Eating Disorders 1 | Bulimia Nervosa | Eating Disorder

Al-Zaytoonah private university of Jordan Faculty of nursing Psychiatric nursing department Psychiatric health Course practice (0301358) Presentation

about Eating disorders.
Prepared by: Heba Al-khozae (200711008) Suha Al-bishawi ( )

Under the supervision of:

Dr. Entesar Al-khodary

Mrs. Sawsan Mr. Hamza Al-shawaheen

Outline:
1- Objectives. 2- Introduction.
3- Etiologies of eating disorders and factors that precipitate that.

4- Implications and prognosis. 5- Anorexia nervosa. 6- Bulimia nervosa. 7- Binge eating disorder. 8- Males eating disorders. 9- Psychotherapeutic management. 1011121314151617Nurse-patient relationship. Psychopharmacology. Milieu therapy. Nursing process for eating disorders. Family and client teaching. Conclusion. Questions. References.

Objectives: After this lecture the students should be able to:
1- Identify eating disorders as an illness, its etiologies, and precipitating factors, implication and prognosis.

2- Identify each type of eating disorders with its signs and symptoms, and diagnostic criteria related to (DSM-IV-TR).

3- Describe treatment issues for professionals who deal with eating disordered patients (psychotherapeutic management, nurse-patient relationship, psychopharmacology, milieu management).

4- Develop nursing care plans for patients with eating disorders.

Eating disorders
Healthy people need to regularly consume a rich variety of foods that are sufficient for energy needs, cellular growth and repair, and maintenance of sufficient weight. Most people normally eat 1,500 – 2,500 calories each day.

Eating is a normal response to hunger should cease when the person attains satiety (comfortable
fullness). People develop problems related to normal food consumption and satiety which is called eating

disorders.
Eating disorders are most common in females (85%-90%) than males (10%-15%) but recent studies find that the incidence of eating disorders in males is increasing by incidence ratio of 2women :1 men for anorexia nervosa and the ratio of 3 women : 1 men for bulimia nervosa, and seems to appear at a later age than in females. Eating disorders are those in which eating: 1- Below or above a person’s caloric needs to maintain a healthy weight. 2- Accompanied by anxiety and guilt.
3- Occurs without hunger or fails to produce satiety.

4- Results in physiologic imbalances or medical complications. The most serious eating disorders are anorexia nervosa and bulimia nervosa. Anorexia nervosa is a life threatening condition of disturbed body image, emaciation, intense fear of becoming obese. Bulimia nervosa is a recurrent pattern of uncontrollable consumption of large amount of food (binge eating) followed by attempts to eliminate the body of the excess calories (purging).

Etiology and precipitating factors:
Most experts agree that eating disorders have multifactorial causes with significant variance among individuals developing from complex interaction of individual, family, sociocultural elements.
1- Biologic factors: increase serotonin levels. 2- Cognitive and behavioral factors: environmental contingencies. 3- Psychodynamic factors: modern psychoanalytic theorists have stressed the role of sexuality in

anorexia nervosa, and some researchers have suggested that anorexia involves a regression to a pre-pubertal state, and another theory has described anorexia nervosa as an obsession with weight stemming from a fear of being out of control because of the lack of a well-defined self.

4- Family factors: emotional restraint, enmeshed relationships, rigid organization in the family, tight

control of child behavior by parents, avoidance of conflict, and odd eating habits and emphasis on appearance and weight by other family members especially mothers and sisters.
5- Sociocultural factors: the increasingly and unrealistically thin body ideal for women, almost a

cultural thinness, and the relational orientation of women, which creates a vulnerability to the opinions of others particularly during adolescence. When working with clients and populations who may be at risk for eating disorders, nurses should remember to discuss the 3Cs:
1- Communication: how to recognize and express feelings. 2- Conflict resolution: how to express needs when they aren’t being met. 3- Coping: what to do when the client can’t directly solve a problem.

Implications and prognosis:
 Peoples with eating disorders rarely seek help, typically aren’t motivated to change, and often leave treatment.  Bulimia nervosa has higher rate of recovery than does anorexia nervosa.  In a 10 years follow-up study of clients with bulimia approximately 30% continued to engage in binge eating or purging behaviors.  Care management is complex and frequently lengthy because these clients may resist treatment because of denial is typically strong.  Nurses, physicians, psychotherapists, social workers, dietitians, occupational therapists collaborate to form a treatment plan.

