Chapter 18: Eating Disorders: Anorexia Nervosa and Bulimia Nervosa Copyright © 2012, 2007 Mosby,...

Chapter 18:Chapter 18:

Eating Disorders: Anorexia Eating Disorders: Anorexia Nervosa and Bulimia Nervosa and Bulimia

NervosaNervosa

Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

22Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

EtiologyEtiology

Biologic FactorsBiologic Factors GeneticGenetic Serotonin abnormalitySerotonin abnormality

Sociocultural FactorsSociocultural Factors Diet and fitness industryDiet and fitness industry Fashion industryFashion industry Women’s movementWomen’s movement Peer pressurePeer pressure


Etiology, cont’d. Etiology, cont’d.

Psychologic FactorsPsychologic Factors PerfectionismPerfectionism Social insecuritySocial insecurity Affective insecurityAffective insecurity Interoceptive deficitsInteroceptive deficits AlexithymiaAlexithymia Low self-esteemLow self-esteem

ImmaturityImmaturity ComplianceCompliance Sense of Sense of

ineffectivenessineffectiveness Interpersonal Interpersonal

distrustdistrust


Etiology, cont’d. Etiology, cont’d.

Familial FactorsFamilial Factors EnmeshmentEnmeshment Poor conflict resolutionPoor conflict resolution Separation, individuationSeparation, individuation


Figure 18-1 The cycle of eating disorders. Figure 18-1 The cycle of eating disorders.


EpidemiologyEpidemiology

Sex ratioSex ratio Age of onsetAge of onset Cross-culturalCross-cultural MortalityMortality ComorbidityComorbidity


Behavioral Symptoms Behavioral Symptoms of Anorexia Nervosaof Anorexia Nervosa

Self-starvationSelf-starvation Compulsive behaviors regarding foodCompulsive behaviors regarding food May use laxatives or diuretics, excessive May use laxatives or diuretics, excessive

exercise, and vomitingexercise, and vomiting Wearing baggy clothesWearing baggy clothes


Physical Symptoms Physical Symptoms of Anorexia Nervosa of Anorexia Nervosa

Weight loss 15% below idealWeight loss 15% below ideal AmenorrheaAmenorrhea Bradycardia, subnormal body temperatureBradycardia, subnormal body temperature Cachexia, sunken eyes, dry skinCachexia, sunken eyes, dry skin Lanugo on faceLanugo on face ConstipationConstipation Cold sensitivityCold sensitivity


Psychologic Symptoms Psychologic Symptoms of Anorexia Nervosaof Anorexia Nervosa

Denial of seriousness of low weightDenial of seriousness of low weight Body image disturbanceBody image disturbance Irrational fear of weight gainIrrational fear of weight gain Constant striving for perfect bodyConstant striving for perfect body Self-concept unduly influenced by shape and Self-concept unduly influenced by shape and

weightweight Preoccupation with food, cookingPreoccupation with food, cooking Delayed psychosexual development (little interest Delayed psychosexual development (little interest

in sex, relationships) in sex, relationships)


Behavioral Symptoms Behavioral Symptoms of Bulimia Nervosaof Bulimia Nervosa

Recurrent episode of binge eatingRecurrent episode of binge eating Purging behavior to compensate Purging behavior to compensate

Self-induced vomiting, use of laxatives, diuretics, Self-induced vomiting, use of laxatives, diuretics, enemas, fasting, excessive exerciseenemas, fasting, excessive exercise


Physical Symptoms Physical Symptoms of Bulimia Nervosaof Bulimia Nervosa

Fluid and electrolyte imbalancesFluid and electrolyte imbalances Hypokalemia, alkalosis, dehydration, idiopathic edemaHypokalemia, alkalosis, dehydration, idiopathic edema

CardiovascularCardiovascular Hypotension, dysrhythmias, cardiomyopathyHypotension, dysrhythmias, cardiomyopathy

EndocrineEndocrine Hypoglycemia, menstrual dysfunctionHypoglycemia, menstrual dysfunction

GastrointestinalGastrointestinal Constipation, diarrhea, gastroparesis, esophageal Constipation, diarrhea, gastroparesis, esophageal

reflux, esophagitis, esophageal tears, dental enamel reflux, esophagitis, esophageal tears, dental enamel erosion, parotid gland enlargementerosion, parotid gland enlargement


Psychologic Symptoms Psychologic Symptoms of Bulimia Nervosaof Bulimia Nervosa

Body image disturbanceBody image disturbance Persistent over concern with weight, shape, Persistent over concern with weight, shape,

proportionsproportions Mood swings, irritabilityMood swings, irritability Self-concept unduly influenced by weightSelf-concept unduly influenced by weight


Discharge CriteriaDischarge Criteria

Be free from self-harm.Be free from self-harm. Achieve minimum normal weight.Achieve minimum normal weight. Consume adequate calories to maintain Consume adequate calories to maintain

normal weight.normal weight. Demonstrate ability to comply with Demonstrate ability to comply with

postdischarge regimen.postdischarge regimen. Verbalize understanding of underlying Verbalize understanding of underlying

psychologic issues.psychologic issues.


Discharge Criteria, cont’d.Discharge Criteria, cont’d.

