Chapter 20: Eating Disorders

Key Terms:
Alexithymia: difficulty identifying and expressing feelings
Anorexia Nervosa: an eating disorder characterized by the clients 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
existence or seriousness of a problem
Binge Eating: 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
Body Image: how a person perceives his or her body, that is, a mental self-image
Body Image Disturbance: occurs when there is an extreme discrepancy between ones body image and
the perception of others and extreme dissatisfaction with ones body image
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 (self-induced vomiting or use of laxatives, diuretics, enemas, or emetics), fasting or excessively
exercising
Enmeshment: lack of clear role boundaries between person
Pica: persistent ingestion of nonnutritive substances such as paint, hair, cloth, leaves, sand, clay or soil
Purging: compensatory behaviors designed to eliminate food by means of self-induced vomiting
Rumination: repeatedly going over the same thoughts
Satiety: satisfaction of appetite
Self-Monitoring: a cognitive-behavioral technique designed to help clients manage their own behavior
Objectives:
Compare and contrast the symptoms of anorexia nervosa, and bulimia nervosa
o Overview of Eating Disorders:
Obesity has been identified as a major health problem in the United States; some call it an
epidemic
In the late 1800s, doctors in England and France described young women who apparently
used self-starvation to avoid obesity
1960s anorexia nervosa was established a mental disorder
Bulimia nervosa was first described as a distinct syndrome in 1979
30-35% of normal weight people with bulimia have a hx of anorexia nervosa and low
body weight
About 50% of people with anorexia nervosa exhibit compensatory behaviors seen in
bulimic behavior, such as purging and excessive exercise
More than 90% of cases of anorexia nervosa and bulimia occur in female; fewer men
than women, but men are least likely to seek tx
1-4% of general population in the U.S
70% of general population simple preoccupied with weight and body image
o Categories of Eating Disorders:
Anorexia Nervosa:
Body weight that is less than the minimum expected weight, considering age,
height, overall physical health
Classified into 2 subgroups depending how weight is lost:
o Restricting subtype: lose weight primarily through dieting, fasting or
excessive exercising
o Binge eating and purging subtype: engage regularly in binge eating
followed by purging
Become totally absorbed in quest for weight loss and thinness
 Anorexia: actually, a misnomer, clients dont lose their appetite, still experience
hunger but ignore it, also ignore signs of physical weakness and fatigue; believe fi
they eat anything they wont be able to stop eating and will get fat
Preoccupied with food related activities
Engage is unusual or ritualistic food behaviors
Bulimia Nervosa:
Amount of food consumed during a binge episode s much larger than a person
would normally eat
Often engages in binge eating secretly, and between binges may eat low-calorie
food or fast
Weight is usually in normal range, although some are over or under weight
Recurrent vomiting destroys tooth enamel leading to dental carries, ragged or
chipped teeth increase
o Anorexia Nervosa Onset and Clinical Course:
Usually begins between ages 14 and 18
Denial early on
Depression and lability with progression
Social isolation, may become paranoid, and mistrust others
Medical Complications of Eating Disorders Table 20.2 pg 397
o Bulimia Nervosa Onset and Clinical Course:
Begins in late adolescences, early adulthood; 18-19 years of age
Often begins during or after dieting episodes
Possible restrictive eating between binges; secretive storage/hiding food
Treated on outpatient basis, unless medical status is compromised hospitalization may be
necessary
Discuss Various etiologic theories of eating disorders
o Risk Factors for Eating Disorders Table 20.1 pg 394
o Biologic Factors:
Genetic vulnerability
Disruptions in the nuclei of the hypothalamus relating to hunger and satiety
Lateral hypothalamus deficit: decreased eating, decreased responses to sensory
stimuli that are important to eating
Disruption of ventromedial hypothalamus: leads to excessive eating, weight gain,,
decreased responsiveness to the satiety effects of glucose, behaviors seen in
bulimia
Neurochemical changes (norpei and serotonin); not known if these changes cause
disorders or are results of eating disorders
Low norepinephrine levels seen during periods of restricted food intake
Low epinephrine levels related to decrease HR, BP, seen in those with anorexia
Increases serotonin and precursor tryptophan been linked with increased satiety
Low levels serotonin, low platelet levels of MAO found in those with bulimia and
binge and purge type anorexia
o Developmental Factors:
Struggle for autonomy, identity
Overprotective or enmeshed families
Body image disturbance/dissatisfaction
Separation-individuation difficulties
o Family Influences: family dysfunction, childhood adversity
Adversity defined as physical neglect, sexual abuse, or parental maltreatment that
includes little care, affection, and empathy as well as excessive paternal control,
unfriendliness, or over protectiveness
 o Sociocultural Factors:
Media: ideal woman is thin; culture equates beauty, desirability, and ultimately,
happiness with being very thin, perfectly toned, and physically fit
Pressure from others such as coaches, parents, and peers, and the emphasis placed on
body form in sports such as gymnastics ballet, and wrestling can promote eating disorder
in athletes
Identify effective treatment for clients with eating disorders
o Anorexia Nervosa:
Very difficult to treat
Often resistant, appear uninterested, and deny problems
Inpatient specialty editing disorder units, partial hospitalization, or day treatment
