EATING
DISORDERS
PSYCHIATRIC NURSING
Eating disorders can be viewed on a
continuum: the anorexic eats too little,
the bulimic eats chaotically, and the
obese person eats too much.
Eating disorders overlap:
50% of clients with anorexia exhibit
bulimic behavior,
35% of normal-weight clients with
bulimia have a history of anorexia.
>90% of clients with eating disorders are
female.
Criteria For In-patient Admission Of A Person
With An Eating Disorder
Weight - < 75 ; < 60 % compelling
Rapid decline in weight
Life threatening physiological problem, e.g. electrolyte imbalance,
infections
Suicidal or severely out of control ( self mutilating or abusing, using
large amounts of laxatives, emetics, diuretics, or street drugs)
Hypothermia d/t loss of subcutaneous tissue
Inability to gain weight repeatedly with out patient
treatment
Anorexia Nervosa
Refusal or inability to maintain a minimally normal body
weight
Intense fear of gaining weight or becoming fat
Distorted body image
Steadfast inability or refusal to acknowledge the seriousness
of the problem or even that one exists .
Fails to gain expected weight during growth
85% or less of expected body weight
Amenorrhea - @ least 3 consecutive period
Preoccupation with food and food-related
activities
Restricting subtype loses
weight dieting fasting, or
Excessively exercising
Specify Type: Anorexia
1. Binge eating/ purging type:engages in binge
eating followed by purging.
2. Restricting type: dose not engage in
recurrent episodes of binge eating or
purging behaviors
Onset and Clinical Course
Typically begins between 14 and 18 years of age
Ability to control weight gives pleasure to the client
Client may feel empty emotionally and be unable to
identify or express feelings
As illness progresses, depression and labile moods are
common
Signs and symptoms
Low weight •Caloric restriction
Amenorrhea •Low weight
Low T3T4 •Starvation
EEG changes •Starvation
Hypotension, Bradycardia, HF •Starvation, dehydration
Impaired renal function
Dehydration, Hypo K
Yellow skin •Hypercarotemia
Lanugo •Starvation
Anemia, pancytopenia •Starvation
Decreased bone density •Estrogen def., low calcium
Cold extremities •Starvation
Peripheral edema •Hypoalbunimia, re –feeding
Muscle weakening •Starvation, elect. imbalance
Constipation •Starvation
Client is socially isolated, mistrustful of others; may
believe that others are trying to make her fat and ugly
Long-term studies show:
30% recover
30% partially improve
30% remain chronically ill
10% die of anorexia-related causes
TREATING ANOREXIA involves three
components:
restoring the person to a healthy weight;
treating the psychological issues related to
the eating disorder; and
reducing or eliminating behaviors or thoughts
that lead to disordered eating, and
preventing relapse.
Bulimia Nervosa
Characterized by recurrent episodes of binge eating,
then compensatory behaviors to avoid weight gain
(purging, use of laxatives, diuretics, enemas, emetics, fasting, excessive
exercise)
Binge eating is done in secret
Excessive preoccupation with weight and body
shape
Weight may be normal, with a history of anorexia
nervosa or restrictive dieting
Typical binge food is sweet and high in calories
Client recognizes behavior as pathologic, causing
feelings of guilt, shame, remorse, or contempt
Usually normal weight
Onset and Clinical Course
Begins at about age 18 or 19
Binge eating begins after an episode of dieting
Between binges, eating may be restrictive
Food is hidden in the car, desk at work, and secret
locations around the house
Behavior may continue for years before it is discovered
Eating large amounts when not physically hungry
Binge eating occurs, on average, at least 2 days a
week for 6 months
Long-term studies show:
50% recover
20% continue to be bulimic
30% have episodic bouts of bulimia
One third of fully recovered clients have a relapse.
Death rate for bulimia is 3% or less.
