Eating Disorders
̶ Middle Ages: willful dieting leading to
self-starvation in female saints who fasted
to achieve purity.
̶ Late 1800s: young women used self-
starvation to avoid obesity.
̶ 1960s: anorexia nervosa was established
as a mental disorder.
̶ 1979: bulimia nervosa was first described
as a distinct syndrome.
̶ Eating disorders can be viewed on a
continuum, with clients with anorexia
eating too little or starving themselves,
clients with bulimia eating chaotically,
and clients with obesity eating too much.
Etiology
Mental Health Assessment for Eating Disorder
•Eating Attitude Test- used in studies of
anorexia and bulimia. This test can also be
used at the end of treatment to evaluate
outcomes because it is sensitive to clinical
changes.
•History- Anorexia: perfectionist with above-
average intelligence, causing no trouble.
Bulimia: impulsive behavior, anxiety,
depression, and personality disorder.
•General Appearance and Motor Behavior-
Anorexia: slow, lethargic, fatigued, reluctant,
and avoid eye contact. Bulimia: underweight
or overweight, open, and willing to talk.
•Mood and Affect- Anorexia: somber and
serious. Bulimia: pleasant and cheerful but
starts to express intense guilt, shame, and
embarrassment when talking about binge
eating and purging.
•Thought Processes and Content- Generally:
body image disturbance is almost delusional,
most of the time thinks about dieting, food,
and food-related behavior. Anorexia:
paranoid ideas about anyone who help them,
perceived as enemies.
•Sensorium and Intellectual Processes-
Generally: alert and oriented. Anorexia
(severely malnourished): mild confusion,
slowed mental processes, difficulty in
concentration and attention.
•Judgement and Insight- Anorexia: limited
insights and poor judgement about their
health status (denial). Bulimia: ashamed of
their behavior but recognizes it as pathologic.
•Self- concept- Generally: low self-esteem,
lack of control over oneself which
strengthens their desire to control their
weight.
•Roles and Relationships- Generally:
withdraw from peers and pay little attention
to friendships.
•Physiological and Self Care
Considerations- excessive exercise to the
point of exhaustion, sleep disturbances,
dental problems (Recurrent vomiting destroys
tooth enamel, and incidence of dental caries
and ragged or chipped teeth increases in these
clients. Dentists are often the first health care
professionals to identify clients with
bulimia.), and mouth sores.
Related Disorders for Eating Disorders
•Binge eating disorder- recurrent episodes of
binge eating; no regular purging.
•Night eating syndrome-morning anorexia,
evening hyperphagia, and nighttime
awakenings to consume snacks.
•Pica- persistent digestion of nonfood
substances
•Rumination- repeated regurgitation of food
than then is rechewed, re-swallowed, or spit
out.
 •Orthorexia nervosa- obsession with proper
or healthy eating.
•Comorbid psychiatric disorders: mood
disorders, anxiety disorders, and substance
abuse/ dependence.
Nursing Diagnoses
•Imbalanced nutrition: Less than/more than
body requirements
•Ineffective coping
•Disturbed body image
•Others: deficient fluid volume, constipation,
fatigue, and activity intolerance.
Nursing Interventions
•Establishing nutritional eating patterns
•Identifying emotions and developing coping
strategies
•Dealing with body image issues
•Client and family education
ANOREXIA NERVOSA
̶ characterized by the client’s restriction of
nutritional intake necessary to maintain a
minimally normal body weight, intense fear
of gaining weight or becoming fat,
significantly disturbed perception of the
shape or size of the body, and steadfast
inability or refusal to acknowledge the
seriousness of the problem or even that one
exists.
̶ BMI: <18.5 (underweight)
̶ Related clinical manifestations:
Osteoporosis, amenorrhea due to decreased
caloric availability, and refeeding syndrome
that could cause life threatening electrolyte
imbalances.
̶ Two subgroups:
• Restricting subtype: lose weight
primarily through dieting, fasting, or
excessive exercising
• Binge eating and purging subtype.
Binge eating consuming an abnormally
large amount of food. Purging are
compensatory behaviors designed to
eliminate foods.
̶ Onset: Ages 14 and 18
̶ Prognosis: 30% to 50% achieve full
recovery, while 10% to 20% remain
chronically ill. Six times more likely to die
from medical complications or suicide.