Anorexia nervosa:
A life threatening condition characterized by a refusal to maintain body weight at or above a minimally normal weight for age and height, an intense few of becoming fat, a distorted body image, and amenorrhea or irregular menstrual cycles in women and low testosterone hormone levels in men. Anorexia is less common than bulimia, 85% of cases developing between the ages of 13 and 20 years, onset varies from preadolescence to early adulthood, these ages correspond with transitional stages in people lives, and the disease have the mortality rate of 5-20%. The anorectics suppress their appetite in an effort to remain thin or get thinner but they don’t lose their appetite, and they have ritualistic eating patterns and compulsive behaviors, often feel hopeless, helpless, and depressed. The anorexia affects menstruation by causing amenorrhea, irregular and spotty menstruation, and affects cardiac muscles (atrophy) and decrease cardiac output. The course of anorexia varies from:
1- A single episode with weight and psychological recovery.

2- Nutritional rehabilitation with relapses. 3- An unremitting course resulting in death. Patients with anorexia nervosa are into two types:
1- Restrictors:

 They are young people in the normal or slightly above normal weight for height.
 This group views losing weight as more probable if they simply eat less and avoid social

situations in which they are expected to eat. Withdraw to their rooms and avoid family and friends.  They could be competitive, compulsive, and obsessive about their activities, highly anxious and unable to relax, become hyperactive.
2- Vomiters- purgers:

 They are more often fluctuating and overweight before the eating disorder begins.  This group use dangerous methods of weight reduction, such as induction of vomiting or excessive use of laxatives or diuretics.  The amount of food isn’t excessive as it with bulimics,
 These patients complain of dental problems, substance abuse, and open family conflict than

restricting anorectics. Signs and symptoms of anorexia nervosa:
 Psychosocial: extreme fear of gaining weight, poor social adjustment, odd food habits,

hyperactivity, mood and\or sleep disturbances, obsessive compulsive behaviors, perfectionist, introverted, denies feeling of sadness or anger and will often appear pleasant and complaint, families often have rigid rules, and have high expectations for their members.
 Physiologic and endocrine symptoms: emaciated physical appearance, changes in cardiac status

(bradycardia, HTN, dysrhythmia), dry yellowish skin, amenorrhea, infertility, hair loss, possible presence of lanugo, decreased metabolic rate, chronic constipation, fatigue and lake of energy, insomnia, loss of bone mass, osteoporosis, enlarged salivary glands, decayed tooth, dehydration, edema, laboratory abnormalities and medical complications. DSM-IV-TR diagnostic criteria for anorexia nervosa: 1- Refusal to maintain body weight at or above a minimum normal weight for age and height. 2- Intensive fear of gaining weight or becoming fat, although significantly underweight. 3- Disturbance in the way in which one’s body weight or shape is experienced, overvaluing of low weight or weight loss. 4- In women and female adolescents, the absence of at least three consecutive menstrual cycles.

 Restricting type: during an episode of anorexia nervosa, individuals don’t engage in recurrent

episodes of binge eating or purging.
 Binge eating or purging type: during an episode of anorexia nervosa, individuals engage in

recurrent episodes of binge eating or purging. Favorable prognostic indicators: 1- Earlier age at onset. 2- Return of menses. 3- Good pre-morbid school\work history. Negative prognostic indicators: 1- Recurrent illness. 2- Multiple hospitalizations. 3- Male. 4- Family pathology. 5- Pre-morbid personality difficulties and poor social adjustment in childhood.

Bulimia nervosa:
Is a condition of uncontrolled rapid ingestion of large quantities of food followed by self-induced vomiting, obsessive exercise, use of laxatives and diuretics, or all of these behaviors. Its maybe occurs alone or in conjunction with the food restriction of anorexia. They may consume an incredible number of calories (an average of 39415 per binge) then in a short period induce vomiting, and perhaps repeat this behavior several times a day. Bulimia nervosa frequently exist with major depression, substance abuse, personality disorders, primarily those with impulsive traits. Clients with bulimia may develop:  Dental caries from the frequent contact of tooth enamel with food and acidic gastric fluids.  ECG changes.  Parotid gland enlargement.  Esophagitis.  Gastric dilation.  Menstrual irregularity.

