Eating and Elimination Disorders

Question 1

Background:

Eating disorders have seen an increase in incidence over the last 60 years. Notably, these disorders are NOT as prevalent in developing countries compared to more developed ones

Question 2

• Main Symptoms: Anorexia Nervosa:

Fear of gaining weight

Answer 2

• Intense fear of gaining weight.
• Maintaining a very low Body Mass Index (BMI).
• Distorted body image, where individuals perceive themselves as overweight even when underweight.

Question 3

• Prevalence: Anorexia Nervosa:

Answer 3

• Lifetime prevalence ranges from 0.5% to 3.7%, indicating that a significant proportion of the population may experience this disorder at some point in their lives.

Question 4

• Mortality Rate: Anorexia Nervosa:

Answer 4

• Anorexia Nervosa has the highest mortality rate of any mental illness, exceeding 10% of mental ilness. This is often due to complications related to malnutrition and other physical health issues.

Question 5

• Etiologies: Anorexia Nervosa:

Answer 5

• Anorexia has multifactorial causes, including familial factors, biological predispositions, psychological factors, and sociocultural influences.

Question 6

• Comorbidities: Anorexia Nervosa:

Answer 6

• Anorexia Nervosa often coexists with other mental health conditions, with high comorbidity rates for personality disorders (especially OCD), depression, and anxiety disorders.

Question 7

Characteristics: Anorexia Nervosa:

Answer 7

• Intense Drive for Thinness/Fear of Gaining Weight:
  • A pervasive and obsessive preoccupation with maintaining a low body weight.
• Severe Body Image Distortion:
  • Perceiving one’s body as overweight or unattractive despite being underweight.
• Decreased Interoceptive Awareness:
  • Difficulty recognizing and understanding internal bodily sensations, which can contribute to neglecting basic physiological needs.
• Difficulty Expressing Anger, Non-Assertiveness:
  • An inclination towards suppressing emotions, particularly anger, and struggling with assertiveness in interpersonal interactions.
• Low Self-Esteem:
  • Individuals with anorexia nervosa often have a distorted and negative view of themselves.
• Perfectionism: Anorexia Nervosa:
  • A tendency to set exceedingly high standards for oneself, often driven by an intense fear of failure.
• Fear of Sexuality, Emotional Maturation:
  • Avoidance or fear related to aspects of emotional and sexual maturation.
• Enmeshed Families (Overprotective, Rigid, Difficulty with Individuation): Anorexia Nervosa:
  • Anorexia may be associated with family dynamics characterized by overprotection, rigidity, and challenges in the development of individual identity.
• “People-Pleasers”:
  • A tendency to prioritize pleasing others at the expense of personal needs and desires.

Question 8

• Gender Distribution: Anorexia Nervosa:

Answer 8

• Historically, the disorder has been more prevalent in females, with a ratio of 9:1. However, there’s evidence that this gender distribution is changing, especially with an increasing prevalence among gay males.

Question 9

• Age of Onset: Anorexia Nervosa:

Answer 9

• Anorexia Nervosa typically manifests in the age range of 10 to 20 years old. However, there’s evidence to suggest that the age of onset is changing, indicating that individuals may develop the disorder at different stages of life.

Question 10

Associated Physical Findings:
Anorexia Nervosa:

Answer 10

• Emaciation “النحول” [very, very thin and not as healthy as they should be] (<75% Ideal Body Weight = Hospitalization):
  • Maintaining a body weight significantly below what is considered healthy or normal, often necessitating medical intervention.
• Complaints of Constipation, Abdominal Pain, Bloating:
  
  • Gastrointestinal symptoms that can arise due to restricted food intake and malnutrition.
• Lethargy, Fatigue, Depressed Mood:
  
  • Physical and emotional symptoms resulting from inadequate nutrition and the impact on overall well-being.
• Hypotension, Hypothermia/Cold Intolerance, Bradycardia:
  
  • Physiological consequences of malnutrition affecting cardiovascular function. (not enough NA, Ca, K)
• Dry Skin, Lanugo (baby hair), Thinning Hair, Amenorrhea (cessation of menstruation):
  
  • Physical manifestations of malnutrition, including dry skin, fine body hair (lanugo), and absence of menstrual periods in females.
• Arrhythmias, Hypokalemia, Anemia:
  
  • Serious complications affecting the heart and blood composition due to malnutrition.
• Osteoporosis:
  
  • Reduced bone density, often resulting from nutritional deficiencies, which can lead to increased susceptibility to fractures.

Prognosis:

• Less Than 50% Recover Fully:
  
  • Anorexia Nervosa has a challenging prognosis, with a significant portion of individuals experiencing only partial or incomplete recovery. The complexity of the disorder, both psychologically and physiologically, contributes to the difficulties in achieving full recovery. Early intervention and comprehensive treatment approaches are crucial in improving outcomes.

Question 11

Nursing Process for Anorexia Nervosa:

Answer 11

Inpatient Care:
-Supervise Meals (Refeeding Protocol):
Ensure that individuals consume an adequate and balanced diet to address malnutrition. Refeeding protocols may be necessary to manage the refeeding process carefully, preventing complications.