Signs and symptoms: Bulimia
Normal to slightly low weight Excessive caloric intake,w/purging, excessive
exercise
Elect. Imbalance:Hypo K, Hypo Na Purging, vomiting, laxative, diuretic
Cardiomyopathy, ECG changes Elect. Imbalance
Dental carries, erosion Vomiting
Parotid swelling Vomiting
Gastric dilation, rupture Binge eating
Calluses, scars on hand Self induced vomiting
Peripheral edema Rebound fluid – diuretic
Muscle weakening Elect. Imbalance
Related Disorders
Rumination disorder, pica, and feeding disorder are diagnosed
in infancy and childhood
Binge eating disorder is binge eating without regular use of
inappropriate compensatory behaviors
Night eating syndrome (NES) is morning anorexia, evening
hyperphagia (consuming 50% of daily calories after the last
evening meal), and nighttime awakenings (at least once a
night) to consume snacks
Comorbidity Issues
Multiple diagnoses associated with eating
disorders:
Major depressive disorders
Obsessive-compulsive disorder
Substance abuse
Borderline personality disorder
Sexual abuse
© Copyright 2003 Delmar
Learning, a division of Thomson
Learning, Inc. 21-18
Etiology
Biologic Factors
Genetic vulnerability
Disruptions in the nuclei of the hypothalamus relating to hunger and
satiety (satisfaction of appetite)
Neurochemical changes are seen, but it is not known if these changes
cause the disorders or are a result of eating disorders
Biological Factors
(1995) Brewerton’s theory suggests:
▪ 5-HT system dysregulation in clients
▪ Failure of neurotransmitter regulation
Factors that affect a vulnerable 5-HT system:
▪ Dieting, binge eating, purging, and psychosocial-interpersonal
stress
Developmental Factors
Struggle to develop autonomy and identity
Overprotective or enmeshed families
Body image disturbance and body image
dissatisfaction
Separation-individuation difficulties
Eating Disorders Across the Life Span
Early Childhood
Feeding disorder symptoms:
▪ Persistent failure to eat adequately
▪ Disturbance not due to an associated gastrointestinal or
other medical condition
▪ Disturbance not better accounted for by another mental
disorder
▪ Onset is before 6 years of age
© Copyright 2003 Delmar
Learning, a division of Thomson
Learning, Inc. 21-21
Eating Disorders Across the Life Span
Adolescence
Central factors of eating disorders:
▪ Independence from family
▪ Increased autonomy in problem solving
▪ Family and peer pressure
▪ Initiation in the process of major life choices
▪ Sexuality is a noteworthy cause because clients tend to
have difficulty with personal intimacy
© Copyright 2003 Delmar
Learning, a division of Thomson
Learning, Inc. 21-22
Eating Disorders Across the Life Span
Adulthood: Special Populations
Adult male
▪ Same core psychopathological features as in female
▪ Some unique features include intent of attaining
idealized masculine shape
▪ 10 % of clients with bulimia are men
▪ 2 per 100,000 clients each year with anorexia are males
© Copyright 2003 Delmar
Learning, a division of Thomson
Learning, Inc. 21-23
Causes of Eating Disorders: Theories
and Perspectives
Psychodynamic Factors
Eating disorders viewed as a form of neurosis
representing regression to oral stages of
development
Underlying deficits in the individual’s sense of self-
identity and autonomy
© Copyright 2003 Delmar
Learning, a division of Thomson
Learning, Inc. 21-24
Family Influences
Families without emotional support
Physical neglect, sexual abuse, or parental
maltreatment
Little care, affection, and empathy
Excessive paternal control, unfriendliness, or
overprotectiveness
Familial factors
▪ Pattern of unconscious collusion where family “agrees”
to divert the conflict onto the symptomatic family
member
▪ Can discourage the development of independence and
autonomy
▪ Child may feel helpless and perceive self as powerless
Sociocultural Factors
Media
Pressure from peers, parents, and coaches
Sociocultural Factors
Eating disorders mainly a Western culture
phenomenon
Models, actresses, and entertainers have high
frequencies of eating disorders
Assimilated minority cultures are at as great a risk
as white females
▪ African American women report laxative and diuretic
use
©
Personality Factors
Anorexia
▪ Resistance to acknowledge problem
▪ Obsessive thoughts about doing well
▪ Hyper-rigid behaviors
▪ Difficulty learning from experience
Bulimia
▪ Problems identifying feelings of helplessness
▪ Variable moods
▪ Sense of control related to bodily experience
©
Cultural Considerations
Eating disorders are more prevalent in countries
where food is prevalent and beauty is linked to
being thin
Immigrants from cultures where eating disorders
are rare may develop eating disorders as they
assimilate the thin ideal body image
Eating disorders are equally common among
Hispanic and white women but are less common
among African American and Asian women
Treatment: Anorexia Nervosa
Setting depends on severity of illness:
Medical management; risk of suicide is significant
Weight restoration
Nutritional rehabilitation
Rehydration
Correction of electrolyte imbalances
Supervised access to a bathroom to prevent
purging
TREATING ANOREXIA involves three
components:
restoring the person to a healthy weight;
treating the psychological issues related to
the eating disorder; and
reducing or eliminating behaviors or thoughts
that lead to disordered eating, and
preventing relapse.
Psychopharmacology
Amitriptyline (Elavil) and the antihistamine
cyproheptadine (Periactin) can promote weight
gain.
Olanzapine (Zyprexa) because of its effect on body
image distortions
Fluoxetine (Prozac) prevents relapse.
