Eating Disorders

EATING DISORDERS

Chapter Overview

  • Key Types of Eating Disorders:
    • Anorexia Nervosa (AN)
    • Bulimia Nervosa (BN)
    • Binge Eating Disorder (BED)
    • Avoidant Restrictive Food Intake Disorder (ARFID)

Objectives

By the end of this course, students will:

  • Differentiate the signs and symptoms of:
    • Anorexia Nervosa
    • Bulimia Nervosa
    • Binge Eating Disorder
    • ARFID
  • Apply the nursing process for care plans for clients with eating disorders.
  • Identify cognitive distortions prevalent in eating disorders.
  • Evaluate personal feelings and attitudes toward clients with eating disorders.

Key Terms

  • Anorexia Nervosa: A psychological eating disorder characterized by severe restriction of food intake leading to significant weight loss.
  • Bulimia Nervosa: A psychological eating disorder characterized by recurrent episodes of binge eating followed by compensatory behaviors.
  • Binge Eating Disorder: An eating disorder characterized by regular episodes of binge eating without subsequent purging.
  • Avoidant Restrictive Food Intake Disorder (ARFID): An eating disorder characterized by limited food intake and avoidance of certain foods due to sensory sensitivities or past negative experiences.
  • Body Image: The subjective picture of one's own body.
  • Cachectic: Characterized by weight loss and muscle wasting, often due to severe chronic illness.
  • Purging: Engaging in behaviors to eliminate food from the body, commonly seen in bulimia nervosa.
  • Lanugo: Fine, soft hair that can develop on the body due to malnutrition, often seen in anorexia nervosa.
  • Refeeding Syndrome: A potentially fatal condition involving metabolic disturbances that can occur during refeeding patients who are malnourished.

Overview of Eating Disorders (EDs)

  • EDs are characterized by abnormal eating behaviors and can have significant physical and psychological impacts.
  • Common in adolescents and young adults but can affect individuals of any age.
  • Not all individuals with EDs are underweight; thorough assessments are necessary to identify those affected.

Pathophysiology of Eating Disorders

  1. Psychological Factors:

    • Body Dysmorphia: A distorted view of one's body appearance.
    • Traits: Perfectionism, self-criticism, and control issues.
    • Low self-esteem and negative body image.
    • Emotional dysregulation, often coupled with:
      • Anxiety
      • Depression
      • Obsessive-Compulsive Disorder (OCD) tendencies.

  2. Biological Factors:

    • Neurobiology: Brain structure and neurotransmitter function.
    • Genetics: Family history and genetic predisposition to EDs.

Diagnostic Criteria: Anorexia Nervosa

  • Onset: Typically begins in early adolescence; chronic condition with relapses possible.
  • Criteria:
    • Restriction of calorie intake leading to severe weight loss (less than 85% of normal; BMI < 17.5).
    • Intense fear of gaining weight or becoming fat.
    • Distorted body image affecting perception of body weight or shape.
    • Evaluates self-worth based on weight.
    • Absence of menstruation (amenorrhea) for females.
  • Subtypes:
    • Restricting Type
    • Binge-Eating/Purging Type

Assessment for Anorexia Nervosa

  • General Appearance:

    • Severe Weight Loss (Marked emaciation, BMI < 17.5)
    • Fatigue: Symptoms include low energy, weakness, and lethargy.
    • Cold Intolerance: Low body temperature, typically around 96°F.

  • Skin Changes:

    • Dry Skin: Dehydration and malnutrition effects.
    • Lanugo: Soft hair growth due to the body attempting to conserve warmth.
    • Bruising: Due to fragile skin and vitamin K deficiency.

  • Cardiovascular Symptoms:

    • Bradycardia: Heart rate often < 60 bpm due to malnutrition.
    • Hypotension: Low blood pressure from dehydration.
    • Arrhythmias: Irregular heart rhythms due to electrolyte imbalances.
    • Potential for cardiomyopathy and sudden death.

  • Gastrointestinal Symptoms:

    • Constipation due to slowed gastrointestinal motility.
    • Abdominal bloating from inadequate nutrition and laxative abuse.

  • Musculoskeletal Symptoms:

    • Osteopenia or osteoporosis due to calcium deficiency.
    • Muscle weakness and cachexia.

