Week 9: Eating Disorders

Anorexia Nervosa (AN) - 3 characteristics 

• Restriction of energy intake, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

• Intense fear of gaining weight or becoming fat, or behavior that interferes with weight gain

• Body image disturbance, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

Anorexia Nervosa Restricting Type

• During the last 3 months, the individual has not engaged in recurrent episodes of binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

• This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise

Anorexia Nervosa Binge-Eating / Purging Type

During the last 3 months, the individual has engaged in recurrent episodes of binge-eating or purging behavior

• i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Anorexia Nervosa severity specifiers BMI — mild, moderate, severe, and extreme

• Mild: BMI ≥ 17 kg/m²

• Moderate: BMI 16-16.99 kg/m²

• Severe: BMI 15-15.99 kg/m²

• Extreme: BMI < 15 kg/m²

What physiological disturbances occur d/t malnutrition r/t Anorexia Nervosa?

• amenorrhea and vital sign abnormalities are common

• most are reversible with nutritional rehabilitation

• some, including loss of bone mineral density, are often not completely reversible

Seriously underweight individuals may have depressive signs and symptoms, such as (5):

• depressed mood

• social withdrawal

• irritability

• insomnia

• diminished interest in sex

those with binge-eating/purging type have higher rates of _____ and are more likely to abuse _____ and _____

• impulsivity 

• alcohol and other drugs

What may precede AN?

Excessive physical activity

When does AN often begin?

adolescence or young adult

• Rarely begins before puberty or after 40

What is often associated with the onset of AN?

Stressful event

• e.g., leaving home for college

AN has an association with _____ _____ or _____

suicidal thoughts or behaviors

What is the second leading cause of death is patients with AN?

suicide

Contributing factors to increased risk of suicide in those with EDs?

• Greater exposure to sexual abuse 

• Impaired decision-making

• High rates of non-suicidal self-injury

• A known risk factor for suicide attempts 

• Comorbidity with mood disorders

Bulimia Nervosa (BN)

recurrent episodes of binge eating

• Eating an amount of food that is much larger than what most people would eat within a short period of time (e.g., 2 hrs) 

• a sense of lack of control over-eating during an episode

With bulimia nervous, there are recurrent inappropriate ______ _____ in order to prevent _____ _____, such as…

• compensatory behaviors

• weight gain

• self-induced vomiting, misuse of laxatives, fasting, and/or excessive exercise 

What are bulimia severity specifiers is based on?

Based on the number of episodes of inappropriate compensatory behaviors per week

• Mild: 1-3

• Moderate: 4-7

• Severe: 8-13

• Extreme: 14+ (2x or more per day)

What is the normal weight range for people with BN?

normal or overweight

• uncommon in overweight people

What do people with BN usually do between binges?

typically restrict their total caloric consumption and preferentially select low-calorie foods while avoiding foods that they perceive to be fattening or likely to trigger a binge

What physiological disturbances may occur d/t BN?

• Menstrual irregularity or amenorrhea (no period)

• Fluid and electrolyte disturbances d/t purging behavior

• Rare but potentially fatal complications: esophageal tears, gastric rupture, and cardiac arrhythmias

• Cardiac and skeletal myopathies

• Laxative dependence

Why may people who chronically abuse laxatives become dependent on them? 

Because their body is now so used to the laxatives that it doesn’t know how to work by itself

What symptoms are commonly assocaited with BN?

Gastrointestinal symptoms

Binge Eating Disorder (BED)

Recurrent episodes of binge eating (no recurrent, compensatory behaviors) at least once a week for 3 months

Binge eating episodes are characterized by 3 or more of the following:

• Eating much more rapidly than normal

• Eating until feeling uncomfortably full

• Eating large amounts of food when not feeling physically hungry

• Eating alone because of feeling embarrassed by how much one is eating

• Feeling disgusted with oneself, depressed, or very guilty afterward

What is the normal weight range for people with BED?

normal-weight, overweight, and obese people

How is BED distinct from obesity?

• consume more calories in laboratory studies of eating behavior

• have greater functional impairment, lower quality of life, more subjective distress, and greater psychiatric comorbidity

• Most obese individuals do not engage in recurrent binge eating

Pica ED

persistent eating of things that are not food

• > 1 month

Rumination Disorder

vomiting up food but not on purpose

Avoidant Restrictive Food Intake Disorder (ARFID)

avoiding specific types of food d/t some fear

• not coupled with body image

• often associated with trauma with a certain food

Other Specified Feeding and Eating Disorder (OSFED) vs Unspecified Feeding and Eating Disorder (UFED)

• OSFED and UFED have symptoms that are similar to one or more eating disorders, but may not meet all the criteria for these conditions 

• The difference is that an OSFED diagnosis is given when a physician has time to fully assess the patient

What social influences may impact the development of EDs? 

