Chapter 19: Eating Disorders

Chapter 19: Eating Disorders

Complex set of behaviors related to eating

Share similarities with anxiety-related disorders

Clients often feel:

• Out of control in other life areas

• Use food as coping mechanism

• Distorted body image → impacts self-esteem

Prevalence & Risks

• Prevalence underestimated due to:

  • Secretiveness of the condition

  • Denial of illness

  • Avoidance of professional help

• High mortality rate

• Suicide risk is significant

Treatment Modalities

• Focus on normalizing eating patterns

• Address underlying issues raised by the illness

Comorbidities

• Depression

• Personality disorders

• Substance use disorder

• Anxiety

Recognition

• Eating disorders defined and classified by DSM-5-TR

Anorexia Nervosa

Persistent energy intake restriction → significantly low body weight (considering age, sex, development, health)

Fear of gaining weight / becoming overweight

Disturbance in self-perceived weight or shape

Characteristics

• Preoccupation with food and eating rituals; voluntary refusal to eat

• Most common in females, adolescence–young adulthood

• Onset may follow a stressful life event (e.g., college)

• Binge-eating/purging type → higher impulsivity, more likely to abuse drugs/alcohol

Types

• Restricting type: Severe restriction of food intake, no binge/purge

• Binge-eating/purging type: Engages in binge eating or purging behaviors

Bulimia Nervosa

Recurrent binge eating (large amounts in short time) + compensatory behaviors (vomiting, laxatives, excessive exercise)

Occurs at least once per week for 3 months

Binges last < 2 hours and involve eating more than most would in similar time

Sense of lack of control

Characteristics

• Weight usually within normal or slightly higher range (BMI 18.5–30)

• Average onset: late adolescence or early adulthood

• Most common in females

• Between binges → restrict caloric intake, use low-calorie “diet” foods

Types

• Purging type: Vomiting, laxatives, diuretics, enemas

• Nonpurging type: Excessive exercise or misuse of laxatives/diuretics/enemas without vomiting

Binge Eating Disorder

Recurrent episodes of eating large amounts of food without compensatory behaviors

Distress follows binge episode

Must include a sense of lack of control

Occurs ≥ 1x per week for 3 months

Characteristics

• Affects both men and women; most common in adults 46–55

• Weight gain → ↑ risk of T2DM, hypertension, cancer, heart disease

• Severity depends on number of binge episodes per week

Other Eating Disorder Categories

Pica: Eating nonfood items (dirt, soap, paint chips)

Rumination disorder: Regurgitating/rechewing food

Avoidant/restrictive food intake disorder: Lack of interest in food → poor growth/nutrition

Eating Disorders Prodromal Manifestations (warning signs)

Weight changes not explained by medical condition

Severe dieting / abnormal eating habits

Ritualized mealtime behaviors (counting calories, cutting food)

Lying about food intake

Preoccupation with weight and body image

Compulsive/excessive exercise

Eating Disorders Risk Factors

Occupational/Behavioral

• Jobs encouraging thinness (e.g., fashion modeling)

• History of being a “picky” eater in childhood

• Athletics (especially elite level or sports requiring lean build/weight class, e.g., wrestling, cycling)

• History of obesity

Family/Genetics

• More common in families with a history of eating disorders

Biological

• Hypothalamic, neurotransmitter, hormonal, or biochemical imbalance

• Serotonin neurotransmitter pathway disturbances implicated

Interpersonal Relationships

• Parental pressure

• Need to succeed

Psychological Influences

• Rigidity, ritualism, separation/individuation conflicts

• Feelings of ineffectiveness, helplessness, depression

• Distorted body image

• Internal/external locus of control or self-identity

• Possible history of physical abuse

Environmental Factors

• Media and societal pressure to achieve the “perfect body”

Temperamental

• Childhood anxiety or obsessional traits

Eating Disorders Expected Findings

Nursing History

• Client’s perception of issue

• Eating habits & dieting history

• Weight control methods (restricting, purging, exercising)

• Value attached to shape/weight

• Interpersonal/social functioning

• Impulsivity & compulsivity

• Family/interpersonal relationships (often chaotic, lack of nurturing)

Mental Status

• Cognitive distortions:

  • Overgeneralization: “People don’t like me because I’m fat.”

  • All-or-nothing thinking: “If I eat dessert, I’ll gain 50 lbs.”

  • Catastrophizing: “My life is over if I gain weight.”

  • Personalization: “Everyone is looking at me.”

  • Emotional reasoning: “I feel bloated, so I must look bad.”

