EATING DISORDERS: Note Taking Outline

Topics Covered:
Anorexia
Bulimia
Not Covered
Overeating
Obesity
Bariatric Surgery

ANOREXIA NERVOSA
DSM IV-TR Criteria (p.545)

Refusal to maintain weight

Fear of weight gain
Body image disturbance, denial of weight loss or low weight
Absence of 3 consecutive menstrual cycles
2 types (to be described)

Anorexia Nervosa: Incidence and Prevalence

Affects 3.7% of women

Less common than bulimia

6 to 20% die as a result of the illness

Higher death rate than any other psychiatric disorder

Etiology
Biologic Factors
Disturbance in serotonin regulation excessive serotonin levels
Many physiologic abnormalities = result rather than cause of
semistarvation
Cultural Factors
Importance of weight and shape
Unrealistic ideals
Media images
Stigma of obesity
Primarily women (90%)
Psychological/Psychodynamic Factors
Childhood sexual abuse
Fear of growing up
Sense of self is shaky

Characteristics: Restricting Type of Anorexia Nervosa

Adolescent

Female

Perfectionist

Introverted

Self-esteem and peer relationship problems

Active in school activities

Rules and regulations for everything

Anxiety over breaking the rules

Regain control by tightening rules and punishing self

Restricting Type: Objective Signs

Low food intake

Deliberate weight loss

Avoid social situations

Competitive

Compulsive and obsessive

Rigid exercise program

Hyperactive, unable to relax

Anxious

Hoard food

Prepare elaborate meals for others

Rituals before and during eating become a compulsion

Binge-Eating and Purging Types of Anorexia Nervosa

(Not on the test!)

Physiologic Consequences of Anorexia Nervosa

Low metabolic rate

Hypotension

Bradycardia

Dry skin, lanugo

Delayed gastric emptying

Feel full much longer

Constipation 2o to overuse of laxatives

Dehydration

Renal failure

Osteopenia or Osteoporosis

Bone mass loss may be irreversible

Cardiac ventricular dilation

Decreased thickness of the ventricular wall

Decreased oxygenation of the cardiac muscle

 Amenorrhea; delayed development of secondary sex characteristics

Electrolyte imbalance
Potassium: hypokalemia
Metabolic Acidosis
Metabolic Alkalosis

Re-feeding Syndrome: Complication of Too-Rapid Re-introduction of food

Severe Fluid Shifts

Extracellular to intracellular

Cardiovascular, neurological and hematologic complications

Prevention: Re-feed slowly

Close supervision
Co-occurring Mental Health Problems and Anorexia Nervosa

Low sex drive

Feelings of helplessness, abandonment, inadequacy

Obsessive-compulsive disorder

Major-depression

(diagnosis possible only after weight gain is established)

Substance abuse

Personality disorders
Anorexia and the Family

Emotional restraint

Enmeshed relationships

Rigid organization

Tight control

Drive for thinness is a way to seek control

Avoidance of conflict

Odd eating habits

Emphasis on appearance
BULIMIA NERVOSA
(Means to have an insatiable appetite)
Incidence and Prevalence

Begins in adolescents

Primarily in women

4% of young adults

Overlap with Anorexia makes diagnosis difficult

DSM IV-TR Criteria (p. 549)

Recurrent binge eating

Feeling of lack of control
Compensatory behavior to prevent wt. gain
Binges and compensatory behavior occur >2X/wk > 3 mos.
Self evaluation strongly influenced by body shape and wt.
2 Types: Purging; Nonpurging

Characteristics of Bulimia

Hide their eating-disordered behaviors

Lack of weight loss

Associated Mental Health Disorders:
Major Depression
Personality disorder
Post traumatic Stress Disorder

Purging develops as a way to compensate for massive amounts of food eaten

Restrictive eating.then purging.cycle

Binge Episode Massive Amounts of Food

Feelings of lack of control

Secretive about behavior

High calorie High carbohydrate

Consumed in less than 2 hours

During the evening or at night

Addicted to the high experienced when eating

Resume usual schedule

Purging = Attempt to get rid of calories consumed
Most often via Self-Induced Vomiting or Laxative Abuse
Consequences and complications of Frequent Binging and Purging

Electrolyte imbalances

Metabolic Acidosis

Metabolic Alkalosis

Cardiomyopathy

Enlarged salivary glands

Erosion of dental enamel

Russells sign

Pancreatitis
Etiology: Differences in Bulimia

Lowered serotonin activity

Binge eating raises levels of serotonin

Good response toTreatment with SSRI particularly fluoxetine (Prozac)

Depression; shame; hide their eating

Family Factors

Mood disorders

Substance abuse

Conflict

Disorganized

Lacking nurturance

Evidence that Bulimia is a response to chaos

Food is a symbolic form of nurturing

Treatment Goals/Management

Anorexia

Increase weight to 90% of average body weight to height ratio

Re-establish appropriate eating behavior

Increase self-esteem

Bulimia
Stabilize weight without purging

Nursing Management: Starvation Phase of Anorexia

Check I&O
Monitor vitals, circulatory
Refeed slowly
Close supervision
Intravenous lines and feeding tubes if client refuses food
Weigh daily

Nurse Client Relationship

Anorectic
Usually forced into treatment
Loss of control over eating (nurse is enemy)
Nurse is the enemy
Keep in mind these clients may also have a Personality disorder
Bulimic
More likely to want help
More likely to enter treatment of their own volition
Tendency to manipulate
Hide the degree of the problem

Nursing Interventions For Eating Disorders

Focus is OFF food


Monitor activity, intake and weight

Empathy and honesty

Teaching about disorder

Model normal eating

Promote positive self-concept and interpersonal relationships

Set appropriate limits

Behavior modifications:
Patient input
Rewards for weight gain or lack of purging
Once a safe weight is attained:
control is given to patient
as long as there is no backslide

Psychopharmacology

Anxiolytics
when re-feeding is occurring
for associated obsessive-compulsive disorder
SSRIs

are not effective for Anorexia Nervosa

If used should not be started until weight restoration is established

Effective for Bulimia

Equally effective for depressed and non-depressed patients

Use antidepressant for co-morbid severe depression

Milieu Management

Warm nurturing environment

Close observation
Do we let these patient go to the rest room alone?
Should we let them go to their room right after a meal?
Nonjudgmental confrontation
CONSISTENCY
Encourage the patient to talk to staff when they feel the need to purge
Family Therapy
Group Therapy: expressive therapies
Dietitian
Follow-up Therapy (outpatient)