• Media and social media

• Peer and family influence 

What psychological influences may impact the development of EDs? 

• Attachment styles 

• Low self-esteem 

• Personality 

• Dieting behaviors

What biological influences may impact the development of EDs? 

• Genetics 

• Neurotransmitters 

• Hormones 

***What hormones impact ED development? (Look in textbook)

When is the highest risk period of anorexia relapse?

Within the first year following hospitalization or day treatment

What is the highest indication that someone will have an ED relapse?

The more severe the ED, the more likely someone is to relapse

What disorder has the highest death rate of all psychiatric disorders?

Anorexia

What is the most important thing to do as a nurse when caring for a patient with an ED?

build rapport

When asking about eating habits, what should you ask about?

• Binge eating

• Purging 

• Other compensatory behaviors 

• Dietary restrictions 

• Weight history 

• Body image

When doing a psychosocial assessment, what should you ask about?

• Behavioral responses 

• Self-concept 

• Stress and coping patterns 

• Social assessment (family and peer relationships) 

• Quality of life 

• Strengths assessment 

Warning signs for an ED and ED relapse

• Change in usual eating pattern

• Ritualized eating behavior

• Weight preoccupation

• Excessive exercise 

• Goes to bathroom immediately after meal 

• Physical signs 

• “Disease of disconnection” from others and self

• *Secretes

What physical signs indicate an ED?

• Weight loss/fluctuations 

• Swollen parotid glands 

• Russell’s sign 

• Tooth decay (d/t stomach acid)

Russel’s sign

scarring on knuckles and hands because of how often they are forcing throwing up 

Eating Attitudes Test (EAT-26)

• Self report measure

• 26 questions – assesses risk of eating disorders and is useful as a screening tool

• 3 factors: bulimia, weight, body-image variables and psychological symptoms

• Scores greater than 20 should be referred for follow up

• Individuals with BED may not score greater than 20, but should still be referred for follow up

Eating Disorder Examination Questionnaire (EDE-Q)

• Self report measure

• 28 questions – assesses core eating pathology in past month

• 4 subscales: restraint, eating concern, shape concern and weight concern

• Each subscale and global scale are summed and averaged; each subscale and global scale are rated 0-6

  • Score of 4 or greater = clinical range

• Used in research but is also useful in clinical settings

Psychiatric comorbidities for EDs

• Anxiety disorders are the most common

• Depression and other mood disorders (bipolar)

• Personality disorder 

• Self-injurious behaviors/impulsivity

What body systems can EDs impact?

• Cardiac

• GI

• GU

• Musculoskeletal

• Endocrine

• Neurological

• Electrolyte imbalances

What is the most dangerous comorbidity/preceding disease for people with EDs?

cardiac because it can kill you 

What does starvation do to someone’s musculoskeletal system?

• loss of muscle mass

• fat loss (emancipation)

• osteoporosis

What does starvation do to someone’s metabolic system?

• Hypothyroidism

• Hypoglycemia 

• Decreased insulin sensitivity 

What symptoms arise d/t hypothyroidism d/t metabolic dysfunction from ED starvation?

• Lack of energy 

• Weakness

• Intolerance to cold 

• Bradycardia

What does starvation do to someone’s gastrointestinal system?

• Delayed gastric emptying 

• Bloating

• Constipation 

• Abdominal pain

• Gas

• Diarrhea

What does starvation do to someone’s reproductive system?

• Amenorrhea (no period) 

• Irregular periods

• Low levels of luteinizing hormone and follicle-stimulating hormon 

What does starvation do to someone’s dermatologic system?

• Dry and cracking skin d/t dehydration

• Brittle nails d/t dehydration 

• Lanugo (fine, baby-like hair over the body)

• Edema

• Acrocyanosis (bluish hands and feet)

• Thinning hair

What does starvation do to someone’s hematologic system?

• Leukopenia

• Anemia

• Thrombocytopenia 

• Hypocholesterolemia

• Hypercarotenemia

What does starvation do to someone’s neuropsychiatric system?

• Abnormal taste sensation (possible zinc deficiency)

• Apathetic depression

• Mild organic mental symptoms

• Sleep disturbances

• Fatigue

What does purging do to someone’s metabolic system?

Electrolyte imbalances:

• Hypokalemia

• Hypochloremic alkalosis 

• Hypomagnesemia 

• Increased blood urea nitrogen 

What does purging do to someone’s gastrointestinal system?

