Ch. 21 Eating Disorders

Question 1

Obesity BMI
Anorexia Nervosa BMI

Answer 1

Obesity is defined as BMI of 30 or greater
Anorexia nervosa is characterized by a BMI of 17 or lower, or less than 15 in extreme cases

Question 2

Anorexia Nervosa is…
Symptoms include…
Diagnosed at…

Answer 2

• Characterized by a morbid fear of obesity
• Symptoms include gross distortion of body image, preoccupation with food, and refusal to eat.
• 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.
• Diagnosed at early or late adolescent
• Amenorrhea is typical and may even precede significant weight loss.
  Cycle absent = 3
• There may be an obsession with food. For example, they may hoard or conceal food, talk about food and recipes at great length, or prepare elaborate meals for others,
• Compulsive behaviors, such as hand washing, may also be present.
• Feelings of anxiety and depression are common (due to low self-esteem)

Question 3

Clinical Picture of Anorexia Nervosa

Answer 3

Orthostatic changes
Bradycardia
Cardiac murmur
Sudden cardiac arrest
Prolonged QT interval
Acrocyanosis
Symptomatic hypotension
Leukopenia
Lymphocytosis
Carotenemia
Hypokalemic alkalosis
Electrolyte imbalances
Osteoporosis
Fatty degeneration of liver
Elevated cholesterol levels
Amenorrhea
Abnormal thyroid functioning
Hematuria
Proteinuria

Question 4

DSM-V of Anorexia Nervosa
Different Types

Answer 4

A. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal, or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
- Restricting Type: This subtype describes presentations in which weight loss is accomplished 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 the misuse of laxatives, diuretics, or enemas).
Specify current severity:
- Mild: BMI > 17 kg/m2
- Moderate: BMI 16–16.99 kg/m2
- Severe: BMI 15–15.99 kg/m2
- Extreme: BMI < 15 kg/m2

Question 5

Bulimia Nervosa is…
Symptoms
Diagnosed at…

Answer 5

• Diagnosed in middle to late adolescence
• Bulimia nervosa is an episodic, uncontrolled, compulsive, rapid ingestion of large quantities of food over a short period (binging).
• The food consumed during a binge often has a high caloric content, a sweet taste, and a soft or smooth texture that can be eaten rapidly
• 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).
• Most patients with bulimia are within a normal weight range; some are slightly underweight, and some are slightly overweight.

Question 6

Clinical Picture of Bulimia Nervosa

Answer 6

Cardiomyopathy (ipecac toxicity)
Cardiac dysrhythmias
Sinus bradycardia
Sudden cardiac arrest
Orthostatic changes in pulse and blood pressure
Electrolyte imbalances
Metabolic acidosis
Hypochloremia
Hypokalemia
Dehydration and renal loss of potassium as a result of self-induced vomiting
Attrition and erosion of teeth
Loss of dental arch
Diminished chewing ability
Parotid gland enlargement
Esophageal tears as a result of self-induced vomiting
Gastric dilation
Russell sign: Calloused knuckles due to putting them down throat

Question 7

DSM-V Criteria for Bulimia Nervosa
Specify severity

Answer 7

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- 1. Eating, in a discrete period of time (e.g., within any 2-hour period) an amount of food that is definitely larger than most individuals would eat during a similar period of time and under similar circumstances.
- 2. 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).
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Mild: An average of 1-3 episodes of inappropriate compensatory behaviors per week.
Moderate: An average of 4-7 episodes of inappropriate compensatory behaviors per week.
Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week.
Extreme: An average of 14 or more episodes of inappropriate compensatory behaviors per week.

Question 8

Binge Eating Disorder is…

Answer 8

• The individual binges on large amounts of food, as in bulimia nervosa.
• BED differs from bulimia nervosa in that the individual does not engage in behaviors to rid the body of the excess calories.
• The episodes of eating are referred to as binges when they occur over a discrete period, usually defined as less than 2 hours
• Food consumption is rapid and often persists to the point that the individual feels uncomfortably full.
• Interpersonal stressors, low self-esteem, and boredom are identified as possible triggers.
• Clients describe eating as out of control (an important diagnostic clinical symptom) and accompanying guilt and depression after an episode

