Eating Disorders Flashcards
Continuum of Symptoms
- normal eating
- develop risk factors: low self esteem, dieting, media ideal bodies
- partial-syndrome ED: binge eating, serious dieting
- full-syndrome ED: increase in freq/severity of binge eating, purging, starvation
- treatment
Nursing Screening for ED
- Questions:
- Are you satisfied with your eating patterns?
- Do you ever eat in secret?
- BMI & nutritional appearance
- ->answers will help decide if further questioning/treatment is necessary - Assess diagnostic criteria for specific eating disorders
- Assess stage of change to determine how to intervene
Prevention
- Requires effort on the part of teachers, school nurses, parents, coaches and society as a whole
- Educate school nurses and teachers in elementary schools
- Emphasize protective factors that mediate between risk factors and the development of an eating disorder
Prevention: Protective Factors
- EDs considered very preventable
- McKnight Risk Factor Survey –> measures prevalence & degree of risk factors (other tools- See Boyd)
- Evidence Based resources (online: UCLA, NIMH, SAMHSA)
- Education of child, adolescent
- Screen for risk factors & assess for treatment
- Follow-up-Monitor for relapse
Protective Factors: Education for Parents
- Real vs. ideal weight
- Influence of attitudes, behaviors, teasing
- Ways to increase self-esteem
- Role of media: TV, magazines
- Signs & symptoms
- Interventions for obesity
- Boys at risk also
- Observe for food rituals
- Supervision of eating and exercise
Protective Factors: Education for Child
- Peer pressure re’ weight, eating
- Menses, puberty normal weight gain, obesity strategies
- Ways to improve self esteem
- Body image traps: media, retail clothing
- Adapting and coping with problems
- Reporting friends with signs of eating disorders
Continuum of Care
- Outpatient treatment- most treatment takes place outpatient
- Family assessment and intervention
- Emergency care
- Hospitalization (suicide risk, starving to death)
Criteria for Hospitalization
Medical-acute weight loss
- Slow Heart Rate- 40 beats per minute (normal 60-80) & other arrhythmias
- Dehydration
- Temp less 36.1 C
- Blood pressure less than 80/50
- Hypokalemia (low potassium, affects heart)
- Hypo-magnesium (low magnesium)
- Poor motivation, failure on outpatient basis
- Risk for suicide (1/2 of fatalities from anorexia), severe depression
Diagnostic Criteria: Anorexia Nervosa
- Refusal to maintain normal body weight
- Intense fear of gaining weight
- Disturbance in body image & self evaluation based on body weight to an extreme
- Perfectionism & does not recognize seriousness
- Severity Rating-BMI-less than or equal to Kg/m2
- –Mild- 17
- –Moderate- 16-16.99
- –Severe- 15- 15.99
Two types of Anorexia
–> must have symptoms for over 3 months
- Restricting type: rigid dieting, fasting, excessive exercise
- Binging/Purging type: eating excess food all at once followed by purging by vomiting laxatives, diuretics or enemas (diff from bulimia b/c low BMI)
Clinical Course of Anorexia Nervosa
- Onset in early adolescence
- Chronic condition with relapses characterized by significant weight loss
- Often continue to be obsessed with food
- Many go on to develop bulimia nervosa
- Poor outcome w/initial lower minimum weight, presence of purging, and later age of onset
- May look depressed, but that may be secondary to starvation
Harmful Effects of Anorexia
- depression/suicide
- hair loss
- thyroid hormone decreases
- low WBC count
- heart failure/death
- rough scaly
- organs deteriorate
- muscles waste away
- hands swell
- period stops
- constipation
- bone loss
- body fat layer gone
How much larger do anorexics view their bodies than normal?
20% larger
Body image: anorexia
discrepancy between self-perception and others
Drive for thinness: anorexia
an intense physical and emotional process that overrides all physiologic body cues, such as hunger and weakness
Interoceptive awareness: anorexia
sensory response to emotional and visceral cues, such as feeling hunger & defining and understanding their feelings
Epidemiology
- 0.5 to 1% lifetime prevalence
- Onset is typically between 14 and 16 years
- Female-to-male ratio 10:1
- Familial predisposition
- Co-morbid with depression and anxiety disorders
- Hispanics & whites more common-culturally defined weight expectations (underlined same in bulimia)
- Genetic heritability-50-80%
Men/Boys w/ED
- Later onset around 20 years old
- Athletes in a sport where weight is an issue –> may want thinness and muscle
- Thinner males have less testosterone
- Community samples have much higher rates than reported in clinical samples indicating under-diagnosis
- Risk factors & comorbid conditions similar to women
Interdisciplinary Treatment: Goals
- Initiating nutritional rehabilitation
- Resolving conflicts around body image disturbance
- Increasing effective coping
- Addressing underlying conflicts
- Assisting family with healthy functioning
- Hospitalization usually necessary
- Intensive therapies-supervision of patient and frequency of contact
Interdisciplinary Treatment: Antidepressant
- Fluoxetine (Prozac): helps with depression, obsessive compulsive & perfectionism symptoms
- ->FDA approved antidepressant, selective serotonin reuptake inhibitor, (SSRI)-for anorexia and bulimia
- Adult dose for eating disorders usually 40-60 mg/day. Take 2X daily if over 20 mg/day.
- May take up to 4 weeks for full antidepressant effects, may increase after a few weeks if needed.
- ->Boxed warning: increased risk suicidal thoughts & behaviors in children, adolescents & young adults.
