EATING DISORDERS

DEFINITION

Eating disorders are health

conditions characterized by a
preoccupation with weight
that results in severe
disturbances in eating
behavior.
Eating Disorders: Etiology
Genetics

Eating
Neurochemical Disorder Psychosocia
s l

Sociocultural
Eating Disorders etiology: Genetics
 Relatives of patients with anorexia are
eight times more likely to develop an
eating disorder
 Twin studies:
 Monozygotic twins have a 58-76%
concordance, while dizygotic twins with 35-
45% concordance
 Monozygotic twins have a 46%-56%
concordance, while dizygotic twins with
18%-35% concordance for bulimia

 Neurochemical
Neurochemical

 Serotonin
Serotonin Involvement
Involvement

4
 Eating Disorders:Etiology

 Psychosocial
 Difficultywith transition to adulthood
 Changes of body associated with
puberty
 Adult autonomy
 Stressful times of transition
 Family conflicts
 Ineffective attempts to cope with stress

5
 Eating Disorders: Etiology
 Sociocultural Pressures

 Hilda Bruch (1978) was the first to suggest that
the media and fashion industry contribute to the
idea that a women cannot be loved or respected
unless they are thin
 The culture in industrialized countries pressures

women to be thin
 Garner et al. (1980) showed that Playboy
centerfolds and Miss America contestants
became thinner from 1960 to 1978

 Promotes
Promotes wide spread body
body dissatisfaction,
dissatisfaction, even among
women
women of
of normal weight
6
 Anorexia Nervosa
 Characterized by self-
starvation

 Weight is <= 85% of normal weight
 Intense fear of gaining weight or


 
becoming fat

 Distorted sense of their body shape
and/or denial of the
seriousness of the current low
body wt                    

 in females, loss of the menstrual
period for three consecutive months

7
 ICD-10 CLASSIFICATION
F50 - F59 Behavioural syndromes associated with
physiological disturbances and physical factors
F50 Eating disorders
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
F50.4 Overeating ass. With psychological disturbances
F50.5 Vomiting ass. with other psychological disturbances
F50.8 Other eating disorders
F50.9 Eating disorder, unspecified (NOS)

8
 F50.0 Anorexia nervosa
A. Weight loss, or in children a lack of weight gain, leading to a
body weight of at least 15% below normal or expected
weight for age and height.
B. The weight loss is self-induced by avoidance of "fattening
foods".
C. Self-perception of being too fat, an intrusive dread of fatness
leading to a self-imposed low weight threshold.
D. A widespread endocrine disorder involving HPG axis,
manifest in female as amenorrhoea, and in male as loss of
sexual interest and potency
E. Does not meet criteria A and B of Bulimia nervosa (F50.2).

9
 Anorexia nervosa (DSM-IV)
(i)
(i) Refusal to maintain a body weight over a minimally
normal weight for age and height (e.g., weight loss
leading to maintenance of a body weight less than
85% of that expected or failure to make expected
weight gain during a period of growth);
(ii)
(ii) Intense fear of gaining weight or becoming fat, even
though underweight;
(iii)
(iii) Disturbance in the way that body weight, size, or
shape is experienced;
(iv)
(iv) Amenorrhea in females (absence of at least three
consecutive menstrual cycles).

10
Diagnostic subtypes (DSM-IV)
 Restricting type : is
defined by rigid restriction of
food intake without bingeing
or purging
 Binge eating/purging
type:
stringent attempts to limit
intake punctuated by
episodes of binge eating as
well as self-induced vomiting
and/or laxative abuse.
 Anorexia nervosa:
Epidemiology
Anorexia Nervosa

 Onset: 85% between 13 and and
20
 mean,
 mean, 17
17 years
years
 Peaks
 Peaks at
at 14
14 and
and 18
18 yrs.
yrs.