Question 9

DSM-V Binge Eating Disorder

Answer 9

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- 1. 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 people would eat in a similar period of time under similar circumstances
- 2. 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)
B. The binge-eating episodes are associated with 3 (or more) of the following:
- 1. Eating much more rapidly than normal
- 2. Eating until feeling uncomfortably full
- 3. Eating large amounts of food when not feeling physically hungry
- 4. Eating alone because of feeling embarrassed by how much one is eating
- 5. Feeling disgusted with oneself, depressed, or very guilty after overeating
C. Marked distress regarding binge eating is present.
D. The binge eating occurs, on average, at least once a week for 3 months.
E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Question 10

Calculate BMI

Answer 10

Weight (kg) divided by Height (m)^2
Weight (lb) / [height (in)]^2 x 703

Question 11

Imbalanced nutrition: Less than body requirements (Anorexia Nervosa)
Behaviors

Answer 11

Refusal to eat
Abuse of laxatives, diuretics, and/or diet pills
Loss of 15 percent of expected body weight
Pale conjunctiva and mucous membranes
Poor muscle tone
Amenorrhea
Poor skin turgor
Electrolyte imbalances
Hypothermia
Bradycardia
Hypotension
Cardiac irregularities
Edema

Question 12

Deficient fluid volume (Anorexia Nervosa)
Behaviors

Answer 12

Decreased fluid intake
Abnormal fluid loss caused by self-induced vomiting
Excessive use of laxatives, enemas, or diuretics
Electrolyte imbalance
Decreased urine output
Increased urine concentration
Elevated hematocrit
Decreased blood pressure
Increased pulse rate
Dry skin
Decreased skin turgor
Weakness

Question 13

Denial
Behaviors

Answer 13

Minimizes symptoms
Unable to admit impact of disease on life pattern
Does not perceive personal relevance of symptoms
Does not perceive personal relevance of danger

Question 14

Obesity (BED)
Behaviors

Answer 14

Compulsive eating
Excessive intake in relation to metabolic needs Sedentary lifestyle
Weight 20 percent over ideal for height and frame
BMI of 30 or more
Reports the perception that eating is out of control

Question 15

Disturbed body image/Low self-esteem
Behaviors

Answer 15

Distorted body image
Views self as fat, even in the presence of normal body weight or severe emaciation
Denies that problem with low body weight exists
Difficulty accepting positive reinforcement
Self-destructive behavior (self-induced vomiting, abuse of laxatives or diuretics, refusal to eat)
Preoccupation with appearance and how others perceive it (anorexia nervosa, bulimia nervosa)
Verbalization of negative feelings about the way he or she looks and the desire to lose weight (obesity)
Lack of eye contact; depressed mood (all)

Question 16

Anxiety (moderate to severe)
Behaviors

Answer 16

Increased tension
Increased helplessness
Overexcited
Apprehensive
Fearful
Restlessness
Poor eye contact
Increased difficulty taking oral nourishment
Inability to learn

Question 17

Reasons for hospitalization include the following:

Answer 17

• Malnutrition: 20% below expected weight for height recommended for inpatient treatment; 30% below expected weight for height recommended for long-term intensive treatment
• Dehydration: Assessment includes thirst, orthostatic hypotension, tachycardia, elevated sodium levels, and other symptoms
• Severe electrolyte imbalance: Potassium levels below 3 mmol/L; Phosphate levels below 3 mg/dL; Magnesium levels below 1.4 mEq/L
• Cardiac arrhythmias: ST segment and T wave changes usually related to electrolyte imbalances
• Severe bradycardia: below 50 bpm
• Hypothermia: Body temperature below 96.8
• Hypotension: A pattern of low blood pressure or orthostatic hypotension (20 mm Hg or greater drop in systolic blood pressure with positional changes and pulse rate increase by 20 or more beats per minute)
• Suicidal ideation

Question 18

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS/DEFICIENT FLUID VOLUME (RISK FOR OR ACTUAL)
Goal
■Patient will gain x pounds per week (amount to be established by the interdisciplinary team including the patient, nurse, and dietitian).
■Patient will drink x mL of fluid each hour during waking hours.
■ By time of discharge from treatment, patient will exhibit no signs or symptoms of malnutrition or dehydration.
Interventions

Answer 18

1. For the patient who is emaciated and is unable or unwilling to maintain an adequate oral intake, the physician may order a liquid diet to be administered via nasogastric tube.
2. For the patient who is able and willing to consume an oral diet, collaborate with the dietitian to determine the appropriate amount of calories and fluids required to provide adequate nutrition and realistic weight gain.
3. Explain to the patient that privileges and restrictions will be based on compliance with treatment and direct weight gain. Minimize the focus on food and eating.
4. Weigh patient daily, immediately upon arising and following first voiding. Always use same scale, if possible. Keep strict record of intake and output. Assess skin turgor and integrity regularly. Assess moistness and color of oral mucous membranes.
5. Stay with patient during established time for meals (usually 30 min) and for at least 1 hour following meals.
6. If weight loss occurs, enforce restrictions.
7. Ensure that the patient and family understand that if nutritional status deteriorates, tube feedings will be initiated. This is implemented in a matter-of-fact, nonpunitive way.
8. Encourage the patient to explore and identify the true feelings and fears that contribute to maladaptive eating behaviors.

