Eating Disorder

CATEGORIES OF EATING DISORDERS

Anorexia nervosa
• 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 steadfast inability or refusal to acknowledge the
seriousness of the problem or even that one exists (APA, 2000)

TWO SUBGROUPS OF ANOREXIA NERVOSA

a. Clients with the restricting subtype
> lose weight primarily through dieting, fasting, or excessive exercising.
b. binge eating and purging subtype
> 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
-diuretics

Anorexia
• actually a misnomer
• clients do not lose their appetites.
• still experience hunger but ignore it and signs of physical weakness
and fatigue
• often believe that if they eat anything, they will not be able to
stop eating and will become fat.

• often are preoccupied with food-related activities such as: grocery shopping,
collecting recipes or cookbooks counting calories, creating fat-free meals cooking
family meals.

• may engage in unusual or ritualistic food behaviors such as: refusing to eat
around others cutting food into minute pieces
not allowing the food they eat to touch their lips.

Bulimia nervosa
•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,
•excessively exercising
•Binging or purging episodes are often precipitated by strong emotions and followed
by:
•guilt, remorse
•shame, or self-contempt

• weight of clients with bulimia usually is in the normal range

• some clients are overweight or under- weight.
• Recurrent vomiting destroys tooth enamel
• incidence of dental caries and ragged or chipped teeth increases in
these clients.

RELATED DISORDER
Binge eating disorder
• characterized by recurrent episodes of binge eating
• no regular use of inappropriate compensatory behaviors, such as
purging or excessive exercise or abuse of laxatives; guilt, shame, and disgust
about eating behaviors; and marked psychological distress.
• frequently affects people over age 35, and it occurs more often in
men than does any other eating disorder.

Night eating syndrome

•characterized by : morning anorexia
evening hyperphagia (consuming 50% of daily calories after the last evening meal)
•nighttime awakenings (at least once a night) to consume snacks.
TX:
•SSRI, antidepressant shown limited yet positive effect.

Eating or feeding disorders in childhood

• Pica
• which is persistent ingestion of nonfood substances
• Rumination
• repeated regurgitation of food that is then rechewed, reswallowed, or
spit out.Both of these disorders are more common in persons with intellectual
disability.
(DONA-donay deperensya)

Orthorexia nervosa
•sometimes called orthorexia
• is an obsession with proper or healthful eating.
• not formally recognized in the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition
• Others believe it is a type of anorexia or a form of obsessive-
compulsive disorder.

• Behaviors include:
• compulsive checking of ingredients
• cutting out increasing number of food groups
• inability to eat only "healthy" or "pure" foods
• unusual interest in what others eat
• hours spent thinking about food. what will be served at an event;
• obsessive involvement in food blogs (Costa, Hardi-Khalil, & Gibbs,
2017)

Anorexia and bulimia

-are both characterized by:
•perfectionism, obsessive compulsiveness •neuroticism, negative emotionality harm
•avoidance, low self-directedness
•low cooperativeness
•traits associated with avoidant personality disorder.

Anorexia and bulimia

are both characterized by:
•perfectionism, obsessive compulsiveness •neuroticism, negative emotionality harm
•avoidance, low self-directedness
•low cooperativeness
traits associated with avoidant personality disorder.
clients with bulimia may also exhibit:
•high impulsivity
•sensation seeking
•novelty seeking, and traits associated with borderline personality disorder


ETIOLOGY
• A specific cause for eating disorders is unknown.
> Initially, dieting may be the stimulus that leads to their development.
• Biologic vulnerability
• developmental problems
• family and social influences can turn dieting into an eating disorder

Biologic Factors
•Disruptions of the nuclei of the hypothalamus may produce many of the symptoms of
eating disorders.
⁃ Deficits in the lateral hypothalamus result in decreased eating and
decreased responses to sensory stimuli.
• Disruption of the ventromedial hypothalamus leads to:
• excessive eating v weight gain
decreased responsiveness to the satiety effects of glucose

low norepinephrine levels

• seen in clients during periods of restricted food intake.
• are related to the decreased heart rate and blood pressure seen in
clients with anorexia
Increased serotonin and its precursor tryptophan
•have been linked with increased satiety

Low levels of serotonin as well as low platelet levels of monoamine oxidase

•have been found in clients with bulimia and the binge and purge subtype of
anorexia nervosa

ANOREXIA NERVOSA
Onset and Clinical Course
• typically begins between 14 and 18 years of age.
•clients often deny they have a negative body image or anxiety regarding their
appearance.
•very pleased with their ability to control their weight.