• Avoid Power Struggles:
  
  • Foster a supportive and non-confrontational environment. Power struggles can exacerbate the resistance to treatment often seen in individuals with anorexia nervosa.
• Don’t Underestimate Their Impairment:
  
  • Recognize the severity of the physical and psychological impairment. Anorexia nervosa is a complex disorder that requires a comprehensive understanding of its impact on overall health.

Interdisciplinary Approach:
- Consistency is Important:
- Collaborate with a diverse team of healthcare professionals, including psychologists, dietitians, and physicians. Consistency in care and communication among team members is essential for effective treatment.

Therapeutic Approaches:
- Family (Maudsley= involving fam) and Individual Therapy:
- Family-based therapy, such as the Maudsley approach, can be effective, especially in adolescent cases. It involves families in the treatment process, recognizing their role in supporting recovery. Individual therapy is also crucial to address personal issues and challenges.

• No Meds During Acute Phase:
  
  • Medications may not be appropriate during the acute phase when the focus is on nutritional rehabilitation. However, once normal weight has been restored, medications such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Olanzapine may be considered to manage co-occurring mood and anxiety symptoms.
• Teach Assertiveness:
  
  • Assist individuals in developing assertiveness skills. This can empower them to express their needs and emotions effectively, reducing the likelihood of relying on maladaptive coping mechanisms.
• Suicide Assessment:
  
  • Conduct a thorough assessment of suicide risk, as comorbid depression is common in individuals with anorexia nervosa. Monitoring for signs of depression and suicidality is essential for the safety and well-being of the patient.

Question 12

Bulimia Nervosa:

Bulimia Nervosa involves binge-eating followed by compensatory behaviors [Ex: Vomiting, Excessive Exercise, Laxatives], while Anorexia Nervosa centers on severe food restriction, resulting in significant weight loss and a distorted body image.

Answer 12

Bulimia Nervosa is an eating disorder characterized by recurrent episodes of binge eating followed by inappropriate compensatory behaviors to prevent weight gain. [Ex: Vomiting, Excessive Exercise, Laxatives]

Question 13

• Main Symptoms: Bulimia Nervosa:

Answer 13

• Recurrent episodes of binge eating, where individuals consume an excessive amount of food in a discrete period.
• Compensatory behaviors to prevent weight gain, which may include self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise.
• Self-esteem is heavily based on body image and weight.

Question 14

• Prevalence: Bulimia Nervosa:

Answer 14

• The lifetime prevalence of Bulimia Nervosa ranges from 1.1% to 4.2% (out of 100 people, approximately 1 to 4 individuals may experience Bulimia Nervosa at some point in their lifetime. ). However, there is a much higher sub-clinical prevalence, with a significant number of individuals engaging in binge-eating and purging behaviors without meeting the full diagnostic criteria. For example, about 25% of college-age women report engaging in binge-eating and purging (“تطهير”) behaviors.

Question 15

• Etiologies: Bulimia Nervosa:

Answer 15

• Bulimia Nervosa has multifactorial causes, including familial factors, biological factors (such as low serotonin/tryptophan levels), psychological factors, and sociocultural influences.

Question 16

• Comorbidities: Bulimia Nervosa:

Answer 16

• There is a high comorbidity rate with other mental health conditions, including Borderline Personality Disorder (BPD), depression, Post-Traumatic Stress Disorder (PTSD), and anxiety disorders.

Question 17

• Gender Distribution: Bulimia Nervosa:

Answer 17

• Historically, the disorder has been more prevalent in females, with a ratio of 9:1. However, similar to Anorexia Nervosa, the gender distribution is changing, especially with an increasing prevalence among gay males.

Question 18

• Age of Onset: Bulimia Nervosa:

Answer 18

• Bulimia Nervosa often begins in late adolescence or early adulthood, with an age of onset typically between 14 and 24 years old. Notably, there is a growing incidence in women aged 25-45.

Question 19

Characteristics: Bulimia Nervosa:

Answer 19

• Similar to Anorexia but with Recognition of Abnormal Eating Behaviors:
  
  • Individuals with Bulimia Nervosa share characteristics with anorexia, such as body image concerns and low self-esteem. However, unlike anorexia, those with bulimia typically recognize that their eating behaviors are abnormal and often seek help.
  • Binging and Purging with a Sense of Lack of Control:
    
    • Binge-eating episodes are marked by the consumption of a large amount of food in a short period, accompanied by a sense of lack of control. Purging behaviors, such as vomiting or misuse of laxatives, follow these episodes.
  • Impulsive:
    
    • Impulsivity is a common characteristic, contributing to the binge-eating and purging behaviors.

Question 20

Prognosis [pronóstico]: Bulimia Nervosa:

Answer 20

• Better Than Anorexia, Usually Treated Outpatient:
  
  • The prognosis for bulimia nervosa is generally better than anorexia nervosa. Treatment is often conducted on an outpatient basis, although the severity of symptoms may warrant more intensive interventions.

