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EATING DISORDERS

PICA

Pica is an eating disorder typically defined as the persistent ingestion of nonnutritive substances for a period of at least 1 month at an age at which this behavior is developmentally inappropriate (e.g., >18-24 mo).

Individuals who present with pica have been reported to mouth and/or ingest a wide variety of nonfood substances, including, but not limited to, clay, dirt, sand, stones, pebbles, hair, feces, lead, laundry starch, vinyl gloves, plastic, pencil erasers, ice, fingernails, paper, paint chips, coal, chalk, wood, plaster, light bulbs, needles, string, cigarette butts, wire, and burnt matches.

Commonly seen in children with mental retardation.


Occasionally occurs in pregnant women.

Comes to the clinicians attention only if a medical complication develops such as a bowel obstruction or an infection or if a toxic condition develops such as lead poisoning. In most instances, the behavior lasts for several months and then remits.

RUMINATION DISORDER

The term rumination is derived from the Latin word ruminare, which means to chew the cud.

Rumination is characterized by the voluntary or involuntary regurgitation and rechewing of partially digested food that is either reswallowed or expelled. This regurgitation appears effortless, may be preceded by a belching sensation, and typically does not involve retching or nausea.

The child brings partially digested food up into the mouth and usually rechews and reswallows the food. The regurgitation does not involve nausea, vomiting, or any medical condition (APA, 2000).

In rumination, the regurgitant does not taste sour or bitter. A diagnosis of rumination requires that the behavior must persist for at least 1 month, with evidence of normal functioning prior to onset.

This disorder is relatively uncommon and occurs more often in boys than in girls. It results in malnutrition, weight loss, and even death in about 25% of affected infants. In infants, the disorder frequently remits spontaneously, but it may continue in severe cases.

FEEDING DISORDER

Feeding disorder of infancy or early childhood is characterized by persistent failure to eat adequately, which results in significant weight loss or failure to gain weight.

Equally common in boys and girls and occurs most often during the first year of life. Estimates are that 5% of all pediatric hospital admissions are for failure to gain weight, and up to 50% of those admissions reflect a feeding disorder with no predisposing medical condition.

In severe cases, malnutrition and death can result, but most children have improved growth after some time (APA, 2000).

ANOREXIA NERVOSA

DSM-IV Criteria:
The major characteristics include: a refusal to maintain a normal body weight even though the individual is underweight; the absence of at least 3 consecutive menstrual cycles; and

a body image disturbance that most commonly manifests itself in patients perceptions of themselves as overweight, when in fact, they are emaciated.

Some studies suggest that it is not necessarily a distortion of body image, but rather a weight phobia that is present in anorectic patients (Pumariega, et al, 1993; Hsu and Sobkiewicz, 1991). Besides size overestimation, weight or shape maybe the most important influence on the persons sense of worth, or they may simply deny the problematic nature of their underweight status.

Behavior:
The onset of anorexia can often be considered insidious (not readily apparent) because the typical adolescent girl who becomes a victim usually portrays an image of being the perfect little girl, never causing problems for anyone. As dieting and fad foods are such common themes in adolescence, it usually is not until the young woman has lost a significant amount of weight that anyone takes notice.

The most common premobid personality profile is that a perfectionist and introverted girl with problems with self-esteem and peer relationships (Beumont, 1995). These girls are typically high achievers, often earning outstanding grades and other honors. The most obvious observable behavior of anorexia nervosa is deliberate weight loss. Patients have such a preoccupation with food and such a need to control their weight that their eating behaviors change significantly.

Patients with anorexia nervosa are in 2 groups: the DIETERS and the VOMITERS/PURGES. The dieters are more often young women who are in the normal weight range for height and build before the eating disorder begins. This group views losing weight as more possible if they simply eat less and avoid social situations in which eating is expected.