Psychotherapy
Family therapy
Individual therapy
Treatment: Bulimia Nervosa
Most clients are treated on outpatient basis:
Cognitive-behavioral therapy
Psychopharmacology
Antidepressants: desipramine (Norpramin),
imipramine (Tofranil), amitriptyline (Elavil),
nortriptyline (Pamelor), phenelzine (Nardil), and
fluoxetine (Prozac)
Application of the Nursing Process
Assessment
History:
Anorexia: model child, no trouble, dependable
(before onset of anorexia)
Bulimia: eager to please and conform, avoid
conflict, but may have history of impulsive
behavior
Assessment (cont’d)
General appearance and motor behavior:
Anorexia: slow, lethargic, even emaciated; slow to
respond to questions, difficulty deciding what to
say, reluctant to answer questions fully; often wear
baggy clothes; limited eye contact; unwilling to
discuss problems or enter treatment
Bulimia: normal appearance, open and talkative
Assessment (cont’d)
General appearance and motor behavior:
Anorexia: slow, lethargic, even emaciated; slow to
respond to questions, difficulty deciding what to
say, reluctant to answer questions fully; often wear
baggy clothes; limited eye contact; unwilling to
discuss problems or enter treatment
Bulimia: normal appearance, open and talkative
Assessment (cont’d)
Sensorium and intellectual processes: generally alert,
oriented, intact; exception is the severely malnourished
client with anorexia, who may have mild confusion, slowed
mental processes, and difficulty with concentration and
attention
Judgment and insight:
Anorexia: very limited insight and poor judgment about
health status
Bulimia: insight into the pathologic nature of their eating
behavior but feel out of control and unable to change that
behavior
Assessment (cont’d)
Self-concept: low self-esteem, see themselves as
powerless, helpless, and ineffective
Roles and relationships:
Anorexia: may have failing grades in school, in sharp
contrast to previous high-level performance;
withdrawal from peers
Bulimia: ashamed of binging and purging, hides it
from others; the amount of time spent buying and
consuming food can interfere with role performance
Physiologic and self-care considerations: exhaustion,
trouble sleeping, sores in the mouth, dental problems
Data Analysis
Nursing diagnoses may include:
Imbalanced Nutrition: Less Than/More Than Body
Requirements
Ineffective Coping
Disturbed Body Image
Other diagnoses such as Deficient Fluid Volume,
Constipation, Fatigue, and Activity Intolerance
may be indicated
Outcomes
The client will:
Establish adequate nutritional eating patterns
Eliminate use of compensatory behaviors such as laxatives,
enemas, diuretics, and excessive exercise
Demonstrate non–food-related coping mechanisms
Verbalize feelings of guilt, anger, anxiety, or excessive need for
control
Verbalize acceptance of body image with stable body weight
Intervention
Establishing nutritional eating patterns
Helping client identify emotions and develop
coping strategies
Dealing with body image issues
Client and family education
Evaluation
Evaluation may involve use of an assessment
tool to measure progress
Body weight within 5% to 10% of normal
No medical complications from starvation or
purging
Hospital admission is indicated only for medical
necessity:
Dangerously low weight, electrolyte imbalances,
or renal, cardiac, or hepatic complications; clients
who cannot control the binge/purging cycle
Community settings include partial hospitalization
or day treatment programs, individual or group
outpatient therapy, and self-help groups
Mental Health Promotion
Educate parents, children, and young people
about strategies to prevent eating disorders
Early identification and appropriate referral
Routine screening of young women for eating
disorders
Self-Awareness Issues
Feelings of frustration when client rejects
help
Being seen as “the enemy” if nurse must
ensure the client eats
Dealing with own issues about body image
and dieting
THE
END
ANOREXIA NERVOSA
Most common in adolescent females-
characterized by fear of obesity, dramatic
weight loss and distorted body image,
anemia , amenorrhea, purging and induced
vomiting,execisive exercise
ANOREXIA NERVOSA
Monitor weight , mio , electrolyte balance
and v.S.
Provide adequate fluids and electrolyte and
nutrition
Behavior modification and family therapy
Support efforts to take responsibility for self
Amenorrhea
No organic factor –weight loss
Obviously thin but feels fat
Refusal to maintain body weight
Epigastric discomfort
X – symptoms – hiding food
Intense fear of gaining weight
Always preoccupied with food
BULIMIA
Characteristics of anorexia and binge
eating( high calorie – short period)
Normal weight or overweight
Managed with anti-depressants, nutritional
assesments and counseling
Binge eating
Under strict dieting/vigorous exercise
Lacks control over binges
Induced vomiting
2 binge eating per week for 3 mnths
Increased concern over body size
Abuse of diuretics and laxatives
INTERVENTIONS
Remain in public/ stay w/ pnt. For two hours
after meals
Monitor weight
Frequent oral hygiene
Behavior modication therapy
