PSYCHIATRIC NURSING EATING DISORDERS Chapter 21

OBJECTIVES Identify the difference among the various eating disorders Describe symptomatology associated with anorexia nervosa and bulimia nervosa Identify the etiological implications in the development of eating disorders Discuss various modalities relevant to treatment of eating disorders 2

Introduction What part of the body is responsible of the appetite regulation (appestat? Hypothalamus Society and culture have a major influence on eating behaviors. BMI Below 18.5Underweight Normal Overweight 30.0 and AboveObese 3

Effect of Culture Cultural stereotypes Preoccupation with the body Cultural ideal of thinness Identity and self-esteem are dependent on physical appearance Changing male ideals of the body

Biologic Theory There may be a genetic predisposition for anorexia. Relatives of clients with eating disorders are 5 to 10 times more likely to develop an eating disorder.

The Effect of Serotonin On Eating Disorders Low serotonin levels decrease satiety Increase food intake High serotonin levels increase satiety Decrease food intake

Other Neurotransmitters Affect Eating Disorders Increase eating behavior: –Norepinephrine –Neuropeptide Y Suppresses food intake: –Dopamine

Eating Disorders Eating is a social activity; almost every social event has food while it occurs. Eating disorders are those associated with under-eating and over-eating. Why do we include eating disorders to psychiatric nursing? Because psychological and behavioral factors play a potential role in the presentation of these disorders.

9 There are basically two psychological or behavioral eating disorders: Anorexia Nervosa (AN), and Bulimia Nervosa (BN). Obesity is not classified as a psychiatric problem in DSM-IV. AN occurs more in females years (approximately 90% vs. 10%); BN is more prevalent than AN, occurs mostly in late adolescence or early adulthood; Obesity is a BMI of 30 or greater, with an inverse relationship with level of education; morbid obesity is a BMI>40 kg/m². Eating Disorders

Anorexia nervosas is a life-threatening eating disorder characterized by the client’s refusal or inability 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 10

11 Anorexia Nervosa Characterized by a morbid fear of obesity. 1.Gross distortion in body image (they perceive self as “fat” when obviously underweight or emaciated). Weight loss is accomplished by reduction in food intake and extensive exercising. They use self-induced vomiting, abuse of laxatives and diuretics. Marked weight loss. 2.Other symptoms include hypothermia, bradycardia, hypotension, edema, lanugo, metabolic changes, and amenorrhea that usually follows weight loss or sometimes precedes it.

12 3.Preoccupation with food: there may be an obsession with food (hoard or conceal food, talk about food at great length only to restrict themselves to limited amount of low-calorie food intake), refusal to eat. 4.Compulsive behaviors, such as hand washing. 5.Psychosexual development is delayed. 6.Feelings of depression and anxiety usually combine this disorder. Studies suggested possible interrelationship between eating disorders and affective disorders. Anorexia Nervosa

13 Age at onset is early to late adolescence. Occurs in approximately 0.5-1% of adolescent females and is times more common in females than in males. There are two types Restricting type; lose weight primarily through dieting, fasting, or excessive exercising Binge-eating/Purging type. engage regularly in binge eating followed by purging. Binge eating means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less. Purging involves compensatory behaviors designed to eliminate food by means of self- induced vomiting or misuse of laxatives, enemas, and diuretics. Anorexia Nervosa

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Physical Manifestation of Anorexia Nervosa Reduction in the following: –Heart rate –Blood pressure –Metabolic rate –Production of estrogen or testosterone

Hallmarks of Anorexia Nervosa Rigidity and control Rigid rules Obsessive rituals

Bulimia nervosa, often simply called bulimia, is an eating disorder characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate compensatory behaviors to avoid weight gain, such as purging, fasting, or excessively exercising 17

18 Bulimia Nervosa BN is an episodic, uncontrolled, compulsive, rapid ingestion of large amounts of food (binging) followed by inappropriate compensation to rid the body from the excess calories. Food consumed during binge has high calorie, sweet taste, soft or smooth texture that can be eaten rapidly without chewing. Binging occurs in secret and usually terminated by abdominal discomfort, sleep, social interruption, or self-induced vomiting. Self-degradation and depressed mood are common despite feelings of pleasure during eating binges.