Question 19

DENIAL
Goal
■ Patient will verbalize understanding of the correlation between emotional issues and maladaptive eating behaviors (within time deemed appropriate for individual patient).
■ By time of discharge from treatment, patient will demonstrate the ability to discontinue use of maladaptive eating behaviors and to cope with emotional issues in a more adaptive manner.
Interventions

Answer 19

1. Establish a trusting relationship with the patient by being honest, accepting, and available, and by keeping all promises. Convey unconditional positive regard.
2. Acknowledge the patient’s anger at feelings of loss of control brought about by the established eating regimen associated with the program of behavior modification.
3. Avoid arguing or bargaining with the patient who is resistant to treatment. State matter-of-factly which behaviors are unacceptable and how privileges will be restricted for noncompliance.
4. Encourage patient to verbalize feelings regarding role within the family and issues related to dependence/independence, the intense need for achievement, and sexuality. Help patient recognize how maladaptive eating behaviors may be related to these emotional issues.Discuss ways in which he or she can gain control over these problematic areas of life without resorting to maladaptive eating behaviors.

Question 20

Anorexia/Bulimia
DISTURBED BODY IMAGE/LOW SELF-ESTEEM
Goal
■ Patient will verbally acknowledge misperception of body image as “fat” within specified time (depending on severity and chronicity of condition).
■ By time of discharge from treatment, patient will demonstrate an increase in self-esteem as manifested by verbalizing positive aspects of self and exhibiting less preoccupation with own appearance as a more realistic body image is developed.
Interventions

Answer 20

1. Help patient to develop a realistic perception of body image and relationship with food. Compare specific measurement of the patient’s body with the patient’s perceived calculations.
2. Promote feelings of control within the environment through participation and independent decision making. Through positive feedback, help patient learn to accept self as is, including weaknesses as well as strengths.
3. Help patient realize that perfection is unrealistic and explore this need with him or her.
4. Assess patient for history of trauma and other adverse childhood life events.

Question 21

IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS
Goal
■ Patient will identify desired weight loss plan.
■ Patient will demonstrate a change in eating patterns that results in the patient’s desired weight loss.
Interventions

Answer 21

1. Encourage the patient to keep a diary of food intake.
2. Discuss feelings and emotions associated with eating.
3. With input from the patient, formulate an eating plan that includes food from the required food groups with emphasis on low-fat intake. It is helpful to keep the plan as similar to patient’s usual eating pattern as possible.
4. Identify realistic incremental goals for weekly weight loss (1–2 pounds per week).
5. Plan a progressive exercise program tailored to individual goals and choice. (Walking is a great choice)
6. Discuss the probability of reaching plateaus when weight remains stable for extended periods.
7. Provide instruction about medications to assist with weight loss if ordered by physician.

Question 22

BED
DISTURBED BODY IMAGE/LOW SELF-ESTEEM
Interventions

Answer 22

1. Assess patient’s feelings and attitudes about being obese.
2. Assess for history of trauma and adverse childhood life events.
3. Ensure that the patient has privacy during self-care activities. (self-conscious)
4. Have patient recall coping patterns related to food in family of origin and explore how these may affect current situation.
5. Determine patient’s motivation for weight loss and set goals. (when it’s for someone else, it’s less successful)
6. Help patient identify positive self-attributes. Focus on strengths and past accomplishments unrelated to physical appearance.
7. Refer patient to support or therapy group.

Question 23

Treatment Modalities: Behavior Modification Therapy

Answer 23

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.
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
The client has control over
- Eating
- Amount of exercise pursued
- Whether to induce vomiting
Staff and client agree about
- Goals
- System of rewards

Question 24

Treatment Modalities: Individual Therapy

Answer 24

Not the therapy of choice.
Helpful when underlying psychological problems are contributing to the maladaptive behaviors

Question 25

Treatment Modalities: Family Therapy

Answer 25

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

Question 26

________ has demonstrated effectiveness in treating eating disorders. Group therapy can be helpful in dealing with underlying psychological concerns.

