1. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 1 Chapter 11 Eating Disorders

2. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 2 Concept of Eating Disorders Patient experiences severe disruption in normal eating and disturbance in perception of body shape/weight Several diagnostic categories identified –Anorexia nervosa –Bulimia nervosa –Eating disorder not otherwise specified (NOS) Binge-eating disorder

3. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 3 Eating Disorders: General Information Prevalence –Anorexia: prevalence among women is 1%, men (0.3%) –Bulimia: prevalence among women is 1.5%, men (0.5%) Comorbidity –Eating disorder usually accompanied by other psychiatric disorders –History of sexual abuse common

4. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 4 Biological Theories Related to Eating Disorders Neuroendocrine abnormalities –Altered serotonin pathway –Altered serotonin receptors –Unknown whether the abnormalities occur first or after development of the eating disorder Genetics –Female relatives of people with eating disorders have 12 times the risk

5. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 5 Other Theories Related to Eating Disorders Psychological (identifies core pathology) –Low self-esteem and doubts about self-worth Harsh self-judgment based on issue of weight Family theory –Anorexia: family system controlling, emphasize perfection, achievement and compulsions –Bulimia: family system chaotic with conflict and negativity

6. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 6 Other Theories Related to Eating Disorders Cultural considerations –Western women driven by ideal of competence in both career and family roles Internalization of societal ideal of thinness Eating disorders not common in other cultures –Male-dominated societies

7. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 7 Anorexia Nervosa Refusal to maintain normal weight for age and height Intense fear of gaining weight Disturbed body image –Belief that one is fat despite emaciation Loss of menses for at least 3 months Types of anorexia –Binge-eating/purging type –Restricting type

8. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 8 Anorexia Nervosa: Physical Complications Decreased vital signs (temp, pulse, BP) Electrolyte imbalances Leukopenia Osteoporosis Amenorrhea

9. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 9 Anorexia Nervosa: Physical Complications Abnormal thyroid function Cardiac abnormalities Fatty degeneration of liver, elevated cholesterol Hematuria Proteinuria

10. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 10 Bulimia Nervosa Recurrent episodes of binge eating Behavior to prevent weight gain –Self-induced vomiting –Laxative and diuretic abuse Types of bulimia –Purging type –Non-purging type

11. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 11 Bulimia Nervosa: Physical Complications Cardiomyopathy Cardiac dysrhythmias Electrolyte imbalances Dehydration Loss of dental enamel Parotid gland enlargement Esophageal tears Russell’s sign (callus on knuckles from self-induced vomiting)

12. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 12 Eating Disorder Not Otherwise Specified (NOS) Category in DSM-IV-TR assigned for disorders of eating that do not meet criteria for a specific eating disorders

13. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 13 Nursing Process: Assessment Guidelines for Patient with Anorexia Determine if medical/psychiatric condition warrants hospitalization (appropriate testing important) –Severe hypothermia, bradycardia, hypotension, hypokalemia, cardiac abnormalities –Weight loss more than 30% over 6 months –Suicidal or self-mutilating behaviors –Severe depression or psychosis –Out of control use of laxatives, diuretics, street drugs

14. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 14 Nursing Process: Assessment Guidelines for Patient with Anorexia Determine level of family understanding about disorder and where to get support Determine level of acceptance of treatment Determine patient and family need for teaching Determine patient’s and family’s desire to participate in support group

15. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 15 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses assigned –Imbalanced nutrition: less than body requirements –Disturbed body image –Chronic low self-esteem –Hopelessness/Powerlessness Common outcomes: patient will: –Normalize eating patterns –Demonstrate improved self-acceptance –Address maladaptive beliefs related to eating

16. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 16 Nursing Process: Planning and Implementing Hospitalization may be necessary for short time (either medical or psychiatric) Long-term treatment with individual, group and family therapy Focus interventions on establishing trust and monitoring eating patterns –Weight restoration and monitoring create opportunities to counter disturbed thought processes (cognitive distortions)

17. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 17 Nursing Communication Guidelines for Patients with Anorexia Avoid authoritarianism and assumptions of parental role Build therapeutic alliance –Frequently acknowledge patient difficulty with goal of gaining weight Address underlying emotions of anxiety, depression, low self-esteem, and feelings of lack of control

18. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 18 Specific Nursing Interventions for Anorexia Weigh patient in minimal clothing, at same time of day, after voiding and before drinking or eating Monitor patient during meals to prevent throwing food away/purging

19. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 19 Specific Nursing Interventions for Anorexia Recognize patient’s distorted body image without minimizing or challenging patient’s perception Educate patient about ill effects of low weight Work with patient to identify strengths

20. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 20 Treatment for Anorexia: Milieu Therapy Relies on interdisciplinary team approach –Work for normalization of eating patterns –Work toward addressing psychological issues Use of highly structured setting with close monitoring to prevent throwing food away, falsely increasing weight, purging –During meals –During weighing –During bathroom visits

21. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 21 Treatment for Anorexia: Psychotherapy Cognitive-behavioral –Diminish errors in patient thinking/perceiving related to eating disordered behaviors Psychodynamic –Address underpinnings of disorder Group –Provide support Family –Does family dysfunction contribute to problem?

22. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 22 Treatment of Anorexia: Medications Medications not recommended until weight has been restored SSRI antidepressants –Fluoxetine (Prozac): to reduce relapse Atypical antipsychotics –Olanzapine (Zyprexa): helpful in improving mood and decreasing obsessional behaviors

23. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 23 Nursing Process: Evaluation Anorexia nervosa is a chronic illness: relapse common Evaluation criteria –Percentage of weight restored –Extent to which self-worth no longer dependent on weight and shape –Decreased disruption in patient’s life

24. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 24 Nursing Process: Assessment Guidelines for Patient with Bulimia Patient may be at or slightly above or below ideal weight Typical signs: enlarged parotid glands, dental caries, enamel loss, Russell’s sign Review patient history for impulsive behaviors (stealing) or compulsions

25. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 25 Nursing Process: Assessment Guidelines for Patient with Bulimia Determine if family relationships are chaotic Review medical evaluation to determine abnormalities warranting medical hospitalization

26. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 26 Nursing Process: Diagnosis and Outcomes Identification Common nursing diagnoses assigned –Decreased cardiac output –Disturbed body image –Chronic low self-esteem –Powerlessness

27. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 27 Nursing Process: Diagnosis and Outcomes Identification Common outcomes: the patient will (in specified time period) –Refrain from binge/purge behaviors –Maintain normal electrolyte balance –Express feelings in non-food–related way –Name personal strengths

28. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 28 Nursing Process: Planning and Implementing May require hospitalization in either medical or psychiatric facility for short time Long-term outpatient treatment expected Implementations directed toward examining underlying conflicts and distorted perceptions of shape and weight

29. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 29 Nursing Communication Guidelines for Patient with Bulimia Patient may readily form therapeutic alliance with nurse –Eating behaviors are ego-dystonic Nurse needs to understand patient’s sensitivity toward perceptions of others –May feel shame and out of control Accepting, nonjudgmental approach guides communication

30. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 30 Treatment of Patient with Bulimia: Milieu Therapy Highly structured inpatient unit has goal of interrupting binge/purge cycle –Close observations during and after meals (similar to patient with anorexia) Teaching focused on: –Healthy diet –Coping skills –Physical and emotional effects of bingeing and purging

31. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 31 Treatment of Patient with Bulimia: Psychotherapy and Medications Psychotherapy –Cognitive-behavioral approach recommended Medications –SSRI antidepressant, fluoxetine (Prozac) Reduces binge eating and vomiting episodes Treats comorbid depression

32. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 32 Nursing Process: Evaluation Evaluation process is ongoing –Short-term and intermediate goals revised as necessary –Specific outcomes identified reviewed for level of achievement

33. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 33 Concept of Binge-Eating Disorder May be variant of compulsive overeating –Binge eating reported as being soothing and helpful with mood regulation May be related to depression (overeating is frequently a sign of this disorder)

34. Copyright © 2009 by Saunders, an imprint of Elsevier Inc. 34 Concept of Binge Eating Disorder Controversy over whether this proposed disorder is a separate eating disorder –20%-30% of obese individuals seeking treatment report binge eating DSM-IV-TR appendix identifies research criteria for further study of binge-eating disorder