 Gender: 10 females: 1 male

 Prevalence:
Prevalence:
 0.5-1.0%
 0.5-1.0% ofof teenage
teenage &&
young
young adult
adult females
females

12
 Anorexia Nervosa:
Co-morbid Conditions

 Mood Disorders
 60% Lifetime Risk

 33% with Current

episode MDD

 Anxiety Disorders
 20%-50% social

phobia
 20% OCD


 Personality Disorders

 50% lifetime
lifetime prevalence
prevalence

13
The Psychology of
Anorexia nervosa
 Intense fear of gaining
weight/becoming fat
 Sense of worth is
contingent upon weight
 Strong desire to please
others
 Need for structure
 Tendency to be more shy
and withdrawn than
average
 Low self-esteem 14
 Self-worth, Weight and
Anorexia nervosa
 Underlying the Eating Disorder is the belief that
 Thinness will lead to happiness, beauty,
acceptance, approval, love….
 Weight loss is the ultimate accomplishment or
achievement
 Weight loss as a sign of discipline and strength
of mind
 A “perfect” body is synonymous with “perfect”
person
 Anorexia Nervosa:
Medical Complications
The medical problems associated with anorexia nervosa
result primarily from physiological starvation.
cardiac abnormalities (slow heart rate, disturbances in the
heart's rhythm)
dangerously low blood pressure
dangerously low body temperature
low white blood cell count
chronic constipation
osteoporosis (brittle, weak bones)
for teenagers, slowed growth or development, short
stature
loss of menstrual periods
infertility
hair loss and nail destruction
 Bulimia Nervosa
 Recurrent binge eating episodes
 Binge= large amount of food in < 2
hours
 sense of lack of control over eating
during binge
 Recurrent purging behaviors to prevent
weight gain
 Frequency of Binge/Purge > 2/week for 3
months
 Preoccupation with body shape & weight
 Specify: purging vs. non-purging 17
Bulimia Nervosa
Understanding the cycle

18
 Bulimia Nervosa: Subtypes

Purging
Nonpurging
 Vomiting

 Fasting
 Laxatives/Diuretics
  Excessive Exercise
 Diet Pills


19
Bulimia nervosa:
Epidemiology
Bulimia Nervosa

 Onset:
 late adolescence or

early adult life

 Gender: 10 females: 1
male

 Prevalence:
 1.0-3.0% of teenage

& young adult
females

20
The Psychology of Bulimia nervosa
 Fear of becoming
fat/gaining weight
 Self-worth contingent
upon weight
 Food as emotional
pacifier
 Shame
 Loss of control/
Impulsivity
 Need for approval
21
JSTAR 2004 22
 Bulimia Nervosa:
Physical Findings

 When vomiting, stomach acids in vomit erode tooth enamel,
resulting in cavities & discoloration

 Vomiting, laxatives and diuretics flush sodium & potassium
from the body resulting in an electrolyte imbalance and
potential arrhythmia.

 Self-induced vomiting can result in irritation and tears in the
lining of the throat, esophagus and stomach, as well as
enlargement of the parotid glands.

 Laxative abuse can create dependence, with subsequent
inability to have normal bowel movements

 Abuse of emetics to induce vomiting can result in toxicity, heart
failure and death

23
 Bulimia Nervosa:
Common Lab Findings of Purging
 Electrolytes
 Low potassium,
Chloride
 BUN/Creatinine >
20
 Elevated serum
amylase

JSTAR 2004 24
 Binge Eating Disorder
A.
A. Recurrent episodes of binge eating
 An episode is characterized by:
 Eating, in a discrete period of time
(e.g., within a 2-hour period) a
larger amount of food that is
definitely larger than most people
would eat in a similar period of
time under similar circumstances
 A sense of lack of control over
eating during the episode (e.g. a
feeling that one cannot stop eating
or control what or how much one
is eating)
JSTAR 2004 25
 Binge Eating Disorder