Answer 26

Cognitive Behavior Therapy

Question 27

Psychopharmacology for Anorexia Nervosa

Answer 27

Medications that have been tried with some success for Anorexia Nervosa include:
Fluoxetine (Prozac)
- Shown some evidence of weight gain, and, in general, SSRIs may be beneficial in the treatment of comorbid depression
- Black-box warning about risk of increasing suicide ideation in adolescents.
Clomipramine (Anafranil)
- The anticholinergic side effects of tricyclic antidepressants, including orthostatic hypotension, may be problematic for patients who are already at risk for these symptoms.
Cyproheptadine (Pariactin)
- Antihistamine (Sedation, weight gain)
Chlorpromazine (Thorazine)
- Antipsychotic
Olanzapine (Zyprexa)
- Antipsychotic

Question 28

Psychopharmacology for Bulimia Nervosa

Answer 28

Medications that have been tried with some success for Bulimia Nervosa include:
Fluoxetine (Prozac)
- May decrease the craving for carbohydrates, thereby decreasing the incidence of binge eating, which is often associated with consumption of large amounts of carbohydrates.
- Remember black box warning
Imipramine (Tofranil)
- Tricyclic antidepressant
Desipramine (Norpramine)
- Tricyclic antidepressant
Amitriptyline (Elavil)
- Tricyclic antidepressant
Nortriptyline (Aventyl)
- Tricyclic antidepressant
Phenelzine (Nardil)
- MAOI

Question 29

Psychopharmacology for BED

Answer 29

Medications that have been tried with some success for BED with obesity include:
Topiramate (Topamax)
- Anticonvulsant
Lisdexamfetamine (Vyvanse)
- A dopamine-norepinephrine reuptake inhibitor, originally used in the treatment of attention-deficit-hyperactivity/disorder

Question 30

SSRIs side effects

Answer 30

Nausea, agitation, headache, sexual dysfunction

Question 31

Tricyclic Antidepressant Side Effects

Answer 31

Sexual dysfunction
Sedation, weight gain
Dry mouth, constipation, blurred vision, urinary retention
Postural hypotension and tachycardia

Question 32

MAOI Inhibitors Side Effects

Answer 32

Sedation, dizziness
Sexual dysfunction
Hypertensive crisis (interaction with tyramine)

Question 33

Anorexia and Bulimia Nervosa: Predisposing Factors
Biological Influences

Answer 33

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.
Neuroendocrine abnormalities
- There has been some speculation about a primary hypothalamic dysfunction in anorexia nervosa.
Neurochemical influences
- Anorexia nervosa may be associated with high levels of endogenous opioids in spinal fluid
- Given naloxone to gain weight (study)
- Bulimia nervosa may be associated with the neurotransmitters: serotonin and norepinephrine.

Question 34

Evaluation For the Patient With Anorexia Nervosa or Bulimia Nervosa

Answer 34

Has the patient:
■Steadily gained 2 to 3 pounds per week to at least 80 percent of expected body weight for age and size?
■Demonstrated no signs or symptoms of malnutrition and dehydration?
■Consistently consumed adequate calories as determined by the dietitian?
■Attempted to stash food from the tray to discard later?
■Attempted to self-induce vomiting?
■Admitted that a problem exists and that eating behaviors are maladaptive?
■Discontinued maladaptive behaviors to manipulate calorie restriction?
■Discussed feelings related to family roles, sexuality, dependence/independence, and the need for achievement?
■Verbalized understanding of how he or she has used maladaptive eating behaviors in an effort to achieve a feeling of some control over life events?
■Acknowledged that perception of body image as “fat” is incorrect?
■Been able to develop a more realistic perception of body image?
■Acknowledged that past self-expectations may have been unrealistic?
■ Verbalized improvement in self-acceptance?
■ Developed adaptive coping strategies to deal with stress without resorting to maladaptive eating behaviors?

Question 35

Evaluation For the Client With BED and Associated Obesity

Answer 35

■Shown a steady weight loss since starting the new eating plan?
■Verbalized a relapse prevention plan to avoid triggers and abstain from binging?
■Verbalized positive self-attributes not associated with body size or appearance?
■Been able to develop a more realistic perception of body image?
■Acknowledged that past self-expectations may have been unrealistic?
■ Verbalized improvement in self-acceptance?
■ Developed adaptive coping strategies to deal with stress without resorting to maladaptive eating behaviors?