Anorexia Nervosa

Progression of symptoms that lead to an eating disorder?

1. Normal eating

2. Development of risk factors:

   • Low self esteem

   • Dieting

     • Parental attitdudes

     • Body disatisfaction

   • Media ideal bodies

3. Partial-syndrome ED

   • bing eating

   • serious dieting

4. Full-syndrome ED

   • Increase in frequency and severity of:

     • binge eating

     • purging

     • starvation

What are eating disorder characterized by?

disturbed eating and eating-related behaviors

low body weight,

intense fear of gaining weight or becoming fat,

disturbance in experiencing body weight or shape (undue influence or distorted self-evaluation of body weight or shape or lack of recognition of the seriousness of low body weight)

Anorexia nervosa

What are the 2 types of anorexia nervosa?

1. Restricting → diet & exercise with no binge eating

2. Binge eating and purging → binge eating with misuse of laxatives, enemas, and diuretics

Diagnostic criteria for anorexia nervosa?

• refusal to maintain ideal body weight and restriction of energy intake

  • significantly low body weight

• intense fear of gaining weight

• BMI used as a measure of severity

Onset for anorexia nervosa

adolescence or as young as 8 years old

True or False: Typically anorexia nervosa late onset is mostly diagnosed in women.

True

True or False: Most commonly eating disorders diagnosed in individuals over 50 years of age.

True

What are the clinical course characteristis for AN?

• body distortion (mental picture of one’s own body)

• drive for thinness

• emotional dysregulation

• Perfectionism

  • the extent to which the individual sets and tries to achieve high standards for oneself

• guilt and anger

  • avoids conflict and has difficulty expressing negative emotions, especially anger

• intense physical an emotional process that overrides all physiologic body cues

• ignores body cues

drive for thinness

• when behavior is organized around food-related activites, such as reparing food, counting calories, and reading cookbooks

• difficulty regulating expressions of feelings

• inability to accept emotional responses

emotional dysregulation

True or False: females are 10x more likely tahan males to develop AN d/t society’s influence on females to internalize a thin body

True

What are the risk factors for AN?

• ↑ BMR; overexercising; elite athlete​

• Low self-esteem, body dissatisfaction, feelings of ineffectiveness​

• Family: overprotective, enmeshed, rigid boundaries, inability to solve conflicts​

Biological theories of AN

• reduced grey and white matter in the brain (may reflect malnourishment)

• individuals with first-degree relatives with AN = increased risk

  • female relatives have higher rates of depression

• increased activation of amygdala and changes in the activation of the cingualte cortex

• increase in endogenous opioids (through exercise) contributes to the denial of hunger

Psychological theories for AN?

• Psychoanalytic paradigm​

• Peer pressure internalization​

• Body dissatisfaction​

occurs when the body is viewed negatively and becomes overvaules as a way of determining one’s work

body dissatification

Social theories for AN

Societal influences: media; conflicting messages; obesity; feminism and roles​

How does the family respond to family members with AN?

• overprotective

• enmeshes

• unable to resolve conflicts

• rigid regarding boundaries

• the family contributes to AN development

• hurtful weight-related comments by family members

An extreme form of intensity in family interactions and represents low individual autonomy in a family

• the individual gets lost in the family system. The boundaries that define individual autonomy are weak

Emeshment

Tx for AN

• focuses on nutritional rehabilitation to restore patient back to a healthy weight

• resolving conflicts with body image disturbance, increassing effective coping, addressing the underlying conflicts, assisting family with health functioning and communication

• need to be trained to eat again

Tx goal for AN

• acceptable weight

• discharged to a partial hospitlization program or intensive outpatient program

• family therapy

• DBT

  • skills training that focuses on emotional dysregulation

• Interpersonal therapy (IPT)

  • tx that focuses on uncovering and resolving the velopmental and psychological issues underlying the disorder

Patient safety with patients with AN?