As the illness progresses

• depression and lability in mood become more apparent.
As dieting and compulsive behaviors increase
• clients isolate themselves.
• social isolation can lead to a basic mistrust of others and even
paranoia
• about 30% to 50% achieve full recovery
• 10 to 20% remain chronically ill
• Clients with lowest body weights and longest duration of illness
tended to relapse most often.

Treatment and Prognosis

Clients with anorexia nervosa can be very difficult to treat:
•often resistant
•appear uninterested
•deny their problems

Treatment settings include :

•inpatient specialty eating disorder units, partial hospitalization or day
treatment programs outpatient therapy
•Major life-threatening complications that indicate the need for hospital
admission:
severe fluid, electrolyte, and metabolic imbalances
•cardiovascular complications
•severe weight loss and its consequences risk for suicide

Medical Management
focuses on :
•weight restoration
nutritional rehabilitation
Rehydration
•correction of electrolyte imbalances

Severely malnourished clients may require:

•total parenteral nutrition tube feedings, or hyperalimentation
•Weight gain and adequate food intake are most often the criteria for determining
the effectiveness of treatment

Psychopharmacology
•Several classes of drugs have been studied, but few have shown clinical success.
• Amitriptyline (Elavil)
• Cyproheptadine (Periactin) in high doses (up to 28 mg/day) can
promote weight gain in inpatients with anorexia nervosa.
• Olanzapine (Zyprexa)

Flouxetine (Prozac)
•has some effectiveness in preventing relapse in clients whose weight has been
partially or completely restored.

Psychotherapy
• Family therapy may be beneficial for families of clients younger than
18 years.
• Family therapy is useful to help members to be effective participants
in the client's treatment.
•In a dysfunctional family, significant improvements in family functioning may take
2 years or more.
• Cognitive- behavioral therapy (CT),

BULIMIA NERVOSA
Onset and Clinical Course
•Bulimia nervosa usually begins in late adolescence or early adulthood
•18 or 19 years is the typical age of onset.
• frequently begins during or after dieting.
• Between binging and purging episodes, clients may eat restrictively,
choosing salads and other low-calorie foods.

General Appearance and Motor Behavior

ANOREXIA
• appear slow, lethargic, and fatigued
• they may be emaciated, depending on the amount of weight loss.
• slow to respond to questions and have difficulty deciding what to say.
•They often wear loose-fitting clothes in layers, regardless of the weather, both
to hide weight loss and to keep warm (clients with anorexia are generally cold).
• Eye contact may be limited.

BULIMIA
• may be underweight or over - weight
•General appearance is not unusual, and they appear open and willing to talk.

MOOD AND AFFECT CLIENTS WITH EATING DISORDERS

•have labile moods that usually correspond to their eating or dieting behaviors.
• Avoiding "bad" or fattening foods
 • eating, binging, or purging leads to anxiety, depression, and feeling
out of control.
• often seem sad, anxious, and worried.
Those with anorexia:
• seldom smile
• laugh, or enjoy any attempts at humor
• they are somber and serious most of the time.

Clients with bulimia

• initially pleasant and cheerful as though nothing is wrong.
• Pleasant façade disappears when begin describing binge eating and
purging.
• express intense guilt, shame and embarrassment

• Ask client about thoughts of self-harm or suicide

Sensorium and Intellectual Processes

• alert and oriented
• intellectual functions are intact.
• The exception is clients with anorexia who are severely malnourished
and showing signs of starvation, such as:
• mild confusion
• slowed mental processes
• difficulty with concentration and attention.