B.
B. Binge episodes are associated with:
 Eating
Eating until feeling uncontrollably full
full
 Eating
Eating much more rapidly thanthan normal
normal
 Eating
Eating large amounts
amounts when
when not
not physically
physically hungry
hungry
 Eating
Eating alone
alone because
because ofof embarrassment
embarrassment by how much one
is
is eating
eating
 Felling
Felling disgusted
disgusted with
with oneself,
oneself, depressed
depressed oror very
very guilty
guilty
after
after overeating

JSTAR 2004 26
 Binge Eating Disorder

C.
C. Marked
Marked distress
distress regarding
binge
binge eating
eating is present
D.
D. Binge
Binge eating
eating occurs,
occurs, on
average,
average, atat least
least 22 days
days aa
week
week for
for six
six months
months
E.
E. The
The binge
binge eating
eating isis not
associated
associated with
with the
the regular
regular
use
use of
of inappropriate
inappropriate
compensatory
compensatory behavior
behavior (e.g.
(e.g.
purging,
purging, excessive exercise)
and
and does
does not
not occur
occur
exclusively
exclusively during
during the
the course
course
of
of Anorexia
Anorexia Nervosa or
Bulimia
Bulimia Nervosa.
Nervosa.
JSTAR 2004 27
 Binge Eating Disorder Associated
Features
 Emotional triggers
 Often history of dieting and obesity
 On average, more obese than population
 May have significant weight fluctuations
 Interference with social, work
environment
 Higher rates of self-loathing, depression &
anxiety, somatic concern, and
interpersonal sensitivity 28
 Eating Disorders:
Goals of Treatment

 Weight Restoration, if
appropriate

 Normalization of Eating

 Treatment of co-morbid
Psychiatric conditions

 Treat/Prevent medical
complications

 Prevention of Relapse

29
 Conditions Warranting
Hospitalization
 Excessive and rapid weight loss
 Serious metabolic disturbances
 Clinical depression
 Risk of suicide
 Severe binge eating and purging
 Psychosis

30
 Who is at Risk?

 perfectionist, rigid, risk-avoiding personality traits

 dieting
 personal or family history of
 obesity
 eating disorders
 substance abuse
 depression


 personal history of physical or sexual abuse, teasing,
and harassment

 elite performance in competitive sports in which
body shape and size are a factor (male and female)

31
Eating Disorders:
Treatment Modalities

PHARMAC-
OLOGIACL

EATING
DISORDER
MANAGE-
MENT

BEHAVIORAL
PSYCHO- &
THERAPY NUTRITIONAL
 Eating Disorders: Treatment Modalities
 Medical
 Treat acute medical problems
 Nutritional Interventions
 Management of Weight
 Change intake slowly
 Therapy

 Cognitive
Cognitive therapy(CBT)
therapy(CBT) helpshelps individuals
individuals identify
identify and
and question
question
the
the reality
reality ofof their beliefs about eating
eating and
and their
their weight
 Behavioral
 Behavioral therapy
therapy isis designed
designed toto help
help change
change the
the behaviors
behaviors that
keep
keep the
the illness
illness going
 Family
 Family therapy
therapy
 Group
 Group therapy
therapy focuses
focuses onon interpersonal
interpersonal interactions
interactions
Treatment Modalities of Eating Disorders:
Psychopharmocology
 Anorexia nervosa:

 No FDA approved medication for AN
 Trials of many classes of medications:

Antipsychotics, Lithium, Cyproheptadine, Zinc
 Antidepressants (may be helpful to prevent relapse

in patients who have regained weight
 Bulimia nervosa:

 Prozac is FDA approved for BN
 Trials of many classes of medications show uncertain

efficacy
 The anticonvulsant , Topamax, has case reports of

decreasing bingeing, purging and self-mutilation
 NURSING
MANAGEMEN
T
Imbalanced nutrition: less than body requirements.
deficient fluid volume (risk for or actual)
 Assess the nutritional status.

 Dietitian consultation to determine calories required.