Question 20

Associated Physical Findings: Bulimia Nervosa:

Answer 20

• Often Normal Weight:
  
  • Individuals with bulimia nervosa may maintain a relatively normal body weight, distinguishing it from anorexia nervosa.
• Salivary (Parotid) Gland Inflammation, Esophageal Varices, Dental Erosion:
  
  • Physical consequences of frequent vomiting, including inflammation of the salivary glands, esophageal varices, and dental erosion due to exposure to stomach acids.
• Electrolyte Imbalances, Seizures, Ipecac Cardiac Arrhythmias:
  
  • Complications related to electrolyte imbalances resulting from purging behaviors, including the misuse of ipecac (natural emetic ( ipecac plant ), which can lead to cardiac arrhythmias.
• Metabolic Alkalosis or Metabolic Acidosis:
  
  • Imbalances in the body’s acid-base status, resulting from vomiting (metabolic alkalosis) or diarrhea (metabolic acidosis).
• Scars or Reddened Areas on Knuckles:
  
  • “Russell's sign” may be present, characterized by scars or reddened areas on the knuckles due to repeated contact with teeth during induced vomiting.

Question 21

Nursing Process: Bulimia Nervosa:

Answer 21

• Cognitive Behavioral Therapy:
  
  • Cognitive-behavioral therapy (CBT) is a primary therapeutic approach for bulimia nervosa. It helps individuals identify and change unhealthy thought patterns and behaviors related to eating and body image.
• Medications:
  
  • SSRIs (Selective Serotonin Reuptake Inhibitors), especially Prozac (fluoxetine) in high doses (e.g., 60 mg/day), have shown efficacy in reducing binge-eating and purging behaviors.
• Teach Assertiveness, Healthy Boundaries:
  
  • Assertiveness training can empower individuals to express themselves effectively and set healthy boundaries in relationships.
• Teach Recognition of Triggers, Alternative Coping Mechanisms:
  
  • Educate individuals on recognizing triggers for binge-eating episodes and purging behaviors. Providing alternative coping mechanisms helps individuals manage stress and emotions without resorting to unhealthy behaviors.

Question 22

• Prevalence: Binge Eating Disorder (BED):

Answer 22

• The lifetime prevalence of BED is estimated to be between 2-5%. It is the most common eating disorder in the United States.

Question 23

Binge Eating Disorder (BED):

Answer 23

• Main Symptoms:
• Binge Eating Disorder is characterized by recurrent episodes of overeating, during which an individual consumes an excessive amount of food in a short period. Importantly, unlike bulimia nervosa, there are no compensatory behaviors such as purging or excessive exercise.

Question 24

• Treatment: Binge Eating Disorder (BED):

Answer 24

• Cognitive-Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT):
  
  • CBT focuses on identifying and changing negative thought patterns and behaviors related to binge eating. DBT combines cognitive-behavioral techniques with mindfulness strategies.

Question 25

• Medications: Binge Eating Disorder (BED):

Answer 25

• SSRIs (Selective Serotonin Reuptake Inhibitors) are often used in the treatment of BED. These medications can help address comorbid depression and may also have appetite-suppressant effects.

Question 26

• Overeater’s Anonymous (como Alcohólicos Anónimos): Binge Eating Disorder (BED):

Answer 26

• Support groups, such as Overeaters Anonymous, may provide individuals with BED a supportive community to share experiences and coping strategies.

Question 27

Feeding Disorders:

Answer 27

• Pica:
  
  • Pica is the consumption of non-food items, such as dirt, hair, or cloth. This behavior is not developmentally appropriate and may pose health risks.
• Rumination:
  
  • Rumination disorder involves the repeated regurgitation of food from STOMACH, which may be re-chewed, re-swallowed, or spit out. It is not due to a medical condition but rather a voluntary behavior.
• Avoidant/Restrictive:
  
  • Avoidant/Restrictive Food Intake Disorder (ARFID) is characterized by limited food preferences, avoidance of certain textures or smells, and refusal to eat specific foods. Unlike anorexia nervosa, ARFID is not driven by concerns about weight or body image.

Question 28

Bulimia Nervosa involves binge-eating followed by compensatory behaviors, while Anorexia Nervosa centers on severe food restriction, resulting in significant weight loss and a distorted body image.

Question 29

The term “borderline” in Borderline Personality Disorder (BPD) originated in the early 20th century and was initially used to describe individuals who seemed to be on the border between neurosis (chronic distress without hallucinations or delusions) and psychosis. This classification suggested that these individuals experienced symptoms that were not easily categorized as purely neurotic (associated with anxiety and distress) or psychotic (associated with a loss of touch with reality).

Over time, the understanding and interpretation of the term have evolved, and the current usage of “borderline” in BPD doesn’t refer to a borderline between neurosis and psychosis. Instead, it reflects the historical perspective that individuals with this disorder may display symptoms that are on the “borderline” of various psychiatric categories.

Question 30

Greek: The word “prognosis” comes from the Greek words “pro” (meaning “before”) and “gnosis” (meaning “knowledge” or “foreseeing”). So, “prognosis” in Greek conveys the idea of foreknowledge or foreseeing.