Judgment and Insight

Clients with anorexia
• limited insight and poor judgment about their health status.
• do not believe they have a problem
• continue to restrict food intake or to engage in purging despite the
negative effect on health
Clients with bulimia
•ashamed of the binge eating and purging
•feel out of control and unable to change

Clients with bulimia

- feel great shame about their binge eating and purging behaviors.
> tend to lead secret lives that include sneaking behind the back of friends and
family to binge and purge in private

NURSING INTERVENTIONS
For Eating Disorders
Establishing nutritional eating patterns
• Sit with the client during meals and snacks
• Offer liquid protein supplement if client is unable to complete meal.
• Adhere to treatment program guidelines regarding restrictions.
• Observe the client following meals and snacks for 1 to 2 hours.
• Weigh the client daily in uniform clothing.
• Be alert for attempts to hide or discard food or inflate weight.

Clients with bulimia

•feel great shame about their binge eating and purging behaviors.
•tend to lead secret lives that include sneaking behind the back of friends and
family to binge and purge in private

NURSING INTERVENTIONS
For Eating Disorders
Establishing nutritional eating patterns
• Sit with the client during meals and snacks
 • Offer liquid protein supplement if client is unable to complete meal.
• Adhere to treatment program guidelines regarding restrictions.
• Observe the client following meals and snacks for 1 to 2 hours.
• Weigh the client daily in uniform clothing.
• Be alert for attempts to hide or discard food or inflate weight.

Helping the client identify emotions and develop non-food-related coping strategies
• Ask the client to identify feelings.
• Self-monitoring using a journal
• Relaxation techniques Distraction
• Assist the client in changing stereotypical beliefs.

Helping the client deal with body image issues

• Recognize benefits of a more near-normal weight.
• Assist in viewing self in ways not related to body imageIdentify
personal strengths, interests, and talents.Providing client and family education

SOMATOFORM SYMPTOM and RELATED

DISORDERS
PYSCHOSOMATIC
• began to be used to convey the connection between the mind (psyche)
and the body (soma) in states of health and illness.
• mind can cause the body either to create physical symptoms or to
worsen physical illnesses.
HYSTERIA
• refers to multiple physical complaints with no organic basis.
• complaints are usually described dramatically.

The three central features of somatoform disorders are as follows:

• Physical complaints suggest major medical illness but have no
demonstrable organic basis.
• Psychologic factors and conflicts seem important in initiating,
exacerbating, and maintaining the symptoms.
• Symptoms or magnified health concerns are not under the client's
conscious control

SOMATIC SYMPTOM DISORDERS INCLUDE:

1. SOMATIC SYMPTOM DISORDER
• characterized by one or more physical symptoms that have no organic
basis.
• Spend a lot of time and energy focused on health concerns.

2. Conversion disorder
• sometimes called conversion reaction
> involves unexplained, usually sudden deficits in sensory or motor function
deficits suggest a neurologic disorder but are associated with psychologic factors.
• An attitude of la belle indifférence, a seeming lack of concern or distress, is a
key feature.
> is a French term that translates to "beautiful ignorance."

3. Pain disorder
- has the primary physical symptom of pain, which generally is unrelieved by
analgesics and greatly affected by psychologic factors in terms of:
onset
Severity :
Exacerbation maintenance

4. illness anxiety disorder

> formerly hypochondriasis
• preoccupation with the fear that one has a serious disease (disease conviction)
> or will get a serious disease (disease phobia). It is thought that clients with
this disorder misinterpret bodily sensations or functions.
• Somatic symptom illnesses are more common in women than in men; they may
represent about 5% to 7% of the general population but estimates can vary greatly.

Onset and Clinical Course

• often experience symptoms in adolescence
> though these diagnoses may not be made until early adulthood (about 25 years of
age).
Conversion disorder
• usually occurs between the ages of 10 and 35 years
Pain disorder and illness anxiety disorder
• can occur at any age.

• Clients with somatic symptom illness and conversion disorder most

likely seek help from mental health professionals after they have exhausted efforts
at finding a diagnosed medical condition.
• Clients with, illness anxiety or pain disorder
likely to received treatment in mental health setting unless they have comorbid
condition.
* Clients with somatic symptom illnesses tend to go from one physician or clinic to
another. or they may see multiple providers at once in an effort to obtain relief
of symptoms.