Consequently, these young women often isolate themselves from their friends and families, often withdrawing into their rooms. It is not uncommon for these young women to be competitive and obsessive about their activities. They also are often observed participating in rigid exercise programs to help reduce their weight.

Psychotherapeutic Management:
Psychotherapeutic management is geared toward the following 3 major objectives: Increasing self-esteem so patients do not need the artificial perfection they believe thinness provides. Increasing weight to at least 90% of the average body weight for the patients height and age. Helping patients reestablish appropriate eating behavior.

When patients are in the starvation phase of the illness, and the malnutrition has become a serious medical environment where appropriate supplies and equipment, such as IV and feeding tube apparatuses are readily available. When the medical crisis is resolved, patients are transferred to a psychiatric unit, or on an outpatient basis in a physicians office.

In any setting, a multidisciplinary treatment approach is crucial. Members of the treatment team should include a physician, a nurse, a dietitian, and a psychotherapist specializing in the treatment of eating disorders. These patients need medical monitoring, nutritional education and counseling, and psychotherapy.

BULIMIA NERVOSA

DSM-IV Criteria:
There are 3 core features of the bulimic patient (Fairbum and Beglin, 1990): Recurrent episodes of uncontrolled binge eating (eating an unusually large amount of food in a short period of time).

Various behavior designed to control shape and weight; that is, extreme dieting, excessive exercising, self-induced vomiting, taking laxatives or diuretics, use of diet pills, or abuse of enemas/suppositories. Persistent over concern with body shape and weight.

The DSM-IV reports bulimia nervosa usually begins in adolescence or early adult life, primarily in females. The prevalence of bulimia among adolescent and young adult women is thought to be approximately 1% in the general population, and 4% among young adult women (Grinspoon, 1997).

Behavior:
The word bulimia literally means to have an insatiable appetite. It is often caused to describe massive overacting and is used interchangeably with binge eating or binging. Other names, such as bulmarexia, have also been associated with binge and vomiting behaviors.

Until recently, bulimia nervosa was considered to be a part of anorexia nervosa because almost half of those diagnosed were observed to have binge-eating episodes. Bulimia nervosa is now accepted as a separate disorder. The true prevalence of bulimia nervosa is unknown because many patients hide their eating-disordered behaviors.

Only those who seek medical attention (which usually is for GI or menstrual disturbances) or psychotherapy is usually identifiable. The onset of the illness is usually between the ages of 15 and 24 years. It may develop after anorexia nervosa but almost always occurs following a period of dieting (Beumont, 1995).

The dieting predisposes the individual to binge eating, and purging develops as a means of attempting to compensate for calories ingested during the disorder, which continues to precipitate binge eating. Most bulimic patients are secretive about their behavior. A variety of foods may be eaten during a binge, but the most common is high-calorie, high-carbohydrate food that is easily ingested in a short period of time.

Some bulimics visit several different fast food restaurants during a binge so that no one knows how much they are eating at once. Some have been caught shoplifting food. Most binges occur in the evening or at night. The amount of calories consumed during a binge varies, but it may be as much as 30 times the recommended daily allowance (Beumont, 1995).

The bulimic episodes usually ends when the patient begins to induce vomiting, is physically exhausted, suffers from painful abdominal distention, is interrupted by others, or has simply ran out of food (Fairburn and Cooper, 1986). Following a binge, patients usually promise themselves they will adhere to strict diet, vowing never to binge again.

Many actually resume their actual schedules as if they never have been interrupted. The frequency of binges varies greatly, depending on the patient. Some patients report having several episodes a day, others report losing control 2 to 3 times a week.

Psychotherapeutic Management:
As in the treatment of anorexia nervosa, medical stabilization of the bulimic patient is the initial goal of treatment (De Zwaan and Mitchell, 1993). Following medical stabilization, psychotherapy is the treatment of choice.