 Electrolyte imbalance. DSM-IV-TR diagnostic criteria for bulimia nervosa: 1. Recurrent episodes of binge eating in a short time period, with intake much greater than average. 2. A feeling of lack of control over eating behaviors during eating binges. 3. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as induced vomiting, use of laxatives, enemas, or diuretics, strict dieting or fasting, vigorous exercise, or taking diet pills. 4. Binge eating and inappropriate compensatory behaviors both occurring, on average, at least twice a week for 3 months.
5. Self-evaluation unduly influenced by body shape and weight.  Purging type: regularly engages in self-induced vomiting or the use of laxatives, diuretics, or

enemas.
 Non-purging type: regularly uses strict diet, fasting, or vigorous exercise, but doesn’t regularly

engage in purging. Treatment: Clinical and dialectical-pharmacologic behavioral therapies (CBT) for those with bulimia appear to have good response in conjunction with interpersonal psychotherapy and pharmacotherapy. Pharmacologic: 1- fluoxetine 60 mg\day for 6-18 weeks reduces the symptoms of binging and purging. 2- tricyclic antidepressant is also found useful in treating bulimia nervosa.

Comparing between anorexia nervosa and bulimia nervosa:
Shared features:  Restriction of intake at times, especially anorectics.  Bingeing overeating at times, especially bulimics.  Purging through vomiting, laxatives, or diuretics.  Over exercise.  Extreme concern about appearance.

 Perfectionist traits-dissatisfaction with appearance and performance in aspects of life such as work or school.  Belief that their worth is based solely on appearance.  Discomfort in social settings, especially with the opposite gender.  Misperception of their size, shape, and level of fat.  Low-self esteem. Differentiation of behaviors: Anorexia Early onset Very low weight Amenorrhea for some patient’s Hormonal imbalance Constipation if not using laxatives Bulimia later onset more normal weight menstrual irregularities but not amenorrhea fluid and electrolyte imbalance GI problems related to bingeing and purging

Binge eating disorder:
Is one of the most challenging current epidemics in western countries involves overweight and obesity, conditions that result from the regular overconsumption of calories and sedentary life styles. BED shares many criteria of bulimia nervosa (lack of control over intake, patient distress, and guilt over bingeing) but without the regular compensation for excess intake through purging, laxatives, fasting, or over exercise. Patient’s with BED tends to be overweight to a moderate or greater degree and their weight tends to fluctuate more compared with those with anorexia or bulimia. As with bulimia, the onset of this disorder tends to be later than anorexia, generally beginning in late adolescence to early adulthood, but currently isn’t considered a psychiatric disorder in the DSM-IV-TR because of the rapidly growing numbers of obese people of all ages. Many researchers view obesity as the result of compulsive eating behavior and it certainly associated with morbidity.

Characteristics of BED include: 1- Recurrent eating binges.
2- Guilt, shame, and disquiet about bingeing.

3- Marked psychological distress.

Males eating disorders:
The incidence of eating disorders among males is currently 10%-15% of the eating-disordered population. And the diagnosis, etiologies, and treatment is similar to eating disorders among females, but there appear to be differences in onset, presentation, and assessment. Males seem to have more difficulty than females in expressing their feelings so the therapeutic relationship could be instrumental in the recovery of them. Males are more likely than females with eating disorders to have a history of obesity before the onset of symptoms of an eating disorder and to have a later and higher initial BMI before becoming eatingdisordered. Males also tend to feel less guilt than in females about episodes of bingeing and purging. And dieting or bingeing is more often related to a desire to build a lean body for participation in sports. There is three areas need particular focus with males for treatment of eating disorder: 1- The excessive attention that adolescent boys can place on attaining a masculine physique and its effect on their body image. 2- Dietary habits to promote health fitness, and muscle mass without using disordered eating patterns. 3- The expression of feelings and the exploration of any underlying sexual identity concerns.

Manifestations of cognitive distortions in clients with eating disorders:
Distortion Catastrophizing\ magnification Dichotomous thinking Emotional reasoning Overgeneralization Explanation Giving an event or its consequences more merit than is realistic Reasoning by extremes, seeing everything as ‘black or white’ Relying on emotions to determine reality Basing beliefs on one or a few, not necessarily related, considerations. Over interpreting an event as having personal significance. Focusing on only some information while choosing to ignore other information. Example These jeans feel tight today. I know everyone can tell that I’ve gained 3 lb. If I’m thin, I must be fat; I’ve already eaten two slices of pizza and wrecked my diet. I might as well eat the whole thing. I know I’m fat because I feel fat. I don’t have a boyfriend. It must be because I’m fat. Liz is so thin and has the perfect life. I should lose weight so my life can be better Dad made a face when I grabbed a piece of candy from the jar, he must think I’m overweight. I’ve lost 10 lb. but I still can’t fit into a size 8 I’m a failure.

personalization Selective abstraction

Psychotherapeutic management:
The psychotherapeutic management of each disorder will vary, depending on the period of treatment being considered and whether the focus is on short or long term treatment.

