EATING DISORDERS

Two Main Types h Anorexia Nervosa h Bulimia Nervosa Share Strong Drive to be Thin Largely a Female Problem Largely a Westernized Problem Largely an Upper SES Problem Many Die as a Result!

Types
 Anorexia nervosa  Bulimia nervosa  Binge Eating

Disorder  Psychogenic vomiting

Anorexia Nervosa
Refusal to maintain weight within a normal range for height and age (more than 15 percent below ideal body weight)  Fear of weight gain  Severe body image disturbance in which body image is the predominant measure of self-worth with denial of the seriousness of the illness  In postmenarchal females, absence of the menstrual cycle, or amenorrhea (greater than three cycles).


 self-starvation
 Persons weight is

85% or less of normal weight  Person has an intense fear of gaining weight  Person has a distorted sense of their body shape  In females, anorexia nervosa leads to a loss of the menstrual period  Common in females  Absence of any other psychiatric disorder  No known medical illness  Life time prevalence is less than 1%
Ch 9.1

Anorexia Nervosa
 Two

types of anorexia nervosa:

loses weight by severely limiting the amount of food consumed  Binge-eating-purging type engages in binges (large amount of food consumed) following by purging (vomiting or use of laxatives)
 Lifetime

 Restricting type

prevalence of anorexia nervosa is less than 1% and is 10 times more frequent in women than in men
Ch 9.3

Anorexia Nervosa
 Anorexia

nervosa is linked to depression  Anorexia nervosa can have severe physical effects including
 Altered electrolyte levels (potassium and

sodium) lead to changes in nerve and muscle function

 Prognosis:

70% of anorexia nervosa patients

recover

Ch 9.4

SIGNS AND SYMPTOMS

         

Dry skin Cold intolerance Blue hands and feet Constipation Bloating Delayed puberty Primary or secondary amenorrhea Nerve compression Fainting Orthostatic hypotension

           

Lanugo hair Scalp hair loss Early satiety Weakness, fatigue Short stature Osteopenia Breast atrophy Atrophic vaginitis Pitting edema Cardiac murmurs Sinus brady hypothermia

Bulimia Nervosa


Bulimia Nervosa involves episodes of rapid overeating followed by purging

A binge is defined as eating an excessive amount of food within two hours  Purging refers to vomiting, laxative abuse, fasting or excessive exercise


Bulimia involves a fear of gaining weight  Prevalence of bulimia nervosa is 1-2% of the female population; only .1% of male population


Ch 9.5

Episodes of binge eating with a sense of loss of control  Binge eating is followed by compensatory behavior of the purging type (self-induced vomiting, laxative abuse, diuretic abuse) or nonpurging type (excessive exercise, fasting, or strict diets).  Binges and the resulting compensatory behavior must occur a minimum of two times per week for three months  Dissatisfaction with body shape and weight


SIGNS AND SYMPTOMS

Mouth sores  Pharyngeal trauma  Dental caries  Heartburn, chest pain  Esophageal rupture  Impulsivity:


Stealing  Alcohol abuse  Drugs/tobacco



Muscle cramps  Weakness  Bloody diarrhea  Bleeding or easy bruising  Irregular periods  Fainting  Swollen parotid glands  hypotension


Binge Eating Disorder

 Binge

Eating Disorder involves

a week for at least 6

 Recurrent binges (twice

months)  Lack of control during the binge episode

 Binge

Eating Disorder does not involve

 Loss

of weight  Compensatory behaviors of purging

Ch 9.6

 Eating,

in a discrete period of time, an amount of food that is larger than most people would eat in a similar period  Occurs 2 days per week for a six month duration  Associated with a lack of control and with distress over the binge eating

 Must

have at least 3 of the 5 criteria

 Eating much

more rapidly than normal  Eating until uncomfortably full  Eating large amounts of food when not feeling physically hungry  Eating alone because of embarrassment  Feeling disgusted, depressed or very guilty over overeating

Predisposing Factors
Psychological- rigidity, perfectionism  Environmental- illnesses, sexual abuse, drug abuse, media influences  Familial- risk increases in female relatives  Biological- probable relationship to serotonin and dopamine levels (regulated in hypothalamus)  Precipitating stressors include peer pressure, daily solitude, interpersonal rejection or loss of a significant other


Etiology of Eating Disorders

 Biological
 Genetic

accounts of eating disorders:

bulimia run in families Twin studies show genetic contribution to anorexia and bulimia With anorexia, evidence for linkage on chromosome 1.
 Endogenous

Anorexia and

opioids may play role in bulimia  Serotonin may be deficient in bulimia:

Bulimics have less

serotonin metabolites Bulimics are less responsive to serotonin agonists Ch 9.7 Serotonergic drugs are often effective for bulimia

Sociocultural Influences on Eating Disorders

 While

cultural standards of the ideal woman have moved toward thinness, the reality is that both men and women are becoming more obese
 Prevalence of

obesity has doubled since 1900  As social views of obesity become more negative, the incidence of eating disorders increases

Ch 9.8

 

Eating disorders more prevalent in industrialized societies which emphasize thinness.  US, Canada, Japan, Europe As countries become more westernized, eating disorders increase. When women from countries with low prevalence rates more to countries with higher prevalence rates, prevalence increases. Variations in assessment methods and diagnostic criteria make it difficult to be certain about differences in prevalence rates from country to country.

Psychological Views of Eating Disorders

 Personality

studies indicate that

 Personality variables such

as perfectionism, low self-esteem, propensity to experience negative emotions and an inability to distinguish bodily states are predictors for the development of eating disorders

 Self-reports

of childhood sexual/physical abuse are higher in eating disorder subjects

Ch 9.9

ASSOCIATED PSYCHIATRIC CONDITIONS

    

affective disorders anxiety disorders obsessive-compulsive disorder personality disorders substance abuse.

