Chapter 21

Eating Disorders

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 Introduction
 The hypothalamus contains the appetite
regulation center within the brain.
 It regulates the body’s ability to recognize
when it is hungry, when it is not hungry, and
when it has been sated.

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 Introduction (continued)
 Eating behaviors are
influenced by
• Society
• Culture
 Historically, society and
culture also have
influenced what is
considered desirable in
the female body.

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 Epidemiological Factors
 Lifetime prevalence for an episode of
anorexia nervosa is 2.4% to 4.3%.
 Men account for 25% of those with anorexia
and bulimia and 36% of those with binge
eating disorders.

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 Epidemiological Factors (continued_1)
 Bulimia nervosa is decreasing in recent
years, with a lifetime prevalence of 2%
among women.
 The onset of bulimia nervosa occurs in late
adolescence or early adulthood.
 It occurs primarily in societies that
emphasize thinness.

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 Epidemiological Factors (continued_2)
 Binge eating disorder consists of recurrent
episodes of eating significantly more than
most people would in a similar period of
time under similar circumstances.
 Obesity has been defined as a body mass
index (B M I) of 30 or greater.
 68.5% of adult Americans are overweight,
and 35% of these are in the obese range.

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 Anorexia Nervosa
 Characterized by a morbid fear of obesity
 Symptoms include gross distortion of body
image, preoccupation with food, and refusal
to eat.

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 Anorexia Nervosa (continued_1)
 Weight loss is extreme, usually more than
15% of expected weight.
 Other symptoms include hypothermia,
bradycardia, hypotension, edema, lanugo,
and a variety of metabolic changes.

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 Anorexia Nervosa (continued_2)
 Amenorrhea is typical and may even
precede significant weight loss.
 There may be an obsession with food.
 Feelings of anxiety and depression are
common.

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 Bulimia Nervosa
 Bulimia nervosa is an episodic, uncontrolled,
compulsive, rapid ingestion of large
quantities of food over a short period
(bingeing).
 The 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).

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 Bulimia Nervosa (continued_1)
 Fasting or excessive exercise may also occur.
 Most patients with bulimia are within a
normal weight range; some are slightly
underweight, and some are slightly
overweight.
 Depression, anxiety, and substance abuse
are not uncommon.

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 Bulimia Nervosa (continued_2)
 Excessive vomiting and laxative or diuretic
abuse may lead to problems with
dehydration and electrolyte imbalances.

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 Binge Eating Disorder
 The D S M-5 identifies binge eating disorder
(B E D) as an eating disorder that can lead to
obesity.
• The individual binges on large amounts of food,
as in bulimia nervosa.
• B E D differs from bulimia nervosa in that the
individual does not engage in behaviors to rid the
body of the excess calories.

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 Predisposing Factors
 Biological influences
• Genetics: 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.

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 Predisposing Factors (continued_1)
 Biological influences (continued)
• Neuroendocrine abnormalities
‒ There has been some speculation about a primary
hypothalamic dysfunction in anorexia nervosa.
• Neurochemical influences
‒ Bulimia nervosa may be associated with the
neurotransmitters serotonin and norepinephrine.
‒ Anorexia nervosa may be associated with high levels
of endogenous opioids.

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 Predisposing Factors (continued_2)
 Psychodynamic influences
• Suggests that eating disorders result from very
early and profound disturbances in mother–infant
interactions, resulting in:
‒ Delayed ego development
‒ Unfulfilled sense of separation-individuation

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 Predisposing Factors (continued_3)
 Family influences
• Historically, family influences were heavily
considered as factors, but there is not sufficient
evidence to support these claims.
• Family members should be involved in treatment
rather than blamed for the issue.

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 Body Mass Index (B M I)

 A B M I range for normal weight is 20 to

24.9.
 Obesity is defined as a B M I of 30 or greater.
 Anorexia nervosa is characterized by a B M I
of 17 or lower, or less than 15 in extreme
cases.

