UNIT-14

EATING DISORDER

INTRODUCTION:

 Eating disorders are psychiatric illnesses with substantial psychosocial and biological consequences.
Although many affected individuals initially appear to function normally, these disorders can cause
significant emotional and physical turmoil.
 Characterized by altered eating patterns and disturbances in body image.
 Eating disorder includes changes in usual eating patterns, regular dieting, skipping meals, and fasting
behavior.
 Ritualized eating related behaviors such as cutting food into tiny pieces and weighing themselves after
meals, are common.
 In addition characteristics of perfectionism are present.
 It includes two important syndromes.

TYPES:

Anorexia Nervosa

Bulimia Nervosa.

Eating disorder not otherwise specified

ANOREXIA NERVOSA.

It is characterized by willful and purposeful behavior directed toward losing weight, weight loss,
preoccupation with body weight and food, peculiar patterns of handling foods, intense fear of gaining
weight. Disturbances of, body image, and amenorrhea.
About half of these persons will lose weight by drastically reducing their total food intake, and some
will also develop rigorous exercising program.
The other half of these patients will rigorously diet but will lose control and regularly engage in binge
eating followed by purging behaviors.

Definition:

Anorexia Nervosa is a psychiatric disorder characterized by a voluntary refusal to eat.

Epidemiology:

 Anorexia nervosa has been reported more frequently over the past several decades than in the past, with
increasing reports of the disorder in prepubertal girls and in males.
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  Common ages of onset of anorexia nervosa are midteens, but up to 5% of the anorectic patients have the
onset of the disorder in their early 20s.

 Anorexia nervosa is estimated to occur in about 0.5% to 1% of adolescent girls. It occurs 10-20 times
more often in females than males.

Etiology

Fundamental causes of anorexia nervosa remain elusive, there is growing evidence that interacting socio
cultural and biological factors contribute
. The disorder is associated with under nutrition of varying severity, with resulting secondary endocrine
and metabolic changes and disturbances of bodily functions.eg. Restricted dietary choice, excessive
exercise, and alterations in body composition, induced vomiting and purgation and the consequent
electrolyte disturbances.
Several etiological theories have been proposed to explain the development of an eating disorder.

Socio-cultural theories.

It has focused on values concerning body weight. For e.g. paradoxical association has been noted in
industrialized countries between the increasing cultural and social values of thinness and the trend for
women to have higher body weights than previously.

Family systems theories:

Have centered on the role of the eating symptomatology in decreasing or avoiding familial conflicts
caused by marital discord, diffused or inappropriate boundaries, among family members and rigid or
demanding standards.
For some clients, the eating disorder may be an attempt to maintain control within a chaotic family
environment.
Also related to family theories are family member’s attitudes toward body images and food.

Developmental psychological theories:

Have focused on clients difficulties with autonomy and identity. Psychodynamic perspectives now
centre on clients desire to suppress or avoid psychological and physiological maturation. Previous
psychodynamic theories suggested a desire for pregnancy as the etiological bases for anorexia nervosa
and bulimia nervosa, respectively.
Difficulties with developmental psychological tasks and psychodynamic conflicts may occur
simultaneously with biological developments such as puberty. Some psychological theories speculate
that inability to integrate the rapid bodily changes of puberty predisposes people to development and
psychodynamic impediments.
A combination of several factors is more likely to cause eating disorder.

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Neurobiological Factors:

Starvation leads to many biochemical changes, some of which are also present in depression, such as
hypercortisolemia and non suppression by dexamethosone.
Thyroid function is suppressed as well. These abnormalities are corrected by realimentation.
Starvation produces amenorrhea, which reflects lowered hormonal levels (L.H., F.S.H.G.R.H.)

Genetic factors:

Monozygotic twins have significantly higher rates for anorexia nervosa than dizygotic twins, which
suggests genetic predisposition.
Few studies in individuals with bulimia nervosa suggests higher rate of illness in monozygotic twins.
Morbid risk for bulimia nervosa in relatives of individuals with illness is 10% higher

Diagnosis
DSM -IV-TR Diagnostic criteria for Anorexia Nervosa.
A. Refusal to maintain body weight at or above a minimally normal weight for age and height.
B. Intense fear of gaining weight or becoming fat, even though underweight.

C. 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.
D. In postmenarcheal females, amenorrhea. At least three consecutive menstrual cycles.

CLINICAL MANIFESTATIONS:

 An intense fear of gaining weight and becoming obese.

o Refuse to eat with their families or in public places.
 Abuse laxatives and even diuretics to lose weight, and ritualistic exercising, extensive cycling, walking,
jogging and running are common activities.
 Obsessive compulsive behavior, depression and anxiety.
 Delayed psychosocial sexual development.
 Patients with the disorder exhibit peculiar behavior about food. They hide food all over the house and
frequently carry large quantities of candies in their pockets and purses.