Medical Complications of Eating Disorders

CNS- Fatigue, seizures, weakness  Renal- Hematuria, proteinuria, and renal calculi  Hematological- Anemia, leukopenia  GI- Dental caries and erosion, esophagitis, gastric dilatation, pancreatitis, high cholesterol  Metabolic- Acidosis, dehydration, starvation, potassium depletion or hypokalemia, osteoporosis, alkalosis  Endocrine- Amenorrhea, irregular menses  CV- Bradycardia, postural hypotension, dysrhythmia (sudden death)


Psychiatric Complications
 Many

people with eating disorders also have depression, anxiety, and substance abuse  Bulimia may also be associated with posttraumatic stress disorder  People with antisocial personality disorders are more likely to have bulimia

HISTORY
Maximum height and weight  Minimum height and weight  Exercise habits: intensity, hours per week  Stress levels  Habits and behaviors: smoking, alcohol, drugs, sexual activity  Eating attitudes and behaviors  Review of systems


PHYSICAL EXAM--anorexia
Vital signs to include orthostatics  Skin and extremity evaluation



Dryness, bruising, lanugo Bradycardia, arrhythmia, MVP

 

Cardiac exam


Abdominal exam  Neuro exam



Evaluate for other causes of weight loss or vomiting (brain tumor)

PHYSICAL EXAM: bulimia

 All

previous elements plus:

 Parotid gland

hypertrophy  Erosion of the teeth enamel

LABORATORY ASSESSMENT
CBC: anemia  Electrolytes, BUN/Cr  Mg, PO4, Calcium  Albumin, serum protein  B-HCG  UA: specific gravity  Thyroid function tests  Serum prolactin  FSH  Bone density


TREATMENT AND OUTCOME

 Most

eating disorder subjects (> 90 %) are NOT in treatment  Treatment of severe anorexia often takes place in a hospital  Bulimia can be treated with antidepressant drugs (involving the serotonin system)  No drugs are currently available for the treatment of anorexia nervosa
Ch 9.10

Psychological Therapy for Eating Disorders



Psychological treatment of anorexia:

 

Short-term increases in body weight



Operant conditioning of eating can lead to short-term weight gains Not yet achieved by any treatment modality

Long-term maintenance of body weight gain



Bulimia treatment involves cognitive behavior therapy: change thought processes that result in overeating; interpersonal therapy also effective.

Ch 9.11

ANOREXIA


Cognitive behavioral therapy



Emphasizes the relationship of thoughts and feelings to behavior  Limited efficacy

Interdisciplinary care team

Medical provider  Dietician with experience in ED  Mental health professional


MEDICATIONS
disappointing results  Effective only for treating comorbid conditions of depression and OCD  Anxiolytics may be helpful before meals to suppress the anxiety associated with eating  Case reports in the literature supporting the use of olanzapine
 Overall,

HOSPITALIZATION
Severe malnutrition (< 75% IBW)  Dehydration  Electrolyte disturbances  Cardiac dysrhythmia  Arrested growth and development  Physiologic instability  Failure of outpatient treatment  Acute psychiatric emergencies  Comorbid conditions that interfere with the treatment of the ED


NUTRITION
 Goal:

regain to goal of 90-92% of IBW  Inpatient treatment varies by facility

 Oral

liquid nutrition  Nasogastric tube feedings  Gradual caloric increase with regular food  Parenteral nutrition rarely indicated

OUTCOME
  

50% good outcome



Return of menses and weight gain Some weight regained

25% intermediate outcome



25% poor outcome

Associated with later age of onset  Longer duration of illness  Lower minimal weight  Overall mortality rate: 6.6%


BULIMIA
 Cognitive

behavioral therapy is effective  Pharmacotherapyhigh success rate

 Fluoxetinestudies reveal up

to a 67% reduction in binge eating and a 56% reduction in vomiting  TCAs  Topiramatereduced binge eating by 94% and average wt. loss of 6.2 kg  Ondansetron, 24 mg/day

BINGE EATING DISORDER

 Cognitive

behavioral therapy  Pharmacotherapy

Examples: Nursing Diagnosis



Anxiety related to fear of weight gain, e/b rituals associated with food preparation and eating  Disturbed body image related to fear of weight gain, e/b verbalization of being fat while being 30% below ideal weight  Powerlessness r/t perceived lack of control over eating behaviors, e/b inability to stop binge eating and avoidance of food-related settings  Imbalanced nutrition: more than body requirements e/b 40% over IBW, and sleep apnea

Nursing Diagnoses (continued)



Imbalanced nutrition: less than body requirements e/b being 25% below body IBW, and weakness r/t malnutrition and anemia  Chronic low self esteem r/t to feelings of low self-worth e/b verbalization of sole standard of success being r/t physical attractiveness  Risk for self-mutilation r/t feelings of inadequacy e/b injuries caused by excessive exercise and self-induced vomiting

 Patient

Outcome/Goal

 Patient will

restore healthy eating patterns and normalize physiological parameters related to body weight and nutrition

 Nursing
 Was

Evaluation

nursing care adequate, effective, appropriate, efficient, and flexible?

Nursing Care
 Assess

subjective and objective responses  Recognize defense mechanisms  Denial, avoidance, intellectualization, isolation of affect  Choose outpatient or inpatient tx setting  Utilize nurse-patient contracts

Implementation
 Stabilize

nutritional status

 Refeeding interventions such as

NG tube feeding or total parenteral nutrition (TPN) are rarely used

 Monitor

activity  Promote family involvement  Utilize group therapies  Administer medication, if ordered
 No

drugs have been completely effective for anorexia, but antidepressants may be helpful

QUESTIONS?

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