Cognitive-behavioral therapy has the greatest research support, although there is limited evidence suggesting interpersonal psychotherapy may have similar long-term effectives (Fairburn, 1995; McGown and Whitebread, 1996). Pharmacotherapy is used as an adjunct to psychotherapy when indicated (Walsh, 1995).

Similar to the treatment of anorexia, nurses may encounter bulimics in an inpatient setting or as outpatients seen for medical monitoring in a physicians office. Overall, they are less likely than anorectics to be inpatients. A multidisciplinary approach, involving physicians, nurses, dietitians, and psychotherapists, is also recommended with bulimics.

PSYCHOSEXUAL DISORDERS

GENDER IDENTITY DISORDER

It is diagnosed when an individual has a strong and persistent cross-gender identification; that is, when an individual has the desire to be, or insists that he or she is of, the other sex, accompanied by the persistent discomfort of his or her assigned sex or a sense of inappropriateness in the gender role of that assigned sex.

The person experiences clinically significant distress or impairment in social, occupational, or other important areas functioning. In boys, there is a preoccupation with traditionally feminine activities, a preference for dressing a girl or grow up to be a woman.

Girls may resist parental attempts to have them wear dresses or other feminine attire, wear boys clothing, have short hair, ask to be called by a boys name, and express the desire to grow a penis and grow up to be a man.

SEXUAL DYSFUNCTIONS

Characterized by a disturbance in the processes of the sexual response cycle or by pain associated with sexual intercourse. The sexual response cycle consists of desire, excitement, orgasm, and resolution. Sexual dysfunctions are may be due to psychological factors alone or a combination of psychological factors and a medical condition.

1. Sexual Desire Disorders involve disruption in the desire phase of the sexual response cycle. Hypoactive Sexual Desire Disorder characterized by a deficiency or absence of sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty.

Sexual Aversion Disorder involves aversion to and active avoidance of genital sexual contact with a sexual partner that causes marked distress or interpersonal difficulty. The individual reports anxiety, fear, or disgust when confronted by a sexual opportunity of a partner.

2. Sexual Arousal Disorders are a disruption of the excitement phase of the sexual response cycle. Female Sexual Arousal Disorder persistent or recurrent ability to attain or maintain, until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement, which causes marked distress or interpersonal difficulty.

Male Erectile Disorder persistent or recurrent inability to attain or maintain, until completion of the sexual activity, an adequate erection, which causes marked distress or interpersonal difficulty.

3. Orgasmic Disorders are disruptions of orgasm phase of the sexual response cycle. Female Orgasmic Disorders Persistent or recurrent delay in, or absence of, orgasm following a sexual excitement phase, which causes marked distress or interpersonal difficulty.

Male Orgasmic Disorders Persistent or recurrent delay in, or absence of, orgasm following a sexual excitement phase, which causes marked distress or interpersonal difficulty. Premature Ejaculation Persistent or recurrent onset of orgasm and ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it, causing marked distress or interpersonal difficulty.

4. Sexual Pain Disorders involve pain associated with sexual activity. Dyspareunia Genital pain associated with sexual intercourse causing marked distress or interpersonal difficulties. It can occur in both males and females, and symptoms range from mild discomfort to sharp pain.

Vaginismus Persistent or recurrent involuntary contractions of the perineal muscles surrounding the outer third of the vagina when vaginal penetration with penis, finger, tampon, or speculum is attempted, causing marked distress or interpersonal difficulties. The contraction may range from mild (tightness and mild discomfort) to severe (preventing penetration).

Sexual Dysfunction due to a General Medical Condition:


Presence of clinically significant sexual dysfunction that is exclusively due to the physiological effects of a medical condition. It can include pain with intercourse, hypoactive sexual desire, erectile dysfunction, orgasmic problems, or other problems as previously described. The individual experiences marked distress or interpersonal difficulty related to the symptoms.

Substance-Induced Sexual Dysfunction:


Clinically significant sexual dysfunction resulting in marked distress or interpersonal difficulty caused by the direct physiological effects of a substance (drug of abuse, medication, or toxin). It may involve impaired arousal, impaired orgasm, or sexual pain.

