Eating Disorders NURS2221 – Complex Mental Health and Recovery

Introduction and Objectives

• Course: NURS2221
  – Complex Mental Health and Recovery

• Lecturer: Julie Waddingham

• Core Objectives:- To develop a comprehensive understanding of various eating disorders.

  • To explore and discuss treatment strategies for individuals affected by eating disorders.

  • To identify and analyze the potential complications associated with eating disorders.

Pathophysiology of Eating Disorders

• The underlying pathophysiology of eating disorders is not yet fully understood.

• Current evidence strongly suggests a multicausal pathogenesis, meaning multiple factors contribute to their development.

• Key contributing aspects include:- Environmental Factors: Societal pressures, cultural norms, family dynamics.

  • Nutritional Factors: Dietary habits, nutrient intake and deficiencies.

  • Biological Factors: Genetic predispositions, neurobiological influences, hormonal imbalances.

• It is also recognized that certain aspects of the eating disorder, such as malnutrition, can not only be a consequence but can also actively contribute to the maintenance and perpetuation of the disorder.

Diagnostic Criteria for Eating Disorders

Anorexia Nervosa

• Core Characteristic: Persistent restriction of energy intake.

• Weight Status: Leads to a significantly low body weight, defined as less than the minimal normal body weight given the individual's age, sex, developmental trajectory, and physical health.

• Psychological Features:- Intense fear of gaining weight or becoming fat.

  • Engagement in persistent behaviors designed to counteract weight gain, even when significantly underweight.

  • A profound disturbance in the way one's body weight or shape is experienced, an undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

• Subtypes:- Restrictive 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 misuse of laxatives, diuretics, or enemas). Weight loss is achieved primarily through dieting, fasting, and/or excessive exercise.

  • 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 misuse of laxatives, diuretics, or enemas).

Bulimia Nervosa

• Core behavioral Cycle: Characterized by recurrent episodes of binge eating followed by recurrent compensatory behaviors to prevent weight gain.- Binge Eating Episode: Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most individuals would eat in a similar period under similar circumstances. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

  • Compensatory Behaviors: Examples include self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.

• Self-Evaluation: Self-evaluation is unduly influenced by body shape and weight.

• Distinguishing Feature: These behaviors occur, on average, at least once a week for 3 months. Importantly, the disturbance does not occur exclusively during episodes of Anorexia Nervosa; individuals with Bulimia Nervosa are typically within or above the normal weight range.

Binge Eating Disorder

• Core Characteristic: Recurrent episodes of binge eating, similar to those seen in bulimia nervosa.

• Associated Behaviors During Binge Episodes: Binge eating episodes are associated with 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.

• Distinguishing Feature: Marked distress regarding binge eating is present. The binge eating occurs, on average, at least once a week for 3 months. Unlike Bulimia Nervosa, it does not involve regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise), and unlike Anorexia Nervosa, it is not associated with the recurrent use of inappropriate compensatory behaviors.

• Exclusion Criteria: A diagnosis of Binge Eating Disorder is excluded if associated features of Anorexia Nervosa or Bulimia Nervosa are present.

General Treatment Approaches

• Psychological Therapies: Forming the cornerstone of treatment.

• Dietary Advice: Essential for restoring healthy eating patterns and nutritional balance.

• Pharmacological Treatments: May be used to address co-occurring mental health conditions or specific symptoms.

• Holistic Consideration: A critical component of treatment is to continuously consider and address the individual's physical health alongside their mental health.

Comorbidities and Physical Health Consequences

Comorbid Mental Health Problems

• Eating disorders frequently co-occur with a range of other mental health conditions, including:- Affective Disorders: Such as Depression and Bipolar disorder.

  • Anxiety Disorders.

  • Increased Suicidality risk.

  • Sleep Disturbances.

Malnutrition

• Malnutrition can manifest as:- Overnutrition: Primarily associated with Binge Eating Disorder, leading to obesity.

  • Undernutrition: Primarily associated with Anorexia Nervosa due to severe restriction.

  • Lack of Specific Nutrients: Can result in:- Dehydration.

    • Specific Deficiencies: Including Vitamins and Minerals (e.g., Iron).

General Physical Health Consequences

• Eating disorders can lead to a wide array of physical health problems affecting multiple bodily systems, such as:- Gastrointestinal (GI) tract problems.

  • Endocrine and metabolic disorders.

  • Cardiovascular problems.

  • Osteoporosis.

  • Chronic pain.

  • Skin problems.

• Prevalence of Possible Eating Disorder by Number of Physical Conditions (Figure 1 Summary):- Data indicates a clear correlation between the number of co-occurring physical conditions and the prevalence of possible eating disorders.

  • Individuals with 0 physical conditions had a 5.8% prevalence of possible eating disorder.

  • This prevalence increased incrementally with more physical conditions, reaching 6.0% for 1 condition, 6.6% for 2 conditions, 8.1% for 3 conditions, and peaking at 8.5% for 4 physical conditions.

  • This trend highlights that as the physical health burden increases, the likelihood of an eating disorder also rises, underscoring the interconnectedness of physical and mental health.

Specific Physical Comorbidities by Disorder

Bulimia Nervosa

• Frequent issues with dental health due to repeated exposure to stomach acid from purging.