• high mortality

• suicide and cardiopulmonary arrest = main cause of death in AN

Criteria for Hospilization of patient with eating disorders

Medical:

• Acute weight loss, <85% below ideal

• Heart rate near 40 beats/min

• Temperature, <36.1°C

• Blood pressure, <80/50 mm Hg

• Hypokalemia

• Hypophosphatemia

• Hypomagnesemia

• Poor motivation to recover

Psychological:

• Risk for suicide

• Severe depression

• Failure to comply with treatment

• Inadequate response to treatment at another level of care (outpatient)

BMI serverity in AN

Mild: BMI ≥17 kg/m2

Moderate: BMI 16 to 16.99 kg/m2

Severe: BMI 15 to 15.99 kg/m2

Extreme: BMI <15 kg/m2

Care for persons with AN disorder?

• Physical health assessment

  • Body system evaluation

  • Weight and BMI

  • Menstraul hx

• Mental status and appearance​

  • Behavioral responses​

    • Body distortion; fear of weight gain​

  • Unrealistic expectations or thinking; ritualistic behaviors​

  • Difficulty expressing negative feelings​

  • Inability to experience visceral cues and emotions​

  • strengths assessment

    • motivation to eat differently; have a more normal life

  • stress and coping mechanisms

  • social assessment

  • quality of life

What are the top priorities when caring for patients with AN?

• Bradycardia ​

• Hypotension ​

• Electrolyte imbalances ​

• Suicide ideation ​

Establishing therapeutic relationship with patients with AN?

• Difficult initial

  • Tend to be suspicious and mistrustful especially of authority figures and health personnel ​

  • Impact and irritable

• A firm, accepting, and patient approach is important

  • Providing rationale for all interventions

  • consistent, nonreactive approach

  • avoid power struggles

What are the psychological s/s for AN?

• Sexuality conflict or fears

• Maturity fears

• Ritualistic behaviors

• perfectionism

• emotional dysregulation

Psychological s/s for bulimia nervosa

• impulsivity

• boundary problems

• limit-setting difficulties

Psychological s/s for AN

Difficulty expressing anger

Low self-esteem

Body dissatisfaction

Powerlessness

Ineffectiveness

Perfectionism

Dietary restraint

Obsessiveness

Compulsiveness

Nonassertiveness

Cognitive distortions

Nursing Interventions for AN

What positive wellness habits will nurses promote for patients AN?

• nutrition

• physical activity

• coping with stress

• sleep

• developing a support system

• Prioritize long and short term goal

• setting realistic goals

Nursing Interventions for AN:

Refeeding protocol for nutritional rehabilitation

1. Start with 1500 cal/day

2. slowly increase until pt can eat 3500 cal/day in several meals

3. gain 1-2lb per week

• Complications from refeeding syndrome

• severe electrolyte disturbances

Refeeding syndrome

What are the s/s of refeeding syndrome?

• circulatory fluid overload

• respiratory failure

• cardiac falure

• hypophosphatemia is a precursor and can lead to sudden death

Nursing Interventions for AN:

Promoting sleep for AN

• structures health sleep routine to conserve energy and calore expenditure d/t low weight

Should pts with AN exercise during the refeeding period?

NO!

What medication would you prescribe a pt with AN?

• Fluexetine (Prozac)

  • SSRI

Nursing Interventions for AN:

Psychosocial intervention for AN

• therapeutic interactions

• enhancing cognitive functioning

• using behavorial interventions

Nursing Interventions for AN:

promoting safety and rehabilitation strategies

Safety:

• sometimes pts are in a privelege earning program that allows them to get rewards such as have vistors if they gain weight

Developing rehabilitation strategies:

• Maintain a normal weight and nutrition ​

• Resist urges to diet and over exercise

Continuum care for pts with AN

Emergency care:

• EC not needed d/t family catching severe weight loss

• pt will be admitted immediately to med-surg inpatient care if s/s is not noticed

Inpatient:

• hospitalization is required

Community care:

• outpatient unit after refeeding