PARAPHILIAS

Paraphilias are recurrent, intensely sexual arousing fantasies, sexual urges or behaviors generally involving: (1) non human objects, (2) the suffering or humiliation of ones self or partner, or (3) children or other nonconsenting persons.

For pedophilia, voyeurism, exhibitionism, and frotteurism, the diagnosis is made if the person has acted on this urges or if the urges or fantasies cause marked distress or interpersonal difficulty.

For sexual sadism, the diagnosis is made if the person has acted on this urges with a nonconsenting person or if the urges, fantasies, or behaviors cause mark distress or interpersonal difficulty.

For the remaining paraphilias, the diagnosis is made if the behavior, sexual behavior, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Exhibitionismexposure of the genitals to the stranger, sometimes involving masturbation; usually occurs before age 18 and less severe after age 40. Fetishismuse of nonliving objects (the fetish) to obtain sexual excitement and/or achieve orgasm. Common fetishes include womens underwear, bras, lingerie, shoes, or other apparel, the person might masturbate while holding or rubbing the object. It begins by adolescence and tends to be chronic.

Frotteurismtouching and rubbing against a non consenting person, usually in a crowded place from which the person with frotteurism can make a quick escape, such as public transportation, shopping mall, or a crowded sidewalk. The individual rubs his genitals against the victims thighs and buttocks or fondles her breasts or genitalia with his hands. Acts of frottage occurs most often between the ages of 15 and 25; frequency declines after that.

Pedophiliasexual activity with a prepubescent child (generally 13 years or younger) by someone at least 16 years old and five years older than the child. It can include an individual undressing the child and looking at the child; exposing himself or herself; masturbating in the presence of the child; touching and fondling the child; fellatio; cunnilingus; or penetration of the childs vagina, anus, or mouth with the individuals fingers or penis or with foreign objects, with varying amounts of force.

Sexual Masochismrecurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving the act of being humiliated, beaten, bound, or otherwise made to suffer. Some individuals act on masochistic urges by themselves, others with a partner.

Sexual Sadismrecurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving acts in which the psychological or physical suffering of the victim is sexually arousing to the person. It can involve domination (caging the victim or forcing the victim to crawl, beg, plead), restraint, spanking, beating, electrical shock, rape, cutting, and, in severe cases, torture and death. Victims may be consenting (those with sexual masochism) or nonconsenting.

Transvestic Fetishismrecurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving cross dressing by a heterosexual male. Voyeurism recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors involving the act of observing an unsuspecting person who is naked, in the process of undressing, or engaging in sexual activity. Voyeurism usually begins before age 15, chronic, and may involve masturbation during the voyeuristic behavior.

ABUSE AND VIOLENCE

INTIMATE PARTNER/SPOUSE VIOLENCE

The mistreatment or misuse of one person by another in the context of an emotionally intimate relationship.
The relationship may be spousal, between partners, boyfriend, girlfriend, or an estranged relationship.

The abuse can be emotional or psychological, physical, sexual, or a combination (which is common). oPsychological abuse (emotional abuse) includes name-calling, belittling, screaming, yelling, destroying property, and making threats as well as subtler forms, such as refusing to speak to or ignoring the victim.

oPhysical abuse ranges from shoving and pushing to severe battering and choking and may involve broken limbs and ribs, internal bleeding, brain damage, and even homicide. oSexual abuse includes assaults during sexual relations such as biting nipples, pulling hair, slapping and hitting, and rape.

From 90% to 95% of domestic violence victims are women. An estimated 324, 000 women experience violence while pregnant. Battering during pregnancy leads to adverse outcomes, such as miscarriage and stillbirth, as well as to further physical and psychological problems for the woman.

