EATING DISORDER

Prepared by:
Mrs.Akila.A, M.Sc (N)., M.Sc (PSY)
Associate Professor
 INTRODUCTION
• Nutrition is required to sustain life. But
many people within the world are starving
from lack of food. Eating is a social
activity. Society and culture have a great
deal of influence on eating behaviours.
 EATING DISORDERS
• Eating disorders are mental illnesses that
cause serious disturbances in a person’s
everyday diet. It can manifest as eating
extremely small amounts of food or
severely overeating. The condition may
begin as just eating too little or too much
but obsession with eating and food over
takes over the life of a person leading to
severe change
 ICD 10 CLASSIFICATION OF EATING
DISORDER
F50 Eating disorders
F50.0 Anorexia nervosa
F50.1 Atypical anorexia nervosa
F50.2 Bulimia nervosa
F50.3 Atypical bulimia nervosa
F50.4 Overeating associated with other psychological
disturbances
F50.5 Vomiting associated with other psychological
disturbances
F50.8 Other eating disorders
F50.9 Eating disorder, unspecified
 TYPES OF EATING DISORDERS

 Anorexia Nervosa
 Bulimia Nervosa
 Binge Eating Disorder
 Not Otherwise Specified (NOS)
 ANOREXIA NERVOSA
• Anorexia nervosa happens when one is
obsessed with becoming thin that they
reach extreme measures and this leads to
extreme weight loss.
• Anorexia Nervosa is characterized by
highly specific behavioral and
psychological symptoms and significant
somatic signs.
 DEFINITION
Anorexia nervosa is characterized as a
disorder in which persons refuse to
maintain a minimally normal weight,
intensely fear of gaining weight and
significantly misinterpret their body and
its shape.”
-DSM IV TR
• Common among Females, onset during
adolescence.
• Core Psychopathological feature is the
dread of fatness, weight Phobia, and a
drive for thinnness.
 EPIDEMIOLOGY
• Increasing in pre pubertal boys and girls
• Onset – 14 – 18 years
• 0.5 – 1% of adolescent girls
• 10 – 20 times more often in females
• In upper classes
• In developed countries
• Mostly among young women in
professions that require thinness
ETIOLOGY:
Biological factors:
• Dysfunction in serotonin, dopamine and
norepinephrine, Corticotropin releasing factor,
neuropeptide , gonadotropin releasing hormone
and thyroid stimulating hormone due to
Hypothalamus function disturbances
Genetics:
• 6-10% of females,
• 1-2% of general Population
Social Factors:
• Influence of mass media,
• beauty contests
Individual Psychological Factors:
• Disturbance of body image and identity
• Traits of perfectionism and low self esteem
Causes within family:
• Disturbances in family relationship, over
protection
• Family members having an unusual food
pattern
 SUB TYPES ANOREXIA NERVOSA

• Restricting Type: during last 3months, the

person has not engaged in recurrent episodes of
binge eating or purging behavior
Binge-Eating/Purging Type: during last 3
months, the person engaged in recurrent episodes
of binge eating or purging behavior
 CLINICAL FEATURES
• 10 – 30 years of age
• Weight loss, 15% below the body weight.
• Refuse to eat with others
• Drastically reducing food intake
• Constant thinking about food
• Binge eating (mostly at night)
• Self induced vomiting, Peculiar behaviour
• Obsessive compulsive behaviour
• Depression ,Anxiety
• Somatic complaints,
• Body image disturbances, Preoccupation
with body size, description of herself as fat.
• Lack of calorie intake
• Sensitivity to cold, delayed gastric emptying
• Constipation, Low BP
• Hypothermia
• Decreased interest in sex
• Amenorrhea, ECG changes
 COURSE AND PROGNOSIS
• Course is varies
• Restricting type less likely to recover
• Prognosis is not good
• Outcome is variable with remissions
and exacerbations.
• Symptoms of bulimia will usually occur
within the 1st year after the onset of
anorexia nervosa
DIAGNOSIS OF CRITERIA OF ANOREXIA
NERVOSA DSM IV
• Refusal to maintain 85% of ideal body weight
• Intense fear of becoming fat
• Body image distortion; undue influence of weight
on self evaluation; denial of risks of low weight
• Amenorrhea (in post-menarchal females)
 DIAGNOSIS OF ANOREXIA NERVOSA (DSM-5)

