • Salivary gland and pancreas, inflammation • Esophageal erosion • Dysfunctional bowel • Dental • Erosion of enamel (frontal teeth) • Neuropsychiatric • Seizures

17. Nursing InterventionsBiologic • Refeeding • Strict monitoring and recording of intake • Weight-increasing protocols (usually a behavioral plan with reward) • Sleep hygiene • Exercise is usually not permitted. Exercise needs to be monitored.

18. Assessment Body distortion Fear of weight gain Unrealistic expectations and thinking Ritualistic behaviors Difficulty expressing negative feelings Inability to experience visceral cues and emotions Instruments textbox 22.8 Nursing Diagnosis Anxiety Disturbed body image Ineffective coping Ineffective interpersonal skills Nursing AssesmentPsychological Domain

19. Nursing InterventionsPsychological • Nurse-patient relationship -- focus on trust development • Journals linking physical state to feelings and surrounding events • Identifying feelings • Avoid trying to change distorted body image • Cognitive Therapies, Self-Monitoring • Education

20. Assessment School attendance Family interaction Nursing diagnosis Social isolation Ineffective family coping Nursing ManagementSocial Domain

21. Social Nursing Interventions • Facilitate transition to school • Family therapy • Family education

22. Continuum of Care • Hospitalization (brief) • Emergency care • Long term treatment with family therapy • Outpatient treatment • Prevention

23. Bulimia Nervosa • Recurrent episodes of binge eating • Generally, not life-threatening • Present as overwhelmed and overly committed individuals who have difficulty setting limits and establishing boundaries -- “social butterflies” • Treatment is outpatient therapy • Usually normal weight • Restriction of total calories between binges • Undue influence of body weight or shape or denial of current low weight • Types: purging and nonpurging

24. Purging

25. Clinical Course • Few outward signs • Binge and purge in secret • Treatment can be delayed for years • Initiate treatment when control of their eating is lost • Once treatment initiated, patients recover completely

26. Concepts • Binge eating. • Rapid, episodic impulsive, and uncontrollable ingest of large amount of food over a short period of time (1-2 hours). • Eating followed by guilt, remorse, and severe dieting is instituted. • Dietary restraint. • Restricting intake is believed to explain the relationship between dieting and binge behavior. • Restraining intake is predictive of overeating.

28. Epidemiology • Lifetime prevalence, 3%-8% (more prevalent than anorexia nervosa) • Onset is between 18-24 years (older than anorexia nervosa) • Females to males 10:1 • Related to Western culture social values • First degree relatives more likely to develop • Comorbid conditions include substance abuse and dependence, depression, and OCD

29. Etiology Biologic • Dieting • Neuropathic changes reverse when symptoms subside • Genetic -- some indications that there are genetic influences • Biochemical -- lowered brain serotonin

30. Psychosocial Theories • Separation -- individuation theories • Cognitive theory explains distorted thinking • Chaotic families with unclear boundaries

31. Interdisciplinary Treatment • Goals • Stabilizing and normalizing eating • Restructuring dysfunctional thoughts and attitudes • Teaching healthy boundary setting • Resolving conflicts about separation-individuation • Multifaceted approach • Intensive psychotherapy • Pharmacologic -- SSRIs • Nutrition counseling • Priority care issues • Comorbid depression and suicide • Risk for self-mutilation • Impulsive behavior -- shop lifting, overspending, etc.

32. Nursing Management • Assessment • Similar to anorexia nervosa • Bingeing/purging behavior • Diagnosis • Intervention • Biologic • Nutritional counseling/management • Pharmacologic -- SSRIs

33. Nursing Management (Cont.) • Psychosocial • CBT and IPT can be used • Behavioral interventions (cue elimination, self-monitoring) • Self-responsibility (Ns-Pt Rel) • Identifying disordered eating patterns • Interrupting binge-purge cycle • Education

34. Eating Disorders Related Links