- May cause dizziness or drowsiness avoid driving
- Small frequent meals if causes nausea & vomiting
- Avoid taking while breastfeeding & pregnant
Anorexia Priority Care Issues
- Mortality rate 7-10%
- Long duration of illness
- Binging and purging
- Co-morbid illnesses
- –Substance abuse
- –Depression (suicide using highly lethal means)
- –Anxiety disorders
Anorexia Nursing Assessment
Evaluation of body and social systems:
- School attendance
- Family interaction
- Careful history (patient and family interactions)
Determine BMI
Body distortion:
-Fear of weight gain
Unrealistic expectations and thinking
Ritualistic behaviors
Difficulty expressing negative feelings
Inability to experience visceral cues and emotions
Suicide ideation-50% of deaths are suicide
Family Assessment:
- Enmeshment-low autonomy
- Overprotective
- Rigid
- Unrealistic attitudes towards weight & appearance with teasing and criticism
Anorexia Nursing Diagnosis
- Imbalanced nutrition: less than body requirements
- Anxiety
- Disturbed body image
- Ineffective coping
Anorexia Nursing Intervention
- Therapeutic relationship
- Be firm, accepting, and patient
- Provide a rationale for all interventions
- Avoid power struggles over eating - Understanding feelings
- Challenge cognitive distortions
- Imagery and relaxation - Interpersonal therapy
- Focus on role transitions, control, and ineffective feelings
- Change distortions about food and interactions with others - Education
- Clarify misinformation about food with patient
- Family education - Weight-increasing protocols
- usually a behavioral plan with positive and negative reinforcements)
- strict monitoring and recording of intake - Exercise
- generally not permitted during refeeding
- any exercise needs to be monitored - Sleep
structured, healthy routine - Facilitate transition to school
- Family therapy
Magnification
Overestimation of the significance of undesirable events (gained 2 pounds can’t wear shorts)
Superstitious thinking
Believing in the cause-effect relationship of noncontingent events (If I eat a sweet it will instantly turn into stomach fat)
Dichotomous or all-or-none thinking
Thinking in extreme or absolute terms such as that events can only be black or white, right or wrong, good or bad (If I eat one piece of candy I blew it and might as well eat all the candy)
Defense Mechanisms
Automatic psychological processes protecting the patient from unwanted anxiety, generally the patient is unaware of using them and of the stresses that precipitate their use. Some are adaptive and some maladaptive.
Avoidance
use food to avoid intimacy & other fears
Denial
in anorexia this gets stronger as others express more concern about the ED
Isolation of affect
inability to recognize their feelings
Intellectualization
use of excessive reasoning or logic to deal with situations rather than feeling their emotions
Overgeneralization
Extracting a rule on the basis of one event and applying it to other dissimilar situations (I used to be a normal weight & I wasn’t happy so I know gaining weight will not help)
Selective Abstraction
Basing a conclusion on isolated details while ignoring contradictory and more important evidence (eating is the only thing that will make me happy)
Personalization/Self-Reference
Egocentric interpretations of impersonal events or over-interpretation of events related to the self (those people were talking and laughing about how fat I am)
Bulimia Nervosa: Diagnostic Criteria
- Recurrent episodes of binge eating
a. Rapid, episodic, impulsive, and uncontrollable ingestion of large amounts of food over a short period of time (up to 2 hours)
b. Feelings of lack of control
- –Restriction of total calories between binges
- –Undue influence of body weight or shape or denial of current low weight - Recurrent episodes of binge eating & compensatory purging: vomiting/laxatives, diuretics/emetics, fasting or over-exercising
- These episodes must occur at least once a week for a period of at least 3 months
- Eating –> guilt, remorse, and severe dieting. Self evaluation unduly influenced by weight. Ashamed and often conceal their eating.
Bulimia Nervosa: Key Concepts
Two types of bulimia nervosa:
1. Restricting type:
Similar to anorexia nervosa-restricting is followed by binge eating, which is then followed by another period of restricting
2. Purging type- vomiting or using laxatives, diuretics, or emetics, fasting or over-exercising
Dietary restraint
- Restricting intake is believed to explain the relationship between dieting and binge behavior
- Restraining intake is predictive of overeating
Usually normal weight- generally not life-threatening
Present as overwhelmed and overly committed individuals who have difficulty setting limits and establishing boundaries (“social butterflies”)
Treatment is usually outpatient therapy
Epidemiology of Bulimia
- Lifetime prevalence 1 to 2.3% (more prevalent than anorexia nervosa)
- Onset is between 15-24 years (older than anorexia nervosa)
- Females to males 10:1
- Related to social values of Western culture
- Co-morbid conditions-substance use disorder, depression, and Obsessive Compulsive Disorder (OCD)
- 1 to 4% of females; 4 to 15% in high school & college females, & 20% of nursing students and female medical students
Bulimia Etiology: Biologic Theories
Neuropathologic-brain changes seen in Magnetic Resonance imaging(MRI) are result of eating dysregulation not the cause
Genetic and familial predispositions-twin studies show genetic influences are stronger than environmental
Biochemical-chronic depletion of plasma tryptophan (serotonin precursor)
Bulimia Etiology: Psychological and Social Theories
Cognitive theory-cognitive distortions maintain illness instead of creating it
Family-separation/individuation-difficulty with healthy boundaries
Clinical Course of Bulimia
- Few outward signs: do great in