Diagnostic Criteria according to DSM-5:
• Restriction of energy intake relative to
requirements leading to a significantly low
body weight in the context of age, sex,
developmental trajectory, and physical
health.
• Intense fear of gaining weight or becoming
fat, even though underweight.
• Disturbance in the way in which one's body
weight or shape is experienced, undue
influence of body weight or shape on self-
evaluation, or denial of the seriousness of
the current low body weight.
NOTE: Even if all the DSM-5 criteria for
anorexia are not met, a serious eating
disorder can still be present. Atypical
anorexia includes those individuals who
meet the criteria for anorexia but who are
not underweight despite significant weight
loss.
Treatment
• Cognitive behavioral therapy- effective in
preventing relapse and improving overall
outcomes.
• Amitriptyline (Elavil) and cyproheptadine
(Periactin) in high doses (up to 28 mg/day)
can promote weight gain in inpatients.
• Olanzapine (Zyprexa): antipsychotic effect
on bizarre body image distortions and
associated weight gain.
• Fluoxetine (Prozac) has some effectiveness
in preventing relapse in clients whose
weight has been partially or completely
restored. However, close monitoring is
needed because weight loss can be a side
effect.
• Family/ Individual Therapy
• Enhanced CBT (CBT-E)- in addition to
addressing the body image disturbance and
dissatisfaction. It addresses perfectionism,
mood intolerance, low self-esteem, and
interpersonal difficulties.
 • Hospital admission is indicated for major
life-threatening conditions like severe fluid,
electrolyte, and metabolic imbalance,
cardiovascular complications, severe weight
loss and risk for suicide.
• Short hospital stays are most effective for
clients who are amenable to weight gain and
who gain weight rapidly while hospitalized.
• Longer inpatient stays are required for those
who gain weight more slowly and are more
resistant to gaining additional weight.
• Outpatient therapy has the best success with
clients who have been ill for fewer than 6
months, are not binging and purging, and
have parents likely to participate effectively
in family therapy.
BULIMIA NERVOSA
̶ Recurrent episodes of binge eating followed
by inappropriate compensatory behaviors to
prevent weight gain, such as vomiting,
misusing laxatives or diuretics, excessive
exercising or long fasting.
̶ Bulimics feel that they are not in control of
how much food they consume during an
episode of binge eating and subsequent
purging, which usually occurs at least once
a week (American Psychiatric Association
2013).
̶ Onset: late adolescent or early adulthood,
usually 18/19 years old. Usually occurs
during or after a period of dieting or a
stressful life event.
̶ Related clinical manifestations: parotitis and
tooth decay, bilateral hypertrophy, russell
sign, hypochloremic, hyperkalemic,
metabolic contraction alkalosis.
̶ Levels of Severity:
• Mild bulimia: 1-3 episodes/ week
• Moderate bulimia: 4-7 episodes/ week
• Severe bulimia: 8-13 episodes/ week
• Extreme bulimia: 14 or more episodes
Diagnostic Criteria according to DSM-5:
• Recurrent episodes of binge eating. An
episode of binge eating is characterized by
both of the following:
̶ Eating in a discrete period of time an
amount of food that is definitely larger
than most people would eat during a
similar period of time and under similar
circumstances.
̶ A sense of lack of control overeating
during the episode
• Recurrent inappropriate compensatory
behavior in order to prevent weight gain,
such as self-induced vomiting, misuse of
laxatives, diuretics, or other medications,
fasting, or excessive exercise.
• The binge eating and inappropriate
compensatory behaviors both occur, on
average, at least once a week for three
months.
• Self-evaluation is unduly influenced by
body shape and weight.
• The disturbance does not occur exclusively
during episodes of anorexia nervosa.
Treatment for Bulimia
• Cognitive behavioral therapy - Focusing
on changing distorted attitudes or beliefs and
actions. Most effective treatment.
• Tricyclic antidepressants and SSRI- used
to reduce the binging and purging cycle. It
also improves mood and reduced
preoccupation with shape and weight;
however, most of the positive results were
short term. Patients who cannot tolerate or
do not respond to other medications may be
given antiepileptic drug topiramate (Dryden-
Edwards, R. MD. 2018).