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 Nursing Diagnoses
 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, and laxative and/or
diuretic abuse

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 Nursing Diagnoses (continued_1)
 Ineffective denial related to delayed 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

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 Nursing Diagnoses (continued_2)
 Disturbed body image / low self-esteem
related to 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

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 Outcomes: The Patient
 Has achieved and maintained at least 80% of
expected body weight
 Has vital signs, blood pressure, and
laboratory serum studies within normal
limits
 Verbalizes importance of adequate nutrition

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 Outcomes: The Patient (continued_1)
 Verbalizes knowledge regarding
consequences of fluid loss caused by self-
induced vomiting (or laxative/diuretic abuse)
and importance of adequate fluid intake
 Verbalizes events that precipitate anxiety
and demonstrates techniques for its
reduction

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 Outcomes: The Patient (continued_2)
 Verbalizes ways in which he or she may gain
more control of the environment and
thereby reduce feelings of powerlessness
 Expresses interest in welfare of others and
less preoccupation with own appearance

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 Outcomes: The Patient (continued_3)
 Verbalizes that image of body as “fat” was
misperception and demonstrates ability to
take control of own life without resorting
to maladaptive eating behaviors
(anorexia nervosa)
 Has established a healthy pattern of eating
for weight control and weight loss toward a
desired goal, and is progressing (B E D)
 Verbalizes plans for future maintenance of
weight control (B E D)
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 Planning and Implementation
 Hospitalization may be necessary in cases of:
• Malnutrition
• Dehydration
• Severe electrolyte imbalance
• Cardiac arrhythmia or severe bradycardia
• Hypothermia
• Hypotension
• Suicidal ideation

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 Planning and Implementation
(continued_1)
 Imbalanced nutrition / deficient fluid volume
• Determine appropriate calories to provide
adequate nutrition and weight gain.
• Do not focus on food and eating specifically.
• Keep a strict record of intake and output.

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 Planning and Implementation
(continued_2)
 Denial
• Establish trusting relationship.
• Avoid arguing or bargaining with the client.
 Obesity
• Encourage diary of food intake.
• Provide instruction about medications.

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 Planning and Implementation
(continued_3)
 Disturbed body image / low self-esteem
• For client with anorexia nervosa or bulimia
‒ Promote feelings of control.
‒ Help client realize perfection is unrealistic.
• For client with B E D
‒ Help identify positive attributes.
‒ Refer client to a support or therapy group.

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 Client/Family Education
 Nature of the illness
• Symptoms of anorexia nervosa and bulimia
nervosa
• What constitutes obesity?
• Causes of eating disorders
• Effects of the illness or condition on the body

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 Client/Family Education (continued_1)
 Management of the illness
• Principles of nutrition
• Ways client may feel in control of life
• Importance of expressing fears and feelings,
rather than holding them inside
• Alternative coping strategies

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 Client/Family Education (continued_2)
 Management of the illness (continued)
• Correct administration of prescribed medications
• Indication for, and side effects of, prescribed
medications
• Relaxation techniques
• Problem-solving skills

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 Client/Family Education (continued_3)
 For the obese client
• How to
‒ Plan a reduced-calorie, nutritious diet
‒ Read food content labels
‒ Establish a realistic weight loss plan
‒ Establish a planned program of physical activity

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 Client/Family Education (continued_4)
 Support services
• Weight Watchers International
• Overeaters Anonymous
• National Association of Anorexia Nervosa and
Associated Disorders
• National Eating Disorders Association

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 Evaluation
 Evaluation of the client with an eating
disorder requires reassessment of the
behaviors for which the client sought
treatment.
 Behavioral change will be required by the
client and family members.

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 Treatment Modalities: Behavior
Modification
 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.

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 Treatment Modalities: Behavior
Modification (continued_1)
 Successes have been 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

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 Treatment Modalities: Behavior
Modification (continued_2)
 The client has control over
• Eating
• Amount of exercise pursued
• Whether to induce vomiting
 Staff and client agree about
• Goals
• System of rewards

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 Treatment Modalities: Individual Therapy
 Helpful when underlying psychological
problems are contributing to the
maladaptive behaviors

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 Treatment Modalities: 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

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 Treatment Modalities: Psychopharmacology
 No medications are specifically indicated for
eating disorders.
 Various medications have been prescribed
for associated symptoms.
• Anxiety
• Depression

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 Treatment Modalities:
Psychopharmacology (continued_1)
 Medications that have been tried with some
success for anorexia nervosa include:
• Fluoxetine (Prozac)
• Clomipramine (Anafranil)
• Cyproheptadine (Pariactin)
• Chlorpromazine (Thorazine)
• Olanzapine (Zyprexa)

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 Treatment Modalities:
Psychopharmacology (continued_2)
 Medications that have been tried with some
success for bulimia nervosa include:
• Fluoxetine (Prozac)
• Imipramine (Tofranil)
• Desipramine (Norpramine)
• Amitriptyline (Elavil)
• Nortriptyline (Aventyl)
• Phenelzine (Nardil)

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 Treatment Modalities:
Psychopharmacology (continued_3)
 Medications that have been tried with some
success for B E D with obesity include:
• Topiramate (Topamax)
• Lisdexamfetamine (Vyvanse)

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