  • Endocrine Symptoms:

    • Amenorrhea due to hormonal changes from low body fat.
    • Hypoglycemia (low blood sugar): Can cause dizziness and shaking.

  • Neurological Symptoms:

    • Cognitive impairment: Difficulty concentrating and memory issues.
    • Dizziness or fainting due to electrolyte imbalances.

Mortality in Anorexia Nervosa

  • Mortality Rate:
    • High mortality rate, ranging from 5-10% annually in severe cases.
    • Lifetime mortality estimates around 18%.
  • Causes of Mortality:
    • Medical Complications:
    • Cardiovascular issues: Bradycardia, hypotension leading to heart failure.
    • Electrolyte imbalances (e.g., hypokalemia leading to cardiac arrest).
    • Organ failure due to malnutrition.
    • Osteoporosis leading to fractures and complications.
    • Suicide: A significant cause of death in this population.
    • Starvation: Impacts on immune function and multi-organ failure.

Nursing Interventions for Anorexia Nervosa

  • Inpatient Care: For severe cases requiring stabilization of health conditions like:

    • Dehydration
    • Electrolyte imbalances
    • Cardiac abnormalities

  • Monitoring:

    • Regular vital signs, weight, and laboratory results including EKG and electrolyte levels (e.g., K+, Na+, Mg).
    • Regular weight tracking and blind weights to assess for signs of malnutrition.

  • Meal Monitoring:

    • Observe patient behavior during meals (e.g., food hiding methods).
    • Restrictions on bathroom use post-meals to prevent purging behavior.

  • Activity Restrictions:

    • Limiting physical activity to 15 minutes per day as needed.

  • Nutritional Support:

    • Gradual meal planning for weight restoration under medical supervision.
    • Monitor for refeeding syndrome.

  • Medications:

    • Use of Olanzapine and SSRIs for accompanying anxiety, OCD, or depression.

  • Psychological Support:

    • Assessment for suicidal ideation (SI).
    • Establish trust and a non-judgmental relationship with patients.
    • Offer supportive counseling and cognitive behavioral therapy (CBT).

  • Family Involvement: Educate family members to support patient involvement in therapy.

  • Referrals: To specialists like nutritionists and therapists focusing on eating disorders.

Refeeding Syndrome

  • Definition: A potentially fatal condition caused by the metabolic shifts when reintroducing food after prolonged fasting and the body’s inability to cope with sudden requirements of electrolytes.
  • Mechanism:
    • Prolonged fasting depletes intracellular minerals.
    • Introduction of food leads to increased protein and fat synthesis, raising metabolic demands.
  • Symptoms Include:
    • Weakness
    • Shortness of breath (SOB)
    • Seizures
    • Mental confusion
    • Cardiac arrest and failure
    • Coma and potentially death.

Nutritional and Diagnosis Concerns During Refeeding Syndrome

  • Common Electrolyte imbalances:
    • Hypophosphatemia
    • Hypomagnesemia
    • Hypokalemia
    • Thiamine deficiency
  • Additionally leads to issues like:
    • Salt and water retention and hypoglycemia.
    • Increased catabolism and decreased insulin levels during refeeding could further complicate the restoration of nutrition.

Wernicke’s Encephalopathy

  • Definition: A neurological disorder resulting from thiamine (Vitamin B1) deficiency, particularly prevalent with severe malnutrition seen in anorexia nervosa.
  • Mechanism:
    • Impaired absorption due to nutritional deficiencies and gastric dysfunction leads to increasing thiamine demand under starvation conditions.
  • Symptoms Include:
    • Confusion
    • Ataxia (lack of voluntary coordination)
    • Ophthalmoplegia (eye movement issues)

Case Studies

  • Case Study 1: Emma (19-year-old female)

    • Characteristics:
    • Underweight (BMI 15.8)
    • Restriction of food intake focusing only on “clean” foods.
    • Excessive exercise and anxiety around missing workouts.
    • Distorted body image, perceiving herself as overweight despite being underweight.
    • Key Symptoms of Anorexia Nervosa:
    • A. Excessive preoccupation with food and weight.
    • C. Severe restriction of food and intense fear of weight gain.
    • E. Intense fear of being overweight, despite being underweight.
    • G. Distorted body image, believing she is overweight.