• Preoccupation with food but refusal to eat

• Intense fear of gaining weight

• Sees self as overweight despite being underweight

• Low self-esteem, impulsivity, poor relationships

• Intense physical regimens

• Guilt/shame after binge eating

• OCD features: recipes, hoarding food, concern about eating in public

Vital Signs

• Low BP, possible orthostatic hypotension

• Decreased pulse & body temperature

• Hypertension possible in binge eating disorder

Weight

• Anorexia nervosa: <85% of expected normal weight

• Bulimia nervosa: weight usually normal or slightly high

• Binge eating disorder: overweight/obese

Integumentary (skin, hair, nails)

• Anorexia → lanugo (fine hair), yellow skin, poor turgor, pale/cool extremities

• Purging behaviors → calluses/scars on hands (Russell’s sign)

Head, Neck, Mouth, Throat

• Enlarged parotid glands (purging behaviors)

• Dental erosion, caries (vomiting)

Cardiovascular

• Dysrhythmias (ECG), heart failure, cardiomyopathy

• Peripheral edema

• Acrocyanosis

Fluid/Electrolyte

• Acidosis or alkalosis

• Dehydration

• Electrolyte imbalances

Musculoskeletal

• Muscle weakness

• Low energy

• Bone density loss

Gastrointestinal

• Constipation (dehydration)

• Diarrhea (laxatives)

• Abdominal pain

• Self-induced vomiting

• Excessive diuretics/laxatives

• Esophageal tears, gastric rupture (bulimia)

Reproductive

• Amenorrhea (anorexia)

• Menstrual irregularities

Psychosocial

• Low self-esteem, impulsivity, poor relationships

• Depressed mood

• Social withdrawal

• Irritability

• Insomnia

Eating Disorders Criteria for Acute Care Treatment

Severe weight loss: >20% below ideal body weight or <10% body fat

Failure in outpatient treatment: unsuccessful weight gain or nonadherence to treatment contract

Abnormal vital signs:

• HR < 50/min

• SBP < 90 mmHg

• Temp < 36°C (96.8°F)

ECG changes

Electrolyte disturbances

Psychiatric criteria: severe depression, suicidal behavior, family crisis, or psychosis

Eating Disorders Laboratory & Diagnostic Tests

Common Abnormalities (Anorexia & Bulimia)

• Hypokalemia (especially bulimia)

  • Direct potassium loss from vomiting

  • Dehydration → ↑ aldosterone → sodium & water retention, potassium excretion

• Anemia, leukopenia, thrombocytopenia

• Impaired liver function (↑ enzymes)

• Hypoalbuminemia

• Possible ↑ cholesterol

• ↑ BUN (dehydration)

• Abnormal thyroid tests

• ↑ Carotene (skin appears yellow)

• ↓ Bone density (osteoporosis)

• Abnormal blood glucose

• ECG changes (prolonged QT interval)

• ↑ Bicarbonate (metabolic alkalosis, vomiting)

• ↓ Bicarbonate (metabolic acidosis, laxatives)

Electrolyte Imbalances (depend on purging method)

• Hypokalemia

• Hyponatremia

• Hypochloremia

• Hypomagnesemia (malnutrition)

• Hypophosphatemia (malnutrition)

• ↓ Estrogen (females, anorexia)

• ↓ Testosterone (males, anorexia)

Eating Disorders Standardized Tools

Eating Disorder Inventory

Eating Disorder Examination

Eating Attitudes Test

Eating Disorders Nursing Care

Assess own feelings of frustration (important: disorder is not simply “self-imposed”)

Provide highly structured milieu in acute care for intensive therapy

Build a trusting nurse–client relationship with consistency and therapeutic communication

Use positive support to promote self-esteem & body image

Encourage client decision-making & participation in care plan (sense of control)

Establish realistic weight goals (2–3 lb/week is acceptable)

Promote CBT therapies:

• Cognitive reframing

• Relaxation techniques

• Journal writing

• Desensitization exercises

Monitor vital signs, intake/output, weight

Use behavioral contracts to modify eating behaviors

Reward positive behaviors (meal completion, set calorie goals)

Closely monitor after meals (prevent purging → may require bathroom supervision)

Monitor maintenance of appropriate exercise (not excessive)

Encourage self-care activities

Involve family in education & discharge planning

Nutritional Care

• Provide nutrition education with a dietitian to correct misinformation

• Consider client food preferences when planning meals

• Structured eating schedule only during set times → prevents binges/purges

• Small, frequent meals (↓ overwhelm)

• Liquid supplements as prescribed

• High-fiber diet (prevent constipation)

• Low-sodium diet (prevent fluid retention)

• Avoid high-fat/gassy foods early in treatment

• Administer multivitamin/mineral supplement

• Limit caffeine (can ↑ energy for disordered behaviors, may be misused as appetite suppressant)

Therapy & Support

• Arrange for individual, group, and family therapy

• Family therapy helps address interpersonal issues contributing to disorder

Eating Disorders Medications

Selective Serotonin Reuptake Inhibitors (SSRIs)