• Electrolyte abnormalities (e.g., hypokalemia, hyponatremia) stemming from fluid and electrolyte loss through purging behaviors, which can be life-threatening.

• Cardiac complications: Including arrhythmias, cardiomyopathy, and sudden cardiac arrest, often secondary to electrolyte imbalances.

• Gastrointestinal complications: Esophageal tears (Mallory-Weiss tears), gastric rupture, chronic reflux, and constipation.

Binge Eating Disorder

• Obesity: A common comorbidity, leading to its own set of health risks.

• Type 2 Diabetes: Increased risk due to obesity and often poor dietary patterns.

• Cardiovascular Disease: Higher prevalence of hypertension, dyslipidemia, and heart disease.

• Certain Cancers: Increased risk for obesity-related cancers.

Anorexia Nervosa

• Bone Health Issues: Low bone mineral density, osteopenia, and osteoporosis, leading to increased fracture risk.

• Arthritis: Can be associated with chronic malnutrition and inflammation.

• Cardiovascular abnormalities: Bradycardia, hypotension, cardiac arrhythmias, and reduction in heart muscle mass.

• Renal injury: Kidney damage due to dehydration and electrolyte imbalances.

• Hypokalemia: Dangerously low potassium levels, often exacerbated by purging behaviors if present.

• Gastrointestinal Issues: Gastroparesis (delayed stomach emptying) and generalized motility issues throughout the GI tract.

Re-Feeding Syndrome

• Definition: A potentially fatal complication that can occur in malnourished individuals when nutritional support is refed too quickly or aggressively.

• Mechanism: Increased caloric intake leads to rapid shifts in fluids and electrolytes, particularly phosphorus, potassium, and magnesium, with severe risks including death.

• Diagnostic Criteria (Proposed by ASPEN – American Society for Parenteral and Enteral Nutrition):- Electrolyte Decrease: A significant decrease in any one, two, or all three of serum phosphorus, potassium, and/or magnesium levels.- Mild RFS: A 10%-20% decrease.
  - Moderate RFS: A 20%-30% decrease.
  - Severe RFS: A >30% decrease and/or the development of organ dysfunction resulting from these electrolyte decreases and/or due to thiamine deficiency.

  • Timing: These changes must occur within 5 days of reinitiating or substantially increasing energy provision (caloric intake).

Treatment Modalities and Monitoring

Primary Treatment Components

• Psychotherapies: Essential for addressing the psychological underpinnings of the disorder.

• Medications: Used to treat co-occurring conditions or specific symptoms.

• Dietary Counselling: Provides guidance on nutritional rehabilitation and establishing healthy eating patterns.

• Coping Skills: Development of effective strategies to manage triggers, emotional distress, and maintain recovery.

• Comprehensive Monitoring: Continuous monitoring of physical health and comorbidities is crucial for safety and efficacy.

Key Physical Health Monitoring Parameters

• Weight: Regular measurements to track nutritional status and progress.

• Height: Measured at the first attendance to calculate BMI accurately.

• BMI (Body Mass Index): Calculated from height and weight to assess a person's weight in relation to their height (BMI =\frac{weight(kg)}{height(m)^2}).

• HR (Pulse Rate): To detect cardiac abnormalities like bradycardia.

• Sitting/Standing BP (Blood Pressure): To monitor for orthostatic hypotension, which can indicate dehydration or overall cardiac compromise.

• Temperature: To detect hypothermia, common in severe malnutrition.

• Blood Tests: To monitor electrolyte levels, organ function, and identify specific nutritional deficiencies.

• ECG's (Electrocardiograms): To assess cardiac function and detect arrhythmias or other heart-related complications early.

Implications for Mental Health Nursing

Experiences Perceived as Unhelpful by Consumers (Patient Perspectives)

• Negative staff attitudes: Can undermine trust and engagement in treatment.

• Being weighed: Can be highly anxiety-provoking and trigger disordered thoughts.

• Recording food intake: While medically necessary, if not handled sensitively, it can feel punitive and exacerbate focus on food.

• Lack of individualized care: Generic approaches fail to address unique needs and circumstances.

• Symptoms dismissed as unimportant: Minimizing a patient's distress or specific concerns.

• Overemphasis on weight and food: Can reinforce the patient's own preoccupation rather than broadening the focus to overall well-being.

Recommended Best Practices for Mental Health Nurses

• Multidisciplinary Approach: Collaborative care involving dietitians, physicians, psychologists, and nurses ensures comprehensive treatment.

• Clear Treatment Plan: Develop and communicate a consistent plan to provide predictability and reduce anxiety for the patient.

• Regular Weights: Conducted sensitively and consistently, with clear rationale, as part of continuous monitoring.

• Recording Food Intake: Managed as a therapeutic tool rather than a punitive measure, with patient understanding.

• Person-Centred Care: Tailoring interventions to the individual's specific needs, preferences, and goals, respecting their autonomy.

• Broader Engagement: Engage patients in diverse activities and conversations that extend beyond food and their eating disorder, promoting a sense of self beyond their illness.

• Treat/Monitor Comorbidities: Actively manage both mental and physical health comorbidities to improve overall outcomes and prevent complications. This includes vigilantly monitoring for re-feeding syndrome and addressing other medical issues.