The increase in violence often results from the partners jealousy, possessiveness, insecurity, and lessened physical and emotional availability of the pregnant woman (Bacchus, Mezey, and Bewly, 2006).

As enumerated in textbooks and literatures, some of the most common forms of violence experienced by Filipino women include: Domestic Violence also known as wife abuse or battery. Not only involves physical abuse but emotional or psychological abuse as well.

Marital Rape due to Filipino culture, women still believe that men can have complete sexual powers and control over them. This includes forcing the wife to have sexual intercourse, striptease and other sexual brutalities. Reproductive Rights Violation includes forced pregnancy, forced sterilization, forced abortion or denial of information to safe birth control methods.

Sexual Harassment an unwanted sexual attention that makes school or workplace environment offensive, hostile, or intimidating. Also includes men who ogle and whistle at women or make obscene and degrading remarks in public places.

Sex Discrimination women are often given lower status or opportunities for advancement. Medical Abuse includes unnecessary and unwanted interventions like internal vaginal examinations, hysterectomy, etc. Culture Bound Practices Harmful to Women arranged marriages, the doublestandard given to virginity and religious practices that bind women tightly to men even if these men are dangerous and violent.

Sexual Slavery, Prostitution and International Trafficking of Women it has been said that prostitution is one of the oldest professions. There is a debate though between forced prostitution and prostitution by choice. Pornography and Abuse of Women in Media advertisement frequently portray women as sex objects. The degrading and dehumanizing effect of pornography cannot be questioned.

The cycle of violence or abuse is another reason often cited why women have difficulty leaving abusive relationships.
VIOLENT BEHAVIOR

TENSIONBUILDING

PERIOD OF REMORSE OR CONTRITION

Cycle of Violence

C H I L D A B U S E/ MALTREATMENT

Generally is defined as the intentional injury of a child. It can include physical abuse or injuries, neglect or failure to prevent harm, failure to provide adequate physical or emotional care or supervision, abandonment, sexual assault or intrusion, and overt torture or maiming (Bernet, 2005).

Types of abuse in children: Physical Abuse often results from unreasonably severe corporal punishment or unjustifiable punishment such us hitting an infant for crying or soiling his/her diapers. Intentional, deliberate assaults on children include burning, biting, cutting, poking, twisting limbs, or scalding with hot water.

Sexual Abuse involves sexual acts performed by an adult on a child younger than 18 years. Examples include incest, rape, and sodomy performed directly by the person or with an object, oral-genital contact, and acts of molestation such as rubbing, fondling, or exposing the adults genitals. Sexual abuse may consist of a single incident or multiple episodes over a protracted period.

Neglect malicious or ignorant withholding of physical, emotional, or educational necessities for the childs wellbeing. Child abuse by neglect is the most prevalent type of maltreatment and includes: refusal to seek health care or delay doing so; abandonment; inadequate supervision; reckless disregard for the childs safety;

punitive, exploitive, or abusive emotional treatment; spousal abuse in the childs presence; giving the child permission to be truant; or failing to enroll the child in school.

Psychological Abuse (Emotional Abuse) includes verbal assaults, such as blaming, screaming, name-calling and using sarcasm; constant family discord characterized by fighting, yelling, and chaos; and emotional deprivation or withholding of affection, nurturing, and normal experiences that engender acceptance, love, security and self-worth.

Emotional abuse often accompanies other types of abuse (e.g., physical or sexual abuse). Exposure to parental alcoholism, drug use, or prostitution and the neglect that results also falls within this category.

ELDER ABUSE

The maltreatment of older adults by family members or caregivers. It may include physical and sexual abuse, psychological abuse, neglect, self-neglect, financial exploitation and denial of adequate medical treatment.

Estimates are that people over age 65 are injured, exploited, abused, or neglected by their caregivers and that only 1 in 14 elder maltreatment cases are reported (Muehlbauer and Crane, 2006). Nearly 60% of the perpetrators are spouses, 20% are adult children, and 20% are others such as siblings, grandchildren and boarders.