• Fluoxetine

Nursing Actions

• Teach: onset 1–3 weeks for initial effect; up to 2 months for maximal effect

• Avoid hazardous activities until side effects are known (e.g., driving, machinery)

• Report intolerable sexual dysfunction to provider

Eating Disorders Interprofessional Care

Interprofessional Care

• Registered dietitian → provides nutritional/dietary guidance

• Consistency of care among all staff is essential

Client Education (Care After Discharge)

• Develop & implement maintenance plan for weight management

• Encourage outpatient follow-up

• Participation in support groups

• Continue individual & family therapy

Eating Disorders Complications

Refeeding Syndrome

• Fatal complication when fluids/electrolytes/carbohydrates are reintroduced too quickly in malnourished clients

Nursing Actions

• Hospitalize client

• Collaborate with provider/dietitian to provide controlled nutrition support

• Monitor electrolytes & provide fluid replacement as prescribed

Cardiac Dysrhythmias, Severe Bradycardia, Hypotension

Nursing Actions

• Continuous cardiac monitoring

• Monitor vital signs frequently

• Report status changes to provider

A nurse is obtaining a nursing history from a client who has a new diagnosis of anorexia nervosa. Which of the following questions should the nurse include in the assessment?

Select all that apply.

a

“What is your relationship like with your family?”

b

“Why do you want to lose weight?”

c

“Tell me about your current eating habits.”

d

“At what weight do you believe you will look better?”

e

“Let’s discuss your feelings about your appearance.”

a “What is your relationship like with your family?”

c “Tell me about your current eating habits.”

e “Let’s discuss your feelings about your appearance.”

---

Asking a “why” question promotes a defensive client response and is therefore nontherapeutic.

Questions that promote cognitive distortion, places the focus on weight, and implies that the client’s current appearance is not acceptable.

A nurse is caring for an adolescent client who has anorexia nervosa with recent rapid weight loss and a current weight of 90 lb. Which of the following statements indicates the client is experiencing the cognitive distortion of catastrophizing?

a

“Life isn’t worth living if I gain weight.”

b

“Don’t pretend like you don’t know how fat I am.”

c

“If I could be skinny, I know I’d be popular.”

d

“When I look in the mirror, I see myself as obese.”

a “Life isn’t worth living if I gain weight.”

---

B - Distortion of personalization

C - Distortion of overgeneralization

D - Distortion of body image

A nurse is performing an admission assessment of a client who has bulimia nervosa with purging behavior. Which of the following is an expected finding?

Select all that apply.

a

Amenorrhea

b

Hypokalemia

c

Yellowing of the skin

d

Slightly elevated body weight

e

Presence of lanugo on the face

b Hypokalemia

d Slightly elevated body weight

---

Anorexia nervosa for the rest

A nurse is planning care for a client who has anorexia nervosa with binge-eating and purging behavior. Which of the following actions should the nurse include in the client’s plan of care?

a

Allow the client to select preferred meal times.

b

Establish consequences for purging behavior.

c

Provide the client with a high-fat diet at the start of treatment.

d

Implement one-to-one observation during meal times.

d Implement one-to-one observation during meal times.

A nurse is caring for a client who has bulimia nervosa and has stopped purging behavior. The client tells the nurse about fears of gaining weight. Which of the following responses should the nurse make?

a

“Many clients are concerned about their weight. However, the dietitian will ensure that you don’t get too many calories in your diet.”

b

“Instead of worrying about your weight, try to focus on other problems at this time.”

c

“I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments.”

d

“You are not overweight, and the staff will ensure that you do not gain weight while you are in the hospital. We know that is important to you.”

c “I understand you have concerns about your weight, but first, let’s talk about your recent accomplishments.”

The correct statement acknowledges the client’s concern and then focuses the conversation on the client’s accomplishments, which can promote client self-esteem and self-image.

---

Statements that minimizes and generalizes the client’s concern is a nontherapeutic response.

The nurse should identify that which of the following electrolyte imbalances are associated with anorexia nervosa?

Select all that apply.

a

Hypokalemia

b

Hypermagnesemia

c

Hyponatremia

d

Hypochloremia

e

Hypophosphatemia

a Hypokalemia

c Hyponatremia

d Hypochloremia

e Hypophosphatemia

Identify the expected findings associated with anorexia nervosa and bulimia nervosa.

Dental erosion

Loss of bone density

Esophageal tears

Menstrual irregularities

Severe dieting

Fear of gaining weight

Amenorrhea

---

Anorexia Nervosa

Bulimia Nervosa

Anorexia Nervosa

• Severe dieting

• Fear of gaining weight

• Amenorrhea

Bulimia Nervosa

• Dental erosion

• Loss of bone density

• Esophageal tears

• Menstrual irregularities