Investigations:
o CBC often reveals leucopenia. Lymphocytes in emaciated anorexia nervosa patient.
o If binge eating and purging are present, serum electrolyte determination reveals hypokalemia alkalosis.
o Fasting Blood Sugar concentration is usually low during emaciated phase, and serum salivary amylase
concentration is often elevated if the patient is vomiting.
o The ECG may show S-T segment and T-wave changes, which are usually secondary to electrolyte
disturbances:
o Young girls may have a high serum cholesterol level. All these values revert to normal with nutritional
rehabilitation and cessation of purging behavior.

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 o Endocrine changes that occur such as amenorrhea, mild hypothyroidism, and hyper secretion of
corticotrophin releasing hormone are due to the underweight condition and revert to normal with weight
gain.

Course and Prognosis

In general the prognosis is not good. Studies have shown a range of mortality rates from 5-18%
The outcome of anorexia nervosa has been assessed in follow up studies by different combinations of
criteria, such as weight status, social and psychological adjustment and work performance.

TREATMENT.

I) Effective, communication strategies.

 Many clients feel abandoned and betrayed by family members or friends or friends and direct their anger
and frustrations at hospital staff.
 Develop a rapport with client
 Create non threatening and non punitive environment to enhance client’s sharing thoughts and
experiences without being judged.
 Put the client at ease while communicating
 Maintain professional boundries.This provides a positive role modeling for the client.
 Inform treatment plan, unit-staff, and the unit expectations.
 Clear communication can reduce the risk of conflict, particularly in the presence of manipulative
behavior.
 Make structured schedule in the unit and behavioral agreements with clients.(Contracts)
 Contracts need to be clear, direct and with consistent communication.

II) Milieu Therapy.

In patient units often use a privilege system associated with treatment progress. Privileges reinforce
desirable behavior.
At the time of admission, a chart outlining the expectations for each level of the programs is provided to
the client.
For the client with anorexia nervosa, medical and nutritional stabilization is the entry level goal.
Activities are limited to the unit and visits are restricted.`
The staff monitors meals, planned by nutritionist.
The client is given a designated amount of time to complete meals.
The client is observed for 1 hour post meal period because the client may exercise to prevent weight
gain. During this time both -room visits are monitored, particularly if self-induced vomiting is
suspected.
As the client improves, privileges like unsupervised bathroom visits, unrestricted activities and
visitations, planning meals, unsupervised eating meals and having meals off the unit.
Unit activities introduced at various levels of the privilege system include community meetings, family
group therapy, stress management, and recreational therapy.
Exercise activities are closely supervised, given the potential compensatory use to prevent weight gain.
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 For the individual with bulimia nervosa, the entry level of the privilege system is directed at interrupting
and decreasing binge eating episodes and purging behaviors.
Encourage the client to keep a dietary log noting the type and amount of food consumed, time and place
associated thoughts and feelings.
Increased privileges are introduced as the individual progresses through each level.
The goal of the final level is to maintain and reinforce normal eating pattern, medical stability, and
decreased or interrupted binge and purge behavior.

iii)Cognitive behavior Approaches:

Cognitive behavior strategies are aimed at reducing symptoms and restructuring the belief system that
perpetuates the illness. Cognitive behavior therapy (CBT) is usually conducted by a therapist on an outpatient
basis, although some strategies may be adopted for inpatient settings. Interventions Particularly for bulimia
nervosa include planning problem solving strategies for times when the individual is most likely to be at risk for
binging or purging behavior. Restructuring the distorted belief system regarding body image and food pre
occupation is facilitated by client education, journal recordings and dietary logs. The dietary logs allows the
client to begin to identify “at risk “ periods, as well as to self monitor eating patterns. Although the dietary log
is frequently helpful in bulimia nervosa, it is generally not used in anorexia nervosa, given his already excessive
preoccupation with food in this patient group.

IV) Behavior and interpersonal Therapies:

In addition to CBT, other therapy approaches include behavior therapy and interpersonal therapy (IPT).
Behavior therapy is directed at extinguishing targeted behaviors, namely the symptoms of the disorder. IPT is
directed at interpersonal difficulties rather than the eating disorder symptomatology.

V) Individual psychotherapy:

Individual psychotherapy is generally included as part of in-patient and out-patient treatment protocols.
Individual therapy is particularly helpful in assisting the client to establish more realistic thinking processes,
increase self esteem, establish a healthy sense of control, and express emotions and needs more directly.