Most victims of elder abuse are 75 years or older; 60-65% are women. Abuse is more likely when the elder has multiple chronic mental and physical health problems and when he/she is dependent on others foe food, medical care, and various activities of daily living. Person who abuse elders are almost always in care giver position or the elders depend on them in some way.

Most cases of elder abuse occur when one older spouse is taking care of another. This type of spousal abuse usually happens over many years after disability render the abused spouse unable to care for himself or herself. When the abuser is adult child, it is twice as likely to be a son as a daughter. A psychiatric disorder or a problem with substance abuse also may aggravate abuse of elders (Goldstein, 2005).

Elders are often reluctant to report abuse, even when they can, because the abuse usually involves family members whom the elder wishes to protect. Victims also often fear losing their support and being moved to an institution.

No national estimates of abuse of elders living in institutions are available. However, under a 1978 federal mandate, ombudsmen are allowed to visit nursing homes to check on the care of elderly. The ombudsmen report that elder abuse is common in institution (Goldstein, 2005).

The most frequently used categories of elder abuse are as follows: oPhysical Abuse lack of personal care, lack of supervision, visible bruises and welts, repeated beatings, and withholding of food. oPsychological Abuse verbal assaults, isolation, threats, and inducement of fear. oFinancial or Material Abuse misuse, appropriation, or theft of money or property.

oUnsatisfactory Living Environment unclean home, urine odor in home, and hazardous living condition. oViolation of Individual or Constitutional Rights reduction of personal freedom or autonomy, involuntary commitment or guardianship, false imprisonment, and incompetence.

RAPE AND SEXUAL ASSAULT


Rape is a crime of violence and humiliation of the victim expressed through sexual means. Rape is the perpetration of an act of sexual intercourse with a female against her will and without her consent, whether her will is overcome by force, fear of force, drugs, or intoxicants.

It is also considered rape when the woman is incapable of exercising rational judgment because of mental deficiency or when she is younger than the age of consent (which varies among states from 14 to 18 years; van der Kolk, 2005). The crime of rape requires only slight penetration of the outer vulva; full erection and ejaculation are not necessary. Forced acts of fellatio and anal penetration, although they frequently accompany rape, are legally considered sodomy.

The woman who is raped also may be physically beaten and injured. Rape can occur between strangers, acquaintances, married persons, and persons of the same sex. Almost 2/3 of rapes are committed by someone known to the victim (RAINN, 2009). Date rape (acquaintance rape) may occur on a first date, on a ride home from a party, or when the two people have known each other for some time.

Rape is a highly underreported crime: Estimates are that only 1 rape is reported for every 4 to 10 rapes that occur. The underreporting is attributed to the victims feelings of shame and guilt, the fear of further injury, and the belief that she has no recourse in the legal system. Victims of rape can be any age: Reported cases have victims ranging in age from 15 months to 82 years. The highest incidence is in girls and women 16 to 24 years of age. Girls younger than 18 years were the victims in 61% of rapes reported (van der Kolk, 2005).

Recent research (van der Kolk, 2005) has categorized male rapists into four categories: Sexual sadists who are aroused by the pain of their victims Exploitive predators who impulsively use their victims as objects for gratification Inadequate men who believe that no woman would voluntarily have sexual relations with them who are obsessed with fantasies about sex Men for whom rape is a displaced expression of anger and rage.

THE END!

COLLEGE OF NURSING

Requirement in Psychiatric Nursing

Prepared by:
GALVEZ, Jillian Rose D. GIRAY, Gencris M. GOBRIN, Dareen F. GORDON, Lorlaine M.

BSN-3a

Prepared by:
GOYENA, John O. HONEY, Czarina O. FROILAN, Antonio J. VARGAS, January Grace G.

BSN-3a

Presented to:
Jeanette J. Rojo, MAN
Clinical Instructor