programs and outpatient therapy
Major life-threatening complications that indicate the need for hospital admission include
severe fluid, electrolyte, and metabolic imbalances; cardiovascular complications; severe
weight loss and its consequences; at risk for suicide
Medical Management:
Weight restoration/ nutritional rehabilitation
Rehydration/ correction of electrolyte imbalances
Psychopharmacology: amitriptyline (Elavil), cyproheptadine (Periactin), Olanzapine
(Zyprexa), fluoxetine (Prozac)
Psychotherapy:
Family therapy
Individual therapy
Cognitive-behavioral therapy
o Bulimia:
Cognitive-Behavioral Therapy
Psychopharmacology: desipramine (Norpramin), imipramine (Tofranil), amitriptyline
(Elavil), nortriptyline (Pamelor), phenelzine (Nardil), fluoxetine (Prozac)
Apply the nursing process to the care of clients with eating disorders
o Assessment:
Eating Attitudes Test Box 20.2 pg 403
History: model child, no trouble, dependable (anorexia); eager to please and conform,
avoid conflict (bulimia)
General Appearance and Motor Behavior: slow, lethargic, emaciation (Anorexia); not
unusual (bulimia)
Mood and Affect: labile
Thought Processes and Content: preoccupation with food or dieting
Sensorium and Intellectual Processes: alert and oriented, intellectual functions in tact;
severely malnourished may be mildly confused, slowed mental processes, difficulty with
concentration and attention
Judgment and Insight: very limited
Self-Concept: low self-esteem
Roles and Relationships: effected by eating habits
Psychologic and Self-Care Considerations: Medical Complications of Eating Disorders
Table 20.2 pg 397
o Data Analysis/ Outcome Identification:
Data Analysis:
Imbalanced Nutrition: Less Than/ More Than Body Requirements
Ineffective Coping
Disturbed Body Image
Chronic Low Self-Esteem
 Outcome Identification:
Establish adequate nutritional eating patterns
Eliminate use of compensatory behaviors such as excessive exercise, use of
laxatives, diuretics, and purging
Demonstrate positive coping mechanism not related to food
Verbalize feelings of guilt, anger, anxiety, or an excessive need for control
Verbalize acceptance of body image with stable body weight
o Interventions:
Establishing nutritional eating patterns (inpatient tx if severe)
Sit with client during meals and snacks
Offer liquid protein supplement if client is unable to complete meal
Adhere to tx program guidelines regarding restrictions
Observe the client following meals and snacks for 1-2 hours
Weight the client daily in uniform clothing
Be alert for attempts to hide or discard food or inflate eight
Identifying emotions and developing coping strategies
Ask client to identify feelings
Self-monitoring using a journal
Relaxation technique
Distraction
Assist the client to change stereotypical beliefs
Helping the client deal with body issues
Recognize benefits of a more near-normal weight
Assist to view in ways not related to body image
Identify personal strengths, interests, talents
Providing client and family education
o Evaluation: use assessment tools; tx is considered successful if client maintains a body weight
within 5-10% of normal, not medical complications
Provide teaching to clients, families, and community members to increase knowledge and understanding
of eating disorders
o Client:
Basic nutritional needs
Harmful effects of restrictive eating, dieting, and purging
Realistic goals for eating
Acceptance of healthy body image
o Family and Friends:
Provide emotional support
Express concern about clients health
Encourage the client to seek professional help
Avoid talking only about weight, food intake, and calories
Become informed about eating disorders
It is not possible for family and friend to force the client to eat. The client needs
professional help from a therapist or psychiatrist
Evaluate your feelings, beliefs, and attitudes about clients with eating disorders
o Feelings of frustration when patient rejects help
o Being seen as the enemy if you must ensure that the patient eats
o Dealing with own issues about body image, dieting
Related disorders, cultural considerations, community based care, mental health promotion
o Related Disorders:
 Binge Eating Disorder: characterized by recurrent episodes of binge eating; no regular
use of inappropriate compensatory behaviors; guilt, shame, and disgust about eating
behaviors; marked psychological distress
Affects people over 35
Occurs more often in men then does any other eating disorders
Most likely to be overweight or obese
Night Eating Syndrome: characterized by morning anorexia, evening hyperphagia
(consuming 50% of daily calories after last evening meal, and night time awakening (at
least once a night) to consume snacks
Associated with life stressors, low self-esteem, anxiety, depression, an adverse
reaction to weight loss
Most people are obese
Tx with SSRIs
Comorbid Psychiatric Disorders: common in clients with anorexia and bulimia nervosa
Mood disorders, anxiety, disorders, and substance abuse/ dependence are
frequently seen
Often linked to a hx of sexual abuse, especially if the abuse occur before puberty,
these patients have higher levels of depression and anxiety, lower self-esteem,
more interpersonal problems, and more severe obsessive-compulsive symptoms
o Cultural Considerations:
o Community Based Care: increased prevalence in industrialized countries
Most common in the U.S, Canada, Europe, Australia, Japan, New Zealand, South Africa
Less frequent among African Americans
Equal amount of Hispanic, Caucasian woman
Hospital admission only for medical necessity
Community Settings:
Partial hospitalizations or day tx programs
Individual or group outpatient therapy
Self-help groups
Healthy People 2020
o Mental Health Promotion:
Education of parents, children, young people about strategies to prevent eating disorders
Early identification, appropriate referral
Routine screening of young women for eating disorders