• Restriction of energy intake relative to requirements

leading to a significantly low body weight in the
context of age, sex
• Intense fear of gaining weight or becoming fat, or
persistent behavior that interferes with weight gain
• Disturbance in one's body weight or shape ,
persistent lack of recognition of the seriousness of
low body weight
• Specify: Restricting type and Purging type/Binge
Eating
 ICD 10 DIAGNOSTIC CRITERIA

• There is weight loss or, in children, a lack

of weight gain, leading to a body weight at
least 15% below the normal or expected
weight for age and height
• The weight loss is self induced by
avoidance of “fattening foods”
 PATHOLOGY AND
LABORATORY EXAMINATIONS
CBC

Serum electrolyte

Fasting serum glucose

Serum salivary amylase

ECG

Serum cholesterol
 Health risks with
anorexia

• Heart failure

• Kidney failure

• Low protein stores

• Digestive problems
 TREATMENT
• Determine inpatient vs. day treatment vs.
outpatient
• Multidisciplinary teams are essential!
Primary care provider
• 1st: weight restoration
• 2nd: psychological
• 3rd: maintenance (long-term)
 HOSPITALIZATION
•< 75% ideal body weight
•Hypothermia T<36
•Bradycardia HR<50 while awake, <45 asleep
•Orthostasis-drop in sbp >10, increase in HR>35
•Dehydration
•Severe hypokalemia (<2-3 mmol/L) or other electrolyte
abnormality
•Acute medical complication
•Severe depression/suicidality– Psychiatric admit
 MANAGEMENT IN
HOSPITALIZATION
• Restore patient’s nutritional state
• Weight below 20% - inpatient programs
• Weight below 30% - psychiatric hospitalization
• Compulsory admission when the risk of death
• Weight checking
• Record intake and output
• Monitor serum electrolyte level
• Stool softeners
• Calories intake (above 500)
• Liquid food supplement
• Continuous outpatient supervision
• DRUGS:
- Neuroleptics
- Appetite stimulants
- Antidepressants
• Psychotherapies:
- Individual psychotherapy
- Cognitive therapy
- Behavioural therapy
- Family therapy
 Nursing Interventions

• Maintain a strict intake and output chart

• Monitor status of skin and oral mucous membrane
• Encourage the patient to verbalize feelings of fear and
anxiety related to achievement
• Avoid discussion that focus on food and weight.
• Short term management on ensuring weight gain and
correcting nutritional deficiencies
• Balanced Diet of 3000 calories should be provided in 24 hours
• Monitor weight , serum electrolytes to prevent amenorrhea,
hypoglycaemia, hypotension etc
 BULIMIA NERVOSA

• Bulimia is an illness in which person binges

on food or has regular episodes of significant
over – eating and feels a loss of control.

• The affected person then uses various

methods such as vomiting or Laxative abuse
to prevent Weight gain.
 EPIDEMIOLOGY

• Lifetime Prevalence
– 1.5% women
– 0.5% men
• Prevalence of binge-purge behaviours:
– 13% girls
– 7% boys
 DEFINITION
It is an emotional disorder characterized by a
distorted body image and an obsessive
desire to lose weight, in which bouts of
extreme overeating are followed by fasting or
self-induced vomiting or purging.
• It is characterised by episodes of binge-
eating followed by feelings of guilt,
humiliation, depression and self
condemnation.
• More common in First degree, biological
relatives of people with bulimia
• Chromosomal abnormalities
• Altered serotonin
• Society’s emphasis on thinness and
appearence
• Family disturbances
• Conflict
• Sexual abuse
• Learned maladaptive behaviour
• Struggle for control or self identity
 TYPES OF BULIMIA
• Bulimia Nervosa Purging type:
This type of bulimia nervosa accounts
for the majority of cases of those suffering
from this eating disorder.

• Bulimia Nervosa non Purging type:

