eating disorders

EATING DISORDER-

•consistently less than or more than body’s caloric need to maintain a healthy body  weight

•Is accompanied by anxiety and guilt

•Occurs without hunger or fails to produce satiety

•Results in physiologic imbalances and medical complications 

two most serious eating disorders:

•Anorexia Nervosa

•Bulimia Nervosa

•Binge Eating Disorder

–Bingeing- recurrent consumption of large amounts of food

•Compulsive overeating

•No inappropriate compensatory behaviors

•Eating associated with

–Fast consumption, eating alone, guilt

•20-30% of obese individuals report binge eating

Anorexia Nervosa-

life threatening condition of disturbed body image, leads to emaciation with the intense fear of becoming obese.  Has very high mortality rate (7-10%) with high rates of suicide

Bulimia Nervosa

•recurrent pattern of uncontrollable consumption of large amounts of food ( binge eating ) followed by attempts to eliminate the body of excess calories ( purging )

Incidence and Prevalence

•1% to 4% estimates of population in the U.S. anorexia and bulimia nervosa

•Difficult to assess as most binge and purge in secret and their weight remains WNL

•Historically whites well educated adolescent to young adults

•Both disorders more widely distributed among classes and cultures

•Can manifest and persist into middle and later adulthood

•Incidence of males with eating disorders is growing

•Studies indicate for every two women one male has anorexia and every three women to one male has bulimia nervosa

•Popular emphasis on fitness, lean muscle mass, stringent weight requirements, contribute to the disorders

•Incidence higher in male homosexuals

•Males are less likely to seek help than females

ETIOLOGY

•Eating disorders vary and are influenced by impaired psychosocial functions, medical conditions, and psychiatric co-morbidities

•Eating disorders are multi-factorial. Develop based on interactions with family, individual, sociocultural

•Vulnerable personalities, uncontrolled dieting, genetics, puberty, major life changes, stressors, family functioning or dysfunction,  emphasis in thinness, all may contribute

•Transactional Model of Stress/Adaptation

  The etiology of eating disorders is most likely influenced by multiple factors.

•Genetic models

A hereditary predisposition to eating disorders has been hypothesized

Anorexia nervosa is more common among  sisters and mothers of those with the disorder than it is among the general population

•Psychological Models

–Eating disorders have been associated with

•Low self esteem

•Self-doubts about personal worth

•Problems with separation

•Problems with sexuality

•Psychosocial influences

–Unresolved dependency needs

–Fixation in the oral stage of psychosexual development

Biologic Theory

•Unsure which came first

•Several neurochemical disturbances with anorexia and bulimia.

•May originate in the Hypothalamic, hormonal, neurotransmitters, or biochemical disturbances

•Norepinephrine- activates and serotonin inhibits as well as dopamine

•OCD, anorexia, bulimia are associated with excessive levels of vasopressin which is released during stress physical and emotional

•Psychodynamic influences

–Suggests that eating disorders result from very early & profound disturbances in mother-infant interactions, resulting in

•  Retarded ego development

•  Unfulfilled sense of separation-individuation

Psychosocial Theory

•May diet to lose weight to gain enhances physical appearance receiving attention from others. Can be positive or negative

•Mood disorders, anxiety disorders, low self-esteem, perfectionism, perseverance (determination ), avoidance, all appear to be predisposing factors for eating disorders

•OCD involves ritualistic behaviors, irrational thoughts and beliefs, anxiety. These are all cognitive and behavioral similarities with  Eating Disorders

–FAMILY INFLUENCES AND CONFLICT AVOIDANCE

•Families may promote & maintain psychosomatic symptoms, including anorexia nervosa, in an effort to avoid spousal conflict.

The sick child becomes the problem, & focus on the conflict is diverted.

–Elements of Power and Control

•Power & control may become the overriding elements within the family.

Parental criticism:

promotes an increase in obsessive & perfectionist behavior on the part of the child, who continues to seek love, approval, & recognition.

