EATING EATING DISORDERSDISORDERS

RNSG 2213RNSG 2213

Topics in this Topics in this PresentationPresentation

Covered:Covered: Anorexia NervosaAnorexia Nervosa Bulimia NervosaBulimia Nervosa

Not Covered:Not Covered: Overeating and Binge Overeating and Binge

Eating DisordersEating Disorders Obesity and BariatricsObesity and Bariatrics

Anorexia NervosaAnorexia Nervosa

Anorexia Nervosa:Anorexia Nervosa: Incidence and Incidence and CharacteristicsCharacteristics

Females, 90% (male numbers are Females, 90% (male numbers are growing)growing) Affects 3.7% of womenAffects 3.7% of women

Less common than bulimiaLess common than bulimia 6 to 20% die as a result of the 6 to 20% die as a result of the

illnessillness Higher death rate than any other Higher death rate than any other

psychiatric disorderpsychiatric disorder

Anorexia Nervosa Characteristics, Anorexia Nervosa Characteristics, cont’dcont’d

Onset:Onset: adolescence to early adulthoodadolescence to early adulthood age of onset is decreasingage of onset is decreasing often insidiousoften insidious occurs during important life transitionsoccurs during important life transitions

No loss of appetiteNo loss of appetite Deliberate Weight lossDeliberate Weight loss

Cultural Factors and Cultural Factors and InfluencesInfluences

Weight and Shape Weight and Shape

very important in US culturevery important in US culture Unrealistic ideals: Unrealistic ideals:

“ “culture of thinness”culture of thinness”

e.g. computer graphics e.g. computer graphics make thin models even make thin models even thinnerthinner

2008

Beauty Queens

1920s

Cultural Factors & Influences, Cultural Factors & Influences, cont’dcont’d

Preoccupation with Preoccupation with fitnessfitness

Epidemic of obesity Epidemic of obesity and dieting and dieting thinness = self-thinness = self-

controlcontrol

DSM IV-TR Criteria DSM IV-TR Criteria for Anorexia Nervosafor Anorexia Nervosa

Refusal to maintain normal weightRefusal to maintain normal weight Intense fear of gaining weight, even if Intense fear of gaining weight, even if

underweightunderweight Body image disturbancesBody image disturbances In female adults or adolescents, absence In female adults or adolescents, absence

of at least 3 consecutive menstrual of at least 3 consecutive menstrual cyclescycles

Types are: Restricting and Binge/Purging Types are: Restricting and Binge/Purging

Psychosocial and Family Psychosocial and Family FactorsFactors

Fears of becoming adult or Fears of becoming adult or independentindependent

Rigid, competitive, perfectionisticRigid, competitive, perfectionistic Anxious, compulsive and obsessive Anxious, compulsive and obsessive

the eating disorder is a way to have the eating disorder is a way to have controlcontrol

Compliant “people pleasers”Compliant “people pleasers”

Psychosocial and Family Psychosocial and Family Factors, cont’dFactors, cont’d

Correlates with childhood sexual Correlates with childhood sexual abuseabuse

Family characteristics that correlate Family characteristics that correlate with anorexia:with anorexia: over-controlling or rigidover-controlling or rigid emphasis on appearanceemphasis on appearance may have unusual eating habitsmay have unusual eating habits

Food-Related Behaviors Food-Related Behaviors in Anorexia Nervosain Anorexia Nervosa

Restricting intake, fastingRestricting intake, fasting Hoarding foodHoarding food Highly avoidant of certain foodsHighly avoidant of certain foods Preoccupation with calories, meals, recipes, Preoccupation with calories, meals, recipes,

etc.etc. Preparing/serving elaborate meals for othersPreparing/serving elaborate meals for others Rituals before and during eating Rituals before and during eating

become compulsionsbecome compulsionsMany characteristic behaviors of Anorexia Many characteristic behaviors of Anorexia