19 To get rid of excessive calories, purging behaviors are engaged in (self-induced vomiting; misuse of laxatives, diuretics, or enemas), or other inappropriate compensatory behaviors (fasting or excessive exercise). People having this binge and purge syndrome are within a normal weight range, with weight fluctuations because of alternating binges and fasts. Bulimia Nervosa

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21 Excessive vomiting and laxative/diuretic abuse lead to dehydration and electrolyte imbalance. Gastric acid of vomitus causes erosion of tooth enamel. Mood disorders, anxiety disorders, and substance abuse or dependence, on amphetamines or alcohol, are common. There are two specific types: 1.Purging type. 2.Nonpurging type. Bulimia Nervosa

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23 Etiological implications for AN & BN 1.Genetics 2.Neuroendocrine abnormalities 3.Neurochemical influences 4.Psychodynamic influences 5.Family influences (conflict avoidance; elements of power and control) Nursing diagnoses: 1.Imbalanced nutrition: less or more than body requirements 2.Disturbed body image/low self-esteem

Binge-Eating Disorder Eating significantly larger-than- normal amounts in a discrete time period, until uncomfortably full Sense of lack of control No compensatory purging

Obesity Thought to represent overcompensation for unmet oral needs in infancy Defense against intimacy with the opposite sex Treatment includes motivational enhancement therapy and psychotherapy aimed at relapse prevention

Contributing Psychosocial Theories Psychoanalytic Family systems Cognitive/behavioral Sociocultural Biologic

Female Attractiveness Equated with thinness, physical fitness Media glamorizes thinness Thinness equated with success and happiness Prejudice against overweight Self-esteem enhanced for those considered attractive

Male Attractiveness Ideal body type is lean and muscular Emphasis on strength and athleticism Less popular if they do not have the ideal body type

Psychosocial Pressures Frequent exposure to articles about dieting is significantly associated with lower self-esteem, depressed mood, and lower levels of body satisfaction.

Psychosocial Considerations Use of anabolic steroids Increased risk for gay or bisexual males Predominately an issue in industrialized, developed countries Not solely a problem of specific cultural groups

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Assessing Clients Dramatic weight loss or gain Medical history and physical examination Client conception/misperceptions about food Denial Blurred boundaries Physical symptoms

Family Dynamics Families seriously affected Anorexia nervosa –Enmeshed –Blurred boundaries Bulimia nervosa –Less enmeshed –Isolate from one another

Prevention and Treatment Anorexia nervosa Bulimia nervosa Binge-eating disorders

Goals (cont'd) The overall goal of treatment for the individual with anorexia nervosa is gradual weight restoration. A target weight is usually chosen by the treatment team in collaboration with a dietitian. Target weight for discharge from treatment is usually 90% of average for age and height.

Goals (cont'd) The goal of nursing interventions with anxious clients with bulimia is to help them: –Recognize events that create anxiety –Avoid binge eating and purging in response to anxiety –Verbalize acceptance of normal body weight without intense anxiety

Goals (cont'd) Providing basic nutritional education is the goal of interventions with clients that have a knowledge deficit in this area.

Nursing Interventions: Client with Anorexia Nervosa Ensure that the client survives. Help the client to learn more effective ways of coping with the demands of life.

Anorexia Nervosa: Specific Interventions Tube feeding Intravenous therapy Weighing the client daily Observing bathroom behavior Recording intake and output Observing the client during meals

Medications Antidepressants –Reduce binge eating and vomiting Symptom control –Anxiety –Depression –Obsessions –Impulse control

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Prevention Nurses in community-based settings can play a valuable role in: –Education –Support –Referral

Screening and Education Nurses can provide screening and education in schools, clinics, homes, health fairs, health clubs Individuals at risk: low self-esteem, irrational behavior related to food, excessive exercise, and other factors

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Prevention and Screening Important to understand cultural factors contributing to eating disorders Nurses can implement primary prevention and secondary screening measures

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47 Treatment modalities Behavior modification Individual therapy Family therapy Psychopharmacology

Cognitive–Behavioral Therapy Strategies designed to change the client’s thinking (cognition) and actions (behavior) about food focus on interrupting the cycle of dieting, binging, and purging and altering dysfunctional thoughts and beliefs about food, weight, body image, and overall self concept. CBT enhanced with assertiveness training and self-esteem enhancement has produced positive results 48

Psychopharmacology The antidepressants were more effective than were the placebos in reducing binge eating. They also improved mood and reduced preoccupation with shape and weight. Most of the positive results, however, were short term, with about one third of clients relapsing within a 2-year period 49

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