VI)Family therapy:

Since family plays a major role in development of eating disorders, family therapy is particularly important
when the client will be returning to the home. As the fmily already feels guilty, helpless, and frightened the
therapy aims to extend supportive, non blaming manner.
Family therapy focuses on fostering open, healthy interaction patterns among members. Some family therapist
find it helpful to focus on the dysfunctional interaction patterns identified enmeshment, over protectiveness,
rigidity and lack of conflict resolution.

VII)Group therapy:

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 Group therapy has a specific goal of fostering self esteem or gaining insight into feelings and behavior.
Groups may also be organized as primarily supportive or self help groups. It is often a relief simply to know
that one is not alone with a problem. Members gain acceptance by sharing concerns with others and receiving
constructive support and feed-back from peers.

VIII)Pharmacologic Treatments:

A) Anorexia Nervosa:
Pharmacologic intervention is generally not the primary intervention in anorexia nervosa.
Antidepressant medication may be considered, but depressive symptoms may be a consequence of
malnutrition that will reunite upon weight restoration.

BULIMIA NERVOSA

Bulimia is a term that means binge eating , which is defined as eating more food than most persons in
similar circumstances and in a similar period of time, accompanied by a strong sense of losing control

When binge eating occurs in normal weight or over weight persons who are also excessively concerned
with their body shape and weight and who regularly engage in behaviors to counteract the calorie gain in
binges, the binge eating is in the context of the disorder known as Bulimia Nervosa.

Epidemiology

 More prevalent than Anorexia Nervosa.

 Range from 1-3% in Young Women.
 Significantly more common in women than men. Onset is often later in adolescence than that of
Anorexia Nervosa or in early adulthood.
 In industrialized countries the prevalence is 1%.

Etiology

Biological Factors:

I. Serotonin, Nor-epinephrine have been linked to satiety And Endorphin levels are raised after vomiting.
II. There is increased frequency of Bulimia Nervosa in first degree relatives of persons with this disorder.

Social Factors:

Tend to be high achievers and to respond to societal pressures to be slender.

Depressed and family tendency to be depressed.
They describe their parents as neglectful and rejecting.
Are more outgoing, angry, and impulsive than anorexia nervosa patients. Alcohol dependence, substance
abuse shop lifting and emotional lability, suicidal attempts are associated with Bulimia Nervosa.
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 The struggle for separation from a maternal figure is played out in the ambivalence toward food: eating
may represent a wish to fuse with the care taker and regurgitating may unconsciously express a wish for
separation.

Pathology and Laboratory Examinations:

 Dehydration & Electrolyte abnormalities,

 Various degrees of starvation.
 They exhibit hypomagnesaemia and hyperamylasemia.

Course and Prognosis.

 Better prognosis than Anorexia Nervosa.

 In the short run, patients with Bulimia Nervosa who can engage in treatment have reported more than
50% improvement in binge eating and purging. Among outpatients, improvement last for 5 years.
Treatment

Hospitalization.

 Uncomplicated bulimia nervosa does not require hospitalization.

 But when eating binges are uncontrollable.
 Electrolyte and metabolic disturbances resulting from severe purging may necessitate hospitalization.

Psychotherapy

 Cognitive Behavior therapy

Pharmacotherapy
Bulimia Nervosa

 Anti- depressant medications that may decrease binging and purging behavior include Tricyclic
antidepressants (TCA’s), Monoamine Oxidase Inhibitors. (MAOI’s) and selective Serotonin Reuptake
Inhibitors.(SSRI”s).
 Anti depressant may be indicated for depressive co morbidity, anxiety, and obsessive symptoms.
Treatment with MAOIs requires strict adherence to dietary restrictions that may be problemetatic for the
client.
 Also, because weight gain is a potential side effect, non-compliance may occur. Insufficient
pharmacologic intervention may result from drug loss during self- induced vomiting and clients should
be encouraged not to purge after taking medications to allow for adequate absorption.

Eating disorder not otherwise specified

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It is a residual category used for eating disorders that do not meet the criteria for a specific eating disorder
For females, all of the criteria for anorexia Nervosa are met except that the individual has regular
menses.
All of the criteria for Anorexia nervosa are met except that despite significant weight loss the
individual’s current weight is in the normal range.
All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate
compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3
months.
The regular use of inappropriate compensatory behavior by an individual of normal body weight after
eating small amounts of food (self induced vomiting after consumption of 2 cookies.)
Repeatedly chewing and spitting out, but not swallowing large amounts of food.
Binge eating disorder: Recurrent episodes of binge eating in the absence of the regular use of
inappropriate compensatory behaviors characteristics of bulimia Nervosa.