Nervosa are associated primarily with low Nervosa are associated primarily with low weight/starvation symptomsweight/starvation symptoms

How Anorexics Get Rid of How Anorexics Get Rid of the “Weight”the “Weight”

Use of laxatives and enemasUse of laxatives and enemas Exercise Exercise

Purging Behavior in Purging Behavior in AnorexiaAnorexia

Purgers and vomitersPurgers and vomiters Eat normally in a social situationsEat normally in a social situations Amount of food eaten is not excessiveAmount of food eaten is not excessive Purge if no success with severe Purge if no success with severe

restrictingrestricting

(Not on the test)(Not on the test)

Physical Assessment: Physical Assessment: Metabolic ConsequencesMetabolic Consequences

Anorexia: More Metabolic Anorexia: More Metabolic ConsequencesConsequences

GI: slowed peristalsis, delayed gastric GI: slowed peristalsis, delayed gastric emptyingemptying Feel full much longerFeel full much longer

Reproductive: loss of menses, loss of libidoReproductive: loss of menses, loss of libido development of secondary sex development of secondary sex

characteristicscharacteristics Osteopenia or Osteoporosis: bone mass Osteopenia or Osteoporosis: bone mass

loss may be irreversibleloss may be irreversible

Other Physical Assessment DataOther Physical Assessment Data

Muscle wasting, weakness and fatigueMuscle wasting, weakness and fatigue DehydrationDehydration Pitting edemaPitting edema Electrolyte imbalance: secondary to Electrolyte imbalance: secondary to

laxative, enema or emetic abuse and laxative, enema or emetic abuse and from starvationfrom starvation Hypocalcemia, hypokalemiaHypocalcemia, hypokalemia

Anorexia: ComplicationsAnorexia: Complications

Heart failure, life threatening Heart failure, life threatening arrhythmiasarrhythmias

Cardiac ventricular dilationCardiac ventricular dilation Decreased thickness of the ventricular wall Decreased thickness of the ventricular wall Decreased oxygenation ofDecreased oxygenation of

cardiac musclecardiac muscle Renal failureRenal failure Metabolic alkalosis or acidosisMetabolic alkalosis or acidosis

Complication of Treatment: Complication of Treatment: Re-feeding SyndromeRe-feeding Syndrome

Severe Fluid Shifts from too rapid Severe Fluid Shifts from too rapid re-introduction of food re-introduction of food

Cardiovascular, neurological and Cardiovascular, neurological and hematologic complicationshematologic complications

Interventions:Interventions: Refeed slowly Refeed slowly Close supervision of physical statusClose supervision of physical status

Nursing Diagnosis: Critical thinking

Write a nursing diagnosis for each of these consequences of Anorexia Nervosa:1) Hides food and is dishonest about

intake2) Heart Rate is persistently 48 bpm3) Uses laxatives several times a week to

achieve wt. loss

Nursing Diagnosis: Critical thinking Some possible

choices1a) Ineffective coping or1b) R/F nutrition less than body

requirements r/t dishonesty about intake and compensatory behaviors

2) R/F falls r/t hypotension3a) Fluid volume deficit r/t laxative

overuse3b) Constipation (or Diarrhea) r/t altered

gastric motility

Mental Health Mental Health Problems Associated Problems Associated

with Anorexiawith Anorexia Anxiety Anxiety

If perceives loss of control over eating If perceives loss of control over eating will lose weight by any means, e.g. will lose weight by any means, e.g. exercising, laxatives, enemas or emeticsexercising, laxatives, enemas or emetics

Sexual dysfunctions, low sex drive Sexual dysfunctions, low sex drive Feelings of helplessness, inadequacyFeelings of helplessness, inadequacy Obsessive-compulsive DisorderObsessive-compulsive Disorder

Mental Health Disorders Mental Health Disorders Associated with Anorexia Associated with Anorexia