Use improved coping strategies. Use improved coping strategies. Exhibit more functional behaviors within Exhibit more functional behaviors within

family system.family system. Attend group therapy.Attend group therapy. Interact with helpful peers.Interact with helpful peers. Keep appointments to monitor behaviors and Keep appointments to monitor behaviors and

medications.medications.


AssessmentAssessment

Therapeutic alliance is vital. Therapeutic alliance is vital.

Assess:Assess: Willingness for treatmentWillingness for treatment Treatment historyTreatment history Patterns and perceptions regarding weightPatterns and perceptions regarding weight Body dissatisfactionBody dissatisfaction Body image distortionBody image distortion


Assessment, cont’d.Assessment, cont’d.

Assess:Assess: Dieting historyDieting history Binge eatingBinge eating Feelings regarding binge behaviorsFeelings regarding binge behaviors Food cravingsFood cravings Purging behaviorsPurging behaviors Menstrual historyMenstrual history Medical side effects of eating disorderMedical side effects of eating disorder Comorbidity factorsComorbidity factors


Nursing DiagnosesNursing Diagnoses

Anorexia NervosaAnorexia Nervosa AnxietyAnxiety Disturbed body imageDisturbed body image Nutrition imbalance: less than body requirementsNutrition imbalance: less than body requirements Social isolationSocial isolation

Bulimia NervosaBulimia Nervosa Ineffective copingIneffective coping Deficient fluid volumeDeficient fluid volume Chronic low self-esteemChronic low self-esteem


Outcome IdentificationOutcome Identification

Participate in therapeutic contact with staff. Participate in therapeutic contact with staff. Consume adequate calories for age, height, and Consume adequate calories for age, height, and

metabolic need.metabolic need. Maintain fluid and electrolyte balance.Maintain fluid and electrolyte balance. Demonstrate more effective coping strategies.Demonstrate more effective coping strategies. Manage family dysfunction more effectively.Manage family dysfunction more effectively. Verbalize awareness of underlying psychologic Verbalize awareness of underlying psychologic

issues.issues. Perceive normal body weight and shape as Perceive normal body weight and shape as

acceptable.acceptable.


PlanningPlanning

Avoid power strugglesAvoid power struggles Need consistent, collaborative efforts by Need consistent, collaborative efforts by

client, family, interdisciplinary staffclient, family, interdisciplinary staff


ImplementationImplementation

Ensure safe, nonthreatening environmentEnsure safe, nonthreatening environment Prevent self-harmPrevent self-harm Therapeutic allianceTherapeutic alliance Behavioral program to restore weight, nutritionBehavioral program to restore weight, nutrition Structured environment with clear limitsStructured environment with clear limits Behavioral plan to reward complianceBehavioral plan to reward compliance Encourage expression of feelingsEncourage expression of feelings


Nursing InterventionsNursing Interventions

Help increase client understanding of body Help increase client understanding of body image distortion.image distortion.

Emphasize client capability to eat small Emphasize client capability to eat small portions without binging.portions without binging.

Maintain clear boundaries.Maintain clear boundaries. Avoid power struggles.Avoid power struggles. Intervene in anxiety.Intervene in anxiety.


Nursing Interventions, cont’d.Nursing Interventions, cont’d.

Give positive feedback for adherence to plan.Give positive feedback for adherence to plan. Engage in group therapy.Engage in group therapy. Assist to identify issues (e.g., esteem, identity Assist to identify issues (e.g., esteem, identity

disturbance).disturbance). Teach adaptive strategies.Teach adaptive strategies. Collaborate with dietician to teach nutrition.Collaborate with dietician to teach nutrition. Collaborate with interdisciplinary staff.Collaborate with interdisciplinary staff.


Biologic and Pharmacologic Biologic and Pharmacologic Treatment ModalitiesTreatment Modalities

BiologicBiologic Medical monitoring/hospitalizationMedical monitoring/hospitalization Correcting deficiencies/imbalancesCorrecting deficiencies/imbalances

PharmacologicPharmacologic SSRIsSSRIs Specific drugs for medical side effects of Specific drugs for medical side effects of

the disordersthe disorders


Psychotherapeutic Psychotherapeutic Treatment ModalitiesTreatment Modalities

Individual psychotherapyIndividual psychotherapy BehavioralBehavioral

ContractsContracts Exposure and response preventionExposure and response prevention

CognitiveCognitive ReframingReframing Cognitive restructuringCognitive restructuring


Psychotherapeutic Psychotherapeutic Treatment Modalities, cont’d.Treatment Modalities, cont’d.

Family therapyFamily therapy Decrease secondary gainDecrease secondary gain Uncover family dysfunctionUncover family dysfunction

Group therapyGroup therapy Safe disclosureSafe disclosure Minimize manipulation and secondary gainMinimize manipulation and secondary gain

Expressive therapies Expressive therapies


Adjunctive TherapyAdjunctive Therapy

Occupational therapyOccupational therapy Nutrition education and counselingNutrition education and counseling Interdisciplinary treatment teamInterdisciplinary treatment team Community support groupsCommunity support groups

Chapter 18: Eating Disorders: Anorexia Nervosa and Bulimia Nervosa Copyright © 2012, 2007 Mosby,...

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