Nursing Management
Assessment Data

Anorexia Nervosa Bulimia Nervosa

Lack of appetite; Lack of interest in eating Binge eating. . Over use of laxatives, diet
pills, or diuretics.
Aversion, to eating. Dysfunctional eating pattern.
Weight loss Weight loss or gain
Body weight, 20%or more under ideal Refusal, to eat.
body weight.
Difficulty eating. Compulsive eating
Malnutrition. Excessive Calorie intake
Electrolyte imbalance. Fluid and electrolyte imbalances
Disturbance in elimination Recurrent Difficulty swallowing. Hypertrophy of
vomiting after eating. salivary or parotid glands Erosion of
enamel(dental)
Lack of, awareness of need for food and Delusions, other psychotic symptoms or
fluids. other psychiatric problems.

1. Nursing Diagnosis:
Altered nutrition; less than body requirements, or more than body requirements evidenced by client,
regarding the time, frequency and procedure weight disturbances, easy fatigability, meal is not
completed on time.
Goal;
To maintain, normal nutritional status, as evidenced by maintaining base line weight.
Intervention

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 a. Make therapeutic contracts with the client regarding the time, frequency and procedure for weighing the
patient.
b. Explain the time when meals will be served and the number of meals that are to be eaten each day.
c. Discuss the amount of time the client will be allotted to each meal, and the consequences if the
evidenced by maintaining base line weight meal is not completed in time.
d. Instruct the amount of water that patient must drink each day..
e. Describe the conditions regarding bathroom privileges.
f. Make schedules for meal timings.
g. Select their own menus.
h. Cooking food, for them with supervision.
i. Set a realistic goal of gaining weight 1 pound per week. If fails, client would get into in patient
treatment.
j. Counsel about, healthy eating pattern.
k. Teach the effect of poor nutrition.
l. Teach proper eating habits.
m. Support the client to make his or her own shopping lists.

2. Nursing Diagnosis

Anxiety regarding weight gain, and body image disturbance.

Goal:
To be free from anxiety and participate in treatment.

Intervention:

Talk with the patient about the importance of modifying eating pattern.
Encourage exercise.
Engage in a new purging or compensatory behavior.
Nursing diagnosis
Irrational belief about eating.

3. Nursing Diagnosis

Maladaptive, coping responses, evidenced by purging improper eating pattern.

Goal:
To maintain normal eating pattern and cope with planned eating programme.

Intervention.

Encourage patient to make list of high-risk situations that use maladaptive eating and purging behavior.
Help the client to identify more adaptive ways of handling the high –risk situations.

4. Nursing Diagnosis:

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 Decision making strategies inadequate evidenced by one participating in treatment plans, lack of
assertiveness.
Goal:
To verbalize, his/her feelings directly.

Interventions:

Review decision making strategies for modification, client knows what he has to do in a given situation
but feels adequate.
Teach assertiveness and conduct role modeling sessions.
5. Nursing diagnosis:

Body image, distortions evidenced by worried about weight gain, lack of confidence and low self esteem.
Goal:

To maintain normal body image and participates in therapeutic milieu.

Intervention:

Determine whether the client has problems with perception, attitude or behavior and then devise a
program targeting the specific problem area.
Provide dance and movement therapies to create pleasant body experiences and can enhance the
integration of body and mind.
Clarify body boundaries.
Modulate negative feeling about the body.
Use imagery and relaxation techniques, working with mirrors and depicting the self through art.

Bibliography.
 Dr.K.Lalitha,Mental health and Psychiatric Nursing An Indian perspective(2007).Banglore;Anand
M,Ramesh V.M.G.Book House.pg.no.480-490
 Parmelee Rowlin Ruth,William Sophronia,Beck Kelly Cornelia.(1993).Mental Health Psychiatric
Nursing. A holistic life cycle.Philadelphia/Mosby Year Book
 Sadock James Benjamin, Sadock Alcott Virginia” Synopsis of Psychiatry”(9th end). Philadelphia:.
Lippincott, Williams &Wilkins. Pg.739-751
 Bimla Kapoor.(2004)A text book of Psychiatric Nursing. Volume II
 Stuart and sunden.(1995).Principles and practice of psychiatric Nursing.(5th edn).Missouri:Mosby.Pg
345-349.
 Linda Skidmore-Roth.(2000)Nursing Drug refrence..Philadelphia: Mosby.pg 11-37
 Sparks.M Sheila, Taylor M.Cynthia.Nursing Diagnosis Reference Manual. (5thEdn) Pennsylvania:
Springhouse.PG 591-593.
 Http//your total health village.com/eating disorder.htmlpg.1-6.
 http://en.wikipedia.org/wiki/Neurosis//t/t.

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