Nervosa, cont’dNervosa, cont’d Major Depression Major Depression

(Dx and tx only after weight gain is (Dx and tx only after weight gain is established)established)

Substance abuse: laxatives and Substance abuse: laxatives and enemas rather than alcohol or illegal enemas rather than alcohol or illegal drugsdrugs

Personality disordersPersonality disorders

Neurobiology of AnorexiaNeurobiology of Anorexia

High levels of serotoninHigh levels of serotonin SSRIs are not effectiveSSRIs are not effective If used should not be started until If used should not be started until

weight weight

restoration is establishedrestoration is established

Bulimia NervosaBulimia Nervosa

Bulimia NervosaBulimia Nervosa

Age of onset: adolescence to young Age of onset: adolescence to young adulthood adulthood

Primarily in womenPrimarily in women 4% of young adults4% of young adults Symptoms overlap with Anorexia, Symptoms overlap with Anorexia,

making diagnosis difficultmaking diagnosis difficult

Bulimia CharacteristicsBulimia Characteristics

Often develops after period of dietingOften develops after period of dieting Weight loss NOT a characteristic sign of Weight loss NOT a characteristic sign of

bulimiabulimia Purging develops as a way to compensate Purging develops as a way to compensate

for massive amounts of food eatenfor massive amounts of food eaten

Restrictive eating...bingeing…purging Restrictive eating...bingeing…purging

cyclecycle

Binge Eating EpisodeBinge Eating Episode

Precipitated by feelings of Precipitated by feelings of lack of control or anxietylack of control or anxiety

Often done in secretOften done in secret High calorie-High High calorie-High

carbohydrate intakecarbohydrate intake Consumed in less than 2 Consumed in less than 2

hourshours Become addicted to the Become addicted to the

“high” experienced when “high” experienced when eatingeating

Purging = Compensatory Purging = Compensatory Behavior for Binge Behavior for Binge

EatingEating May use manual stimulation, May use manual stimulation,

laxatives, and/or emetics laxatives, and/or emetics Over time, self-induced vomiting Over time, self-induced vomiting

occurs with minimal stimulationoccurs with minimal stimulation Post-purging: sense of relief, calm Post-purging: sense of relief, calm

Consequences and Consequences and Complications of PurgingComplications of Purging Electrolyte imbalances Electrolyte imbalances Metabolic AcidosisMetabolic Acidosis Metabolic AlkalosisMetabolic Alkalosis CardiomyopathyCardiomyopathy Enlarged salivary glandsEnlarged salivary glands Erosion of dental Erosion of dental

enamelenamel Russell’s sign Russell’s sign PancreatitisPancreatitis

Etiology: Psychosocial Etiology: Psychosocial and Family Factors in and Family Factors in

BulimiaBulimia Depression, low self-esteemDepression, low self-esteem Shame: will hide the excessive eatingShame: will hide the excessive eating Associated family characteristics:Associated family characteristics:

Mood disordersMood disorders Lack of nurturingLack of nurturing

food is a form of self-nurturingfood is a form of self-nurturing Substance abuseSubstance abuse Family conflict or disorganizationFamily conflict or disorganization

evidence Bulimia is a response to chaosevidence Bulimia is a response to chaos

EtiologyEtiology: : Neurobiology of Neurobiology of BulimiaBulimia

Lowered serotonin activityLowered serotonin activity Binge eating raises levels of Binge eating raises levels of

serotoninserotonin Treat with SSRI, particularly Treat with SSRI, particularly

fluoxetine (Prozac)fluoxetine (Prozac)

Management of Management of Eating DisordersEating Disorders

Goals for client with Goals for client with Anorexia NervosaAnorexia Nervosa Increase weight to Increase weight to

90% of average body 90% of average body weight for heightweight for height

Increase self-esteemIncrease self-esteem Decrease need for Decrease need for

perfection (provided perfection (provided by thinness)by thinness)