Binge episodes, such asexcessive
exercising or fasting.
 Clinical Features
• Sore throat, Heart burn
• Callused or scarring on back of hands and knuckles
• Tooth staining or discolouration
• Loss of dental enamel
• History of more food intake
• During binge eating periods, sense of lack of control
• Thin,normal or slightly overweigh appear
• Pain
• Amenorrhoea
• Fluid and electrolyte disturbances
• Perfectionism
• Distorted body image
• Exaggerated sense of guilt
• Feelings of alienation
• Poor impulse control
• Low tolerance to frustration
• Peculiar eating habits
• Excessive exercise regimen
• Withdrawal from friends and family
• Frequent weighing
 PROGNOSIS
• 33% remit every year
• But another 33% relapse into full criteria
• Adolescent-onset better prognosis than
adult-onset
• Death-rate = 1%
 Medical Complication
• Electrolyte abnormalities leads to dehydration
• Dental – loss of enamel, chipped teeth, cavities
• Parotid enlargement
• Conjunctival hemorrhages
• Calluses on dorsal side of hand (Russel’s sign)
• Esophagitis
• hematemesis
• Irregular bowel movements
• Increased risk of suicide
• Latxative-dependent: cathartic colon, melena, rectal prolapse
• Increased risk of substance abuse
DIAGNOSTIC GUIDELINES
• A. Recurrent episodes of binge eating:
Eating large amount in a discrete period
of time and lack of control over eating
• B. Recurrent compensatory behavior in
order to prevent weight gain
• C. Binge eating and inappropriate
compensatory behaviors is at least once a
week for 3 months
 Other diagnostic criteria
• Medical evaluation
• Psychological evaluation
• Beck Depression inventory
• Serum electrolytes, glucose, ECG
 TREATMENT
•Multidisciplinary team
•High-dose fluoxetine/prozac (SSRI) very good evidence!

•Sertraline/Zoloft (SSRI) – some good evidence

•Buproprion/Wellbutrin (other
antidepressant)contraindicated!
•Topiramate/Topomax (mood stabalizer, promotes weight
loss) some good evidence, but use with caution esp if
low-weight
• Evidence based : CBT + Antidepressant (SSRI)
• Family therapy is a good option if patient is young
and still lives at home (But not as much evidence as
for Anorexia)
• Interpersonal therapy (IPT) (short-term treatment
focused on life transitions)
• Psychodynamic Psychotherapy (good for long-term
results in people with chronic depressive and
personality symptoms)
• Nutrition plan, exercise, physical activity
 NURSING INTERVENTIONS

• Encourage patient to recognize and verbalize

her feelings about her eating behaviour.

• Set a timetable for each meal

• Identify patient elimination patterns

• Provide assertiveness training

• Assess and monitor patients suicide potential

 BINGE EATING DISORDER

• Binge eating is disorder in which someone eats a lot

amount of food at a time but they don't vomit.
ETIOLOGY :
• Behaviours are unhealthy coping mechanisms
– Factors to consider:
• Psychological
• Interpersonal
• Social/Cultural
• Biological
 Psychological Factors

• Low self-esteem
• Feelings of inadequacy or failure
• Feeling out of control
• Response to change (puberty)
• Response to stress (sports, dance)
• Personal illness
 Interpersonal Factors

• Troubled family and personal relationships

• Difficulty expressing emotions and feelings
• History of being teased or ridiculed based on
size or weight
• History of physical or sexual abuse
Social and Cultural Factors:
• Cultural pressures that glorify thinness and
place value on obtaining the perfect body
• Narrow definitions of beauty that include only
women and men of specific body weights
and shapes
• Cultural norms that value people on the
basis of physical appearance and not inner
qualities and strengths
Biological Factors:
• Eating disorders often run in families (learn
coping skills and attitudes in family)
• Genetic component—research about brain
and eating in taking place (certain chemicals
in the brain control hunger, appetite and
digestion have been found unbalanced).
 CLINICAL FEATURES
• Intake of a lot of food
• Sense of relief during a binge, but later
feel shame
• Eating without hungry
• Eating alone
• Feelings of guilt
DIAGNOSTIC GUIDELINES
• Atleast one episode of binge eating per
week for minimum of three weeks
Minimum 1 to 3 binge eating per week to
14 or more.
 TREATMENT
Medication
• SSRI
–high dose reduces binge behavior short-term
–but doesn’t help weight loss
• Topomax, Zonisamide (anticonvulsants, mild mood
stabalizer)
–Helps binge reduction
–Helps weight loss
–Caution for adverse effects, high discontinuation
rates
Therapies:
• Therapies either prioritize…weight loss
binge-reduction and neither (ie. relationships,
depression etc)
• Group psychotherapy
• There is little evidence that obese individuals
who binge should receive different therapy
than obese individuals who do not binge
 Nursing interventions

• Encourage family to participate in education

regarding connection between family process
and patients disorder
• Monitor weight and serum electrolytes
• Encourage patient therapeutic alliance to obtain
commitment to treatment.
THANK YOU