Management of anorexia is geared toward three primary objectives: 1- Increasing weight to at least 90% of the average body weight for the patient’s height. 2- Helping the patient to establish appropriate eating behavior. 3- Increasing self-esteem, so the patient doesn’t need to attain the perfection that they believe thinness provides. For bulimics, the objectives are similar but rather than the need for weight increase, are more likely to focus on stabilizing weight without purging, because bulimics are more likely to be of normal weight. And pharmacotherapy is used as an adjunct to psychotherapy for bulimics when indicated. A stepped care approach might be useful, in which patient first participate in a simple treatment such as guided self-help or a psycho educational group with their families and if they don’t respond are referred for cognitive-behavior therapy, and if don’t improve will be referred for a more intensive form of treatment, such as interpersonal psychotherapy, partial or full hospitalization, and possibly antidepressants medication. Cognitive-behavioral therapy has the greatest research support, although limited evidence exist suggesting that interpersonal psychotherapy might have similar effectiveness. Effective therapeutic modalities for people suffering from eating disorders:
1- Behavioral therapy: using apparent conditioning paradigm, effective in inducing short-term

weight gain.
2- Cognitive therapy: examining underlying assumptions, modifying basic assumptions,

reinterpreting body image misperceptions, help client to challenge the validating of distorted beliefs and perceptions that are perpetuating their illness.
3- Family therapy: interventions focus on fostering open, healthy interaction patterns among

members. Behavior family systems therapy (BFST) is an approach that blends behavior modification, cognitive therapy, and family therapy. It relies on empirically tested behavioral and cognitive techniques. And consist of four stages:  Assessment.  Control rationale.  Weight gain.  Weight maintenance.
4- Individual psychotherapy: successful psychotherapy needs to be highly interactive, explore

relevant issues, educate, negotiate, challenge assumptions underlying anorectic behavior, and encourage the client directly and openly.

Nurse-patient relationship:
Specific therapeutic communication techniques helpful for eating-disordered patients include the following: 1- Convey warmth and sincerity. 2- Listen empathically. 3- Be honest. 4- Set appropriate behavioral limits. 5- Assist patient in identifying their positive qualities. 6- Collaborate with patients. 7- Teach patients about their disorders. 8- Determine the anorectic’s ability to be weighted in the early stages of treatment. 9- Initiate a behavior modification program with patient input that rewards weight gain or lack of purging with meaningful privileges or rewards. 10- Model and teach appropriate social skills. 11- Help patient identify and express bodily sensations and feelings related to their disorders. 12- Identify non-weight-related interests of the patient.

Psychopharmacology:
Currently, no psychopharmacologic agent is approved specifically for anorexia nervosa; medication management of anxiety, depression, somatic disturbances, or other co-morbid conditions is appropriate and might assist in treatment of the patient anorexia. Generally, psychotherapy is recommended before a trial of an antidepressant, antidepressants are considered when the patient has failed to respond adequately to psychotherapy alone or when there is comorbidity with severe clinical depression. Low dose imipramine in conjunction with dietary counseling and psychological support is also associated with decreases in binge eating and weight loss.
 Anxiolytics: to decrease anxiety that fuel’s a bulimic’s bingeing and purging.  Antidepressants: to reduce bingeing, purging, and depression in bulimic patients.  Atypical antipsychotic olanzepine (zyprexa): has been tried to promote weight gain.  Antihistamine: effective in emaciated anorectic in decreasing depression.  Lithium: to improve mood.

Milieu management:
1- Provide an orientation to the sitting to prepare the patient for inpatient or outpatient treatment so that fears will be reduced. 2- Provide a warm, nurturing atmosphere. 3- Closely observe patients. 4- Encourage the patient to approach a team member if feeling the need to purge. 5- Involve the patient’s family in treatment when appropriate. 6- Respond with consistency. 7- Encourage participation in art, recreation, and other types of therapy. 8- Involve a dietitian in the treatment plan who can teach proper nutrition while providing patients with an opportunity to select menus. 9- Encourage patient attendance at group therapy sessions. 10- Recommend follow-up psychotherapeutic groups and support groups for patients and their families and individual psychotherapy for patients with a qualified therapist.

Nursing process:
 Assessment:

1- Health history: nutrition, elimination, reproduction and hormones, activity and rest, psychosocial. 2- Physical examination: body weight, skin, nutritional state examination, cardiac examination, GI examination. 3- Laboratory testing: electrolyte abnormalities and cardiac dysfunction. 4- Diagnostic procedure: ECG, endoscopy.  Nursing diagnosis: 1- Imbalanced nutrition less than body requirements related to refusal to ingest or retain ingested food, physical excess of caloric intake. 2- Disturbed thought process related to intellectualization, obsessions, overgeneralization and malnutrition. 3- Disturbed body image related to unresolved psychosocial conflicts. 4- Chronic low self-esteem related to unrealistic expectations from self or others, lack of positive feedback, striving to please others to gain acceptance.
5- Powerlessness related to belief that one’s actions will not result in desired outcome.