  • Case Study 2: Bulimia Nervosa (Olivia, 24-year-old female)

    • Characteristics:
    • Binge eating episodes, feeling out of control followed by compensatory behaviors of vomiting and laxative use.
    • Fluctuating weight and feelings of shame and guilt after episodes.
    • Key Symptoms:
    • A. Recurrent binge eating followed by compensatory behaviors.
    • C. Intense fear of gaining weight.
    • G. Fluctuating weight and feelings of guilt.

  • Case Study 3: Binge Eating Disorder (Sarah, 25-year-old female)

    • Symptoms:
    • Recurrent binge eating without compensatory behaviors.
    • Eating large amounts of food even when not hungry while feeling guilt.
    • Key Symptoms:
    • A. Recurrent binge episodes.
    • C. Lack of control during episodes.
    • E. Feelings of guilt after binges.
    • G. Eating in secret to avoid detection.

ARFID (Avoidant/Restrictive Food Intake Disorder)

  • Definition: Characterized by a persistent lack of interest in food and significant food avoidance unrelated to fear of weight gain.
  • Key Features:
    • Significant food restrictions, often due to sensory sensitivities.
    • Limited food variety, sometimes related to traumatic past experiences with eating.
    • Nutritional deficiencies leading to malnutrition and failure to thrive, particularly in children.
    • No concern for body weight or image, unlike other EDs.
    • Social implications: Eating avoidance in social situations, leading to isolation.

Causes of ARFID

  • Sensory Sensitivities: Hyper-sensitivity to smell, taste, or texture.
  • Negative Past Experiences: Past trauma related to eating.
  • Developmental Disorders: More common in individuals with autism.
  • Psychological Factors: Anxiety and other emotional issues leading to food avoidance.

Treatment for ARFID

  • Nutritional Support: Collaboration with dietitians to develop healthy eating plans.
  • Cognitive Behavioral Therapy (CBT): Addressing anxiety and disordered eating habits.
  • Exposure Therapy: Gradually introducing new foods.
  • Family-Based Therapy: Engagement with family, particularly in children, to support healthy eating habits.
  • Medical Intervention: Monitoring and restoring nutritional status where severe.

Cognitive Distortions in Eating Disorders

  1. Overgeneralization: Making broad conclusions based on limited incidents.
    • Example: “I was happy at size 4. I must get back to that weight.”
  2. All-or-Nothing Thinking: Viewing situations in extreme without middle ground.
    • Example: “If I eat one cookie, I’ve ruined my diet.”
  3. Catastrophizing: Expecting the worst outcome.
    • Example: “If I gain weight, my whole weekend will be ruined.”
  4. Personalization: Blaming oneself for external events.
    • Example: “If I don’t lose weight, my friends will see me as lazy.”
  5. Emotional Reasoning: Allowing feelings to dictate reality.
    • Example: “I feel guilty after eating; therefore, it must have been bad.”

Interventions to Address Cognitive Distortions

  • Cognitive Behavioral Therapy (CBT): Teaching skills for coping, problem-solving, and decision-making to improve self-perception and reduce disordered thinking.

Nursing Problem List for Care Plans

  • Disturbed body image (Goal: Improve self-acceptance)
  • Imbalanced nutrition (Goal: Eat >/= 75% of meals, gain weight)
  • Anxiety related to feeling of loss of control
  • Ineffective coping mechanisms (Identify triggers)
  • Hemodynamic alterations due to fluid shifts
  • Cardiac output concerns
  • Electrolyte imbalances due to nutritional deficiencies.

Patient History and Review of Systems (HPI)

  • Case Study 2: Jessica (22-year-old female)
    • Exhibits binge eating and purging behavior, significant weight fluctuation, distorted body image closely tied to self-worth.
  • Physical symptoms:
    • Frequent headaches and gastrointestinal issues post-binge episodes.
    • Complaints of irregular menstrual cycles and fluctuations in mood related to eating habits.
    • No major life stressors but chronic work stress impacting self-perception and inviting isolative behaviors around food.

Prioritization in Care Management

  • Ensuring patient safety through stabilization of physical health.
  • Establishing a therapeutic relationship to build trust.
  • Developing effective communication and support strategies for recovery.

These notes provide thorough details regarding various aspects of eating disorders, including definitions, diagnostic criteria, assessment methods, treatment options, cognitive distortions, and real-case examples to illustrate the concepts, fulfilling the requirement for an exhaustive and organized study guide for university-level education.