• Salivary gland And pancreatic inflammation and enlargement with increase in serum amylase 

• Esophageal and gastric erosion (esophagitis) rupture 

• Dysfunctional bowel with dilation 

• Superior mesenteric artery syndrome

What does purging do to someone’s dental system?

Erosion of dental enamel (perimylolysis), especially front teeth 

What does purging do to someone’s neuropsychiatric system?

• Seizures

• Mild neuropathies 

• Fatigue

• Weakness

• Mild organic mental symptoms 

look at bigger chart on ppt

Purpose of running a CBC for people with EDs

useful to determine if there is an infection, trauma to issues, anemia, fluid loss/dehydration, malnutrition, or vitamin B deficiency

Purpose of running a iron test for people with EDs

• Low iron can indicate malnutrition or iron deficiency anemia

• Iron supplements can cause constipation 

Purpose of running a CMP (comprehensive metabolic panel) for people with EDs

• Determines if malnutrition, dehydration, over hydration, kidney or liver problems or diabetes could be present

• Electrolyte imbalances should be monitored

Purpose of running a liver panel for people with EDs

• Elevated liver enzymes are a marker of liver damage/inflammation due to low body weight and malnutrition or obesity

• Sometimes liver enzymes are elevated during refeeding

Purpose of running a thyroid panel for people with EDs

alterations seen in malnutrition and obesity

Purpose of running a amylase/lipase for people with EDs

elevations may indicate purging

Purpose of running a Creatine Kinase (CK) for people with EDs

• May be low or high in individuals with EDs

• Elevations may indicate excessive exercise, muscle and tissue breakdown, and rhabdomyosis

Purpose of running a vitamin D for people with EDs

• May be low in people who are malnourished (vitamin D is in the stomach)

• Vitamin D is necessary for calcium reabsorption 

Purpose of running B vitamin levels for people with EDs

• May be long in people who are malnourished 

• Some “energy” supplements and teas contain mega doses of B vitamins 

What medications are approved for Anorexia treatment?

No FDA approved medications

Olanzapine (Zyprexa)

Off-label medication for anorexia to promote weight gain and decrease ruminative thoughts

Fluoxetine (Prozac)

FDA approved treatment to help reduce binge-eating episodes by treating anxiety/depression

Ondansetron (Zofran) and Topiramate (Topamax)

Off-label treatment for bulimia to reduce binge-eating episodes

What medications are prescribed to help binge-eating disorder?

• Lisdexamfetamine dimesylate (Vyvanse) (FDA approved)

• Antidepressants 

• Topiramate (Topamax)

What drug is contraindicated in anorexia and bulimia? Why?

• Bupropion (Wellbutrin)

• Bupropion increases norepinephrine, so it has stimulant properties that will decrease appetite

What are medications often meant to treat and/or manage?

• Treat psychiatric/medical comorbidities

• Manage symptoms (e.g., GI distress/pain)

Non-pharmacological treatment options for EDs

• CBT

• Dialectical Behavioral Therapy 

• Family Therapy

• Interpersonal Therapy

• Nutritional Therapy/Meal planning 

• Group Therapies for Individuals or Families 

• Mindfulness

CBT-E (Enhanced Cognitive Behavioral Therapy)

Short-term therapy targeting distorted beliefs about weight, shape, and appearance; changes thought patterns that maintain eating disorder behaviors

DBT (Dialectical Behavioral Therapy)

Behavior-focused therapy that builds mindfulness, emotion regulation, distress tolerance, and healthy coping to replace disordered eating habits

Family Therapy

Involves family during or after hospitalization to improve communication, understanding, and support for recovery

Interpersonal Therapy

Addresses relationship issues, role transitions, and social stressors that contribute to the eating disorder

Medical criteria for hospitalization of patients with EDs

• Acute weight loss, <85% below ideal

• Heart rate near 40 beats/min

• Temperature, <36.1°C

• Blood pressure, <80/50 mm Hg

• Hypokalemia

• Hypomagnesemia

• Poor motivation to recover

Psychiatric criteria for hospitalization of patients with EDs

• Risk for suicide 

• Severe depression 

• Failure to comply with treatment 

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

Anorexia inpatient interventions

• Establishing mental health and wellness goals

• Physical care

• Safety

Anorexia physical inpatient interventions 

• Nutritional rehabilitation 

• Promotion of sleep 

• Medications

• Management of complications (e.g., administering electrolytes)

• Therapeutic interactions

• Enhancing cognitive functioning

• Psychoeducation (patient and family)

• Promote safety