Goals for client Goals for client with Bulimiawith Bulimia Stabilize weight Stabilize weight

without purgingwithout purging

Management of Eating Management of Eating Disorders, cont’dDisorders, cont’d

Both Anorexia and Bulimia:Both Anorexia and Bulimia: Inpatient treatment for medical Inpatient treatment for medical

stabilization and dietary managementstabilization and dietary management Long-term outpatient tx. addresses Long-term outpatient tx. addresses

psychosocial issuespsychosocial issues

InterventionsInterventions: : Starvation Starvation Phase of AnorexiaPhase of Anorexia

Assess labs:Assess labs: Monitor intake/output Monitor intake/output Assess for cardiovascular, neurological Assess for cardiovascular, neurological

complications complications Refeed slowly; careful dietary Refeed slowly; careful dietary

supervisionsupervision Intravenous lines and feeding tubes Intravenous lines and feeding tubes

if client refuses food if client refuses food

Nurse Patient Nurse Patient RelationshipRelationship

Anorexia NervosaAnorexia Nervosa Usually forced into Usually forced into

tx.tx. Tx means loss of Tx means loss of

control over eatingcontrol over eating Nurse is the enemyNurse is the enemy

Bulimia NervosaBulimia Nervosa More likely to want More likely to want

help: break the cyclehelp: break the cycle More likely to enter More likely to enter

treatment of their treatment of their own volitionown volition

Tendency to Tendency to manipulatemanipulate

Hide the degree of Hide the degree of the problemthe problem

Critical Thinking: Critical Thinking: Nursing InterventionsNursing Interventions

Give rationales for interventions listed on next slide

Some Interventions for Some Interventions for Eating DisordersEating Disorders

Do not confront Do not confront denial, but encourage denial, but encourage feelings identificationfeelings identification

HonestyHonesty CollaborateCollaborate TEACHTEACH patient about patient about

their disordertheir disorder Assist to identify Assist to identify

positive qualitiespositive qualities Eat with the clientEat with the client

Set appropriate limitsSet appropriate limits Encourage decision -Encourage decision -

making concerning making concerning issues other than foodissues other than food

Behavior modification:Behavior modification: Patient inputPatient input Rewards for weight Rewards for weight

gaingain

PsychopharmacologyPsychopharmacology

Anxiolytics when re-feeding is Anxiolytics when re-feeding is occurringoccurring

SSRI for BulimiaSSRI for Bulimia Equally effective for depressed and non-Equally effective for depressed and non-

depressed patientsdepressed patients Psychotherapy for AnorexiaPsychotherapy for Anorexia

Use antidepressant for co-morbid severe Use antidepressant for co-morbid severe depressiondepression

Milieu ManagementMilieu Management Orient to program and goals of treatmentOrient to program and goals of treatment Warm nurturing environmentWarm nurturing environment

Convey an understanding of their fearsConvey an understanding of their fears Close observation during and after mealsClose observation during and after meals

Do we let these patient go to the rest room alone?Do we let these patient go to the rest room alone?

Should we let them go to their room right after a Should we let them go to their room right after a meal?meal?

Nonjudgmental confrontation of eating disordered Nonjudgmental confrontation of eating disordered behaviorbehavior

CONSISTENCYCONSISTENCY Encourage the patient to talk to staff when Encourage the patient to talk to staff when

they feel the need to purgethey feel the need to purge

Milieu Management, cont’dMilieu Management, cont’d

Dietitian: individual planning and Dietitian: individual planning and consultationconsultation

Weighing protocolsWeighing protocols Group TherapyGroup Therapy

Which groups would be best for clients Which groups would be best for clients with eating disorders?with eating disorders?

MovementTherapy

Art Therapy &Expressive Arts

Meditation &Relaxation

Other InterventionsOther Interventions

Family Involvement: Family Involvement: teaching and family teaching and family therapytherapy

Follow-up therapy Follow-up therapy (outpatient)(outpatient)