Anorexia Nervosa assessment:

•Weight loss is extreme, usually more than 15 percent of expected weight

–Other symptoms include amenorrhea hypothermia, bradycardia, hypotension, edema, lanugo, & a variety of metabolic changes

–Family involvement

–Amenorrhea is typical & may even precede significant weight loss

–There may be an obsession with food

–Feelings of anxiety & depression  common

Bulimia assessment:

–an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (bingeing)

–Episode is followed by inappropriate compensatory behaviors to rid the body of the excess calories (self-induced  vomiting or the misuse of laxatives, diuretics, or enemas)

Nursing Diagnosis

•Imbalanced nutrition: less than body requirements related to refusal to eat

•Deficient fluid volume (risk for or actual) related to decreased fluid intake, self-induced vomiting, & laxative and/or diuretic abuse

•Disturbed body image/low self-esteem/retarded ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance

•Ineffective denial related to retarded ego development and fear of losing the only aspect of life over which he or she perceives some control (eating)

•Imbalanced nutrition: More than body requirements related to compulsive overeating

•Disturbed body image/low self-esteem/retarded ego development, dysfunctional family system, or feelings of dissatisfaction with body appearance

•Anxiety (moderate to severe) related to feelings of helplessness and lack of control over life events

EMERGENCY

•Excessive vomiting & laxative or diuretic abuse may lead to problems with dehydration & electrolyte imbalances

•Multiple physiological disorders related to the consequences of starvation

•Kidney and liver disorders

objectives for the client with anorexia/bulimia:

–Verbalizes knowledge regarding consequences of fluid loss caused by self-induced vomiting (or laxative/diuretic abuse) & importance of adequate fluid intake

–Verbalizes events that precipitate anxiety & demonstrates techniques for its reduction

–Verbalizes ways in which (s)he may gain more control of the environment & thereby reduce feelings of helplessness

–Expresses interest in welfare of others & less preoccupation with own appearance

–Verbalizes that image of body as “fat” was misperception

–Demonstrates ability to take control of own life without resorting to maladaptive eating behaviors     (anorexia nervosa)

Planning and Implementation

•Nursing care of the client with an eating disorder is aimed at restoring nutritional balance

•Emphasis is also placed on helping the client gain control over life situation in ways other than inappropriate eating behaviors

•Self-esteem and positive self-image are promoted in ways that relate to aspects other than appearance

Treatment Modalities

–Issues of control are central to the etiology of these disorders.

–For the program to be successful, the client must perceive that he

   or she is in control of the treatment.

•Success observed when the client

•Is allowed to contract for privileges based on weight gain

•Has input into the care plan

•Clearly sees what the treatment choices are

–The client has control over

•Eating

•Amount of exercise pursued

•Whether to induce vomiting

–Staff and client agree about

•Goals

•System of rewards

•Individual Therapy

–Helpful when underlying psychological problems are contributing to the maladaptive behaviors

•Family Therapy

–Involves educating the family about the disorder

–Assesses the family’s impact on maintaining the disorder

–Assists in methods to promote adaptive

   functioning by the client

•Attend to cognitive distortions

–Overgeneralizations

–All or nothing thinking

–Catastrophizing

–Personalization

–Emotional Reasoning

outcomes for the The client with anorexia/bulimia:

– Has achieved & maintained at least 80 percent of expected body weight

–Has vital signs, blood pressure, & laboratory serum studies within normal limits

–Verbalizes importance of adequate nutrition

•Adequacy or usual pattern of nutritional intake

•Body weight, muscle & fat are congruent with gender & age

•Positive body image

•Psychopharmacology

–No medications are specifically indicated for eating disorders

–Various medications have been prescribed for associated symptoms such as anxiety and depression

•Medications that have been tried with some success For anorexia nervosa:

•Fluoxetine (Prozac)

•Clomipramine (Anafranil)

•Cyproheptadine (Periactin)

•Chlorpromazine (Thorazine)

•Olanzapine (Zyprexa)

•Sertraline (Zoloft)

•Medications that have been tried with some success for binge-eating disorder with obesity:

•Topiramate (Topamax)

• Lisdexamfetamine (Vyvanse)

•Nature of the illness education

–Symptoms of anorexia & bulimia nervosa

–Causes of eating disorders

–Effects of the illness or condition on the body

•Management of the illness education

–Principles of nutrition

–Ways client may feel in control of life

–Importance of expressing fears & feelings, rather than holding them inside

–Alternative coping strategies

SUPPORT SERVICES

–National Association of Anorexia   Nervosa and Associated Disorders

–The American Anorexia/Bulimia Association, Inc.

Evaluation

•Evaluation of the client with an eating disorder requires reassessment of the behaviors for which the client sought treatment. Management of symptoms

•Behavioral change will be required by the client and family members.