 Explain privileges & restrictions will be based on

compliance with treatment & wt gain.
 Weigh client daily, immediately upon arising and

following first voiding. Always use same scale, if possible.
Keep strict record of intake and output. Assess skin
turgor and integrity regularly. Assess moistness and color
of oral mucous membranes.
 Stay with client during established time for meals

(usually 30 min) and for at least 1 hour following meals.
 If weight loss occurs, use restrictions. Client must

understand that if nutritional status deteriorates, tube
feedings will be initiated. This is implemented in a
matter-of-fact, non punitive way.
Ineffective denial r/t retarded ego development
and fear of losing the only aspect of life over
which client perceives some control (eating)


 Develop a trusting relationship. Convey positive
regard.

 Avoid arguing or bargaining with the client who is
resistant to treatment. State matter-of-factly which
behaviors are unacceptable and how privileges will
be restricted for noncompliance.

 Encourage client to verbalize feelings regarding role
within the family and issues related to
dependence/independence, the intense need for
achievement, and sexuality. Help client recognize
ways in which he or she can gain control over these
problematic areas of life
Disturbed body image/low self-esteem r/t retarded
ego development and dysfunctional family
system


 Help client to develop a realistic perception of body
image and relationship with food. Compare specific
measurement of the client’s body with the client’s
perceived calculations.

 Promote feelings of control within the environment
through participation and independent decision making.
Through positive feedback, help client learn to accept
self as is, including weaknesses as well as strengths.

 Help client realize that perfection is unrealistic, and
explore this need with him or her.
 Maintaining Safety

 Assess current suicide risk.

 Implement appropriate level of observation based on a
focused suicide assessment (e.g. constant observation or
15-minute checks).

 Explain observation precautions to patient.

 Remove harmful objects from patient's possession, and
assess environmental safety of patient's room and unit.

 Encourage patient to negotiate a no-self-harm and no-
suicide agreement with the staff.

 Monitor need to revise level of observation.

 Provide additional structure by keeping patient involved
in therapeutic and psycho-rehabilitative activities.
STRENGTHENING COPING AND SENSE OF HOPE
 Initiate interaction with patient at a regularly scheduled

time.
 Be clear and honest about your own feelings related to

patient's behavior.
 Encourage verbal expression of feelings.

 Validate feelings that are appropriate to the situation

 Encourage patient to identify events that cause

unpleasant emotional responses.
 Assess significant losses patient has experienced.

 Identify cultural and social factors that may contribute

to how patient copes with loss and feelings.
 Assess patient's support network.

ENCOURAGING PARTICIPATION IN ADLS
 Collaborate with occupational and physical therapists to

determine patient's functional capacity to accomplish
ADLs.
 If patient cannot accomplish ADLs independently,

provide hygiene activities in collaboration with patient.
 Acknowledge and reinforce patient's efforts to maintain

appearance; do not rush patient when self-care is slow.
 Reinforce what patient can do rather than what patient

cannot do without assistance.
 Remain with patient during mealtime to determine the

level of need for assistance or cueing in the ability to
eat.
FACILITATING SLEEP
 Determine patient's past and current sleep patterns and

sleep hygiene.
 Consider decreasing the amount of daytime sleep by

encouraging participation in an activity.
 Discuss alternative methods for facilitating sleep/ SLEEP

HYGEINE:

 Avoid
Avoid caffeine
caffeine and
and nicotine.
nicotine.

 Avoid
Avoid emotionally
emotionally charged
charged or
or upsetting
upsetting discussions
discussions before
before bedtime.
bedtime.

 Avoid
Avoid exercise
exercise 30
30 minutes
minutes to
to 1 hour
hour before
before bed.
bed.

 Increase
Increase physical activity within
within functional
functional limits.
limits.

 Use
Use relaxation
relaxation techniques.
techniques.

 Try
Try aa warm
warm bath
bath or
or warm
warm milk.
 Administer
 prescribed drugs that cause sleepiness at
bedtime; avoid giving drugs that cause insomnia at night.
Questions