RELATED DISORDERS
Malingering
• the intentional production of false or grossly exaggerated physical
or psychologic symptoms.
• motivated by external incentives such as: avoiding work
• evading criminal prosecution obtaining financial compensation obtaining
drugs
• have no real physical symptoms or grossly exaggerate relatively minor
symptoms
• Their purpose: external incentive or outcome that they view as
important and results directly from the illness.

Factitious disorder
• occurs when a person intentionally produces or feigns physical or
psychologic symptoms solely to gain attention.
• may even inflict injury on themselves to receive attention
• common term for factitious disorder is Munchausen syndrome.
•also called fabricated or induced illness
Munchausen Syndrome

Munchausen syndrome by proxy

• A variation of factitious disorder
• occurs when a person inflicts illness or injury on someone else to
gain the attention of emergency medical personnel or to be a "hero" for saving the
victim.
• occur most often in people who are in or familiar with medical
professions, such as nurses, physicians, medical technicians, or hospital
volunteers.
• An example would be a nurse who gives excess intravenous potassium to
a client and then "saves his life" by performing cardiopulmonary resuscitation.

Medically Unexplained Symptoms (MUS) and Functional Somatic

Syndromes
•terms used more frequently in general medical setting.
• refer to physical symptoms and limitations of function that has no medical
diagnoses to explain their existence.

ETIOLOGY
Psychosocial Theories
• people with somatoform disorders keep stress, anxiety, or frustration
inside rather than expressing them outwardly internalization.
• Clients express these internalized feelings and stress through
physical symptoms (somatization).

Biologic Theories
• differences in the way that clients with somatoform disorders
regulate and interpret stimuli.
• cannot sort relevant from irrelevant stimuli and respond equally to
both types.
• they may experience a normal body sensation such as peristalsis and
attach a pathologic rather than a normal meaning to it (Hollifield, 2005)
• Too little inhibition of sensory input amplifies awareness of
physical symptoms and exaggerates response to bodily sensations
• For example, minor discomfort such as muscle tightness becomes
amplified because of the client's concern and attention to the tightness.

TREATMENT
• focuses on managing symptoms and improving quality of life.
• health care provider must show empathy and sensitivity to the
client's physical complaints.
• A trusting relationship helps to ensure that clients stay with and
receive care from one provider instead of "doctor shopping."

ANTIDEPRESSANTS USED TO TREAT SOMATIC SYMPTOM ILLNESSES

FLUOXETINE (Prozac)
20-60 mg/day
•Monitor for rash, hives, insomnia, headache Vanxiety, drowsiness, nausea, loss of
appetite, avoid alcoholic

SERTRALINE (Zoloft)
50- 200 mg/day
Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolence or insomnia,
sweating, sexual dysfunction; avoid alcohol

PAROXETINE (Paxil)
v 20- 60 mg/day
Monitor for nausea, loss of appetite, dizziness, dry mouth, somnolence or insomnia,
sexual dysfunction; avoid alcohol

CLIENT AND FAMILY EDUCATION For Somatic Symptom Illnesses

• Establish daily health routine, including adequate rest, exercise,
and nutrition
• Teach about relationship of stress and physical symptoms and mind-
body relationship.
• Educate about proper nutrition, rest, and exercise.
• Educate client in relaxation techniques: progressive relaxation, deep
breathing, guided imagery, and distraction such as music or other activities.
•
• Educate client by role-playing social situations and interactions.
• Encourage family to provide attention and encouragement when client
has fewer complaints.
• Encourage family to decrease special attention when client is in
"sick" role:

NURSING INTERVENTIONS For Somatic Symptom Illnesses

• Health teaching
• Establish a daily routine.
• Promote adequate nutrition and sleep.
• Expression of emotional feelings
• Recognize relationship between stress/ coping and physical symptoms.
• Keep a journal.
• Limit time spent on physical complaints. Limit primary and secondary gains.

" Coping strategies

• Emotion-focused coping strategies such as relaxation techniques, deep
breathing. guided imagery, and distraction
• Problem-focused coping strategies such as problem-solving strategies
and role-playing