6- Ineffective coping related to unmet developmental tasks (trust, autonomy), dysfunctional family system. 7- Interrupted family process related to ineffective communication patterns, denial of problems and conflict, unresolved issues of control, inability to manage conflict.
 Planning:

1- Body image enhancement. 2- Emotional support. 3- Nutrition management. 4- Weight gain assistance. 5- Fluid and electrolyte management. 6- Mood management. 7- Hope instillation. 8- Self-esteem enhancement. 9- Values clarification. 10- Cognitive restructuring.
 Nursing interventions:

1- Monitor daily caloric intake and electrolyte status while in the hospital, patient shouldn’t gain too much weight too quickly. 2- Observe patients for signs of purging or other compensation for food consumed. 3- Monitor activity level and encourage appropriate levels of activity for patients.
4- Weight daily while in hospital, but encourage patients to diminish focus on weight after re-

feeding. 5- Plan for a dietitian to meet with patients and families to provide accurate information on nutrition, discuss a realistic and healthy diet, and assist the nurse in monitoring the nutritional intake of the patient. 6- Encourage use of therapies or support groups to attain healthy weight and prevent relapse. 7- Promote patient decision making concerning issues other than food. 8- Promote positive self-concept and perceptions of body, as well as interactions with others.
 Indicators of expected outcomes:

1- Verbalizes satisfaction with appearance. 2- Reports a positive internal picture of self.

3- Moves toward congruence between self-perception and reality. 4- Improved food and fluid intake. 5- Improved weight-to-height ratio. 6- Stabilized vital signs. 7- Stabilized fluid and electrolyte levels. 8- Reports positive feelings of self-worth. 9- Describes self positively. 10- Verbalizes strengths and limitations.

Family teaching:
Do’s and don’ts of helping someone recover from an eating disorder (provided by ANAD): Do’s: 1- Gently encourage the patient to eat properly. 2- Express your love and support. 3- Try to understand, although this seems impossible. 4- Take time to listen.
5- Try to see how the patient perceives the situation.

6- Realize that the patient is terrified of gaining weight. 7- Emphasize the patient positive. 8- Encourage the patient to accept support and honestly express his feelings. 9- Talk honestly and sincerely with love and understanding. 10- Recognize that other, nonfood factors are at the heart of the problem. 11- Help the patient find someone to support him. 12- Realize that, although he must have help from others, he must want to get better and he needs to love himself. Don’ts: 1- Try to force the patient to eat or stop exercising. 2- Get angry or punish the patient. 3- Be impatient. 4- Lecture.

5- Bee too busy, even you have to give up important things. 6- Jump to conclusions or see things only through your eyes and mind. 7- Make the patient feel bad or guilty for having an eating disorder. 8- Spy on the patient. 9- Place the blame on anyone, 10- Be afraid to talk about the problems. 11- Pretend it will all just go away. 12- Expert an instant recovery. 13- Let the patient feel that he is the only one with this problem.

Conclusion:
1- Anorexia nervosa and bulimia nervosa share many etiologic factors. Although multiple theories exist. Most experts agree that eating disorders develop from a complex interaction of individual, family, sociocultural, and physiologic factors. 2- Clients with eating disorders exhibit disturbances in many or all of the functional health patterns. 3- Treatment of clients with eating disorders occurs in community-based and inpatient settings and is a complex and often lengthy process. 4- Desired client outcomes include normalization of weight and eating patterns, improved selfesteem, and development of realistic thought process, adaptive coping mechanisms, and constructive family processes. 5- Most clients require follow-up treatment to reinforce behavioral changes and prevent a return of disordered eating.

References:
1- Elizabeth M. varcarolis, 2006, manual of psychiatric nursing care plans, third edition, Elsevier Inc, p:348-384. 2- Wanda K. Mohr, 2006, psychiatric-mental health nursing, seventh edition, Philadelphia, Lippincott Williams and wilkins, p: 504-528. 3- Norman l. keltner, lee halyard schwecke, carol E. bostrom, 2007, psychiatric nursing, 5th edition, USA, mosby, p:544-561.
4- www.ANAD.org. 5- www.edreferral.com. 6- www.anred.com.

7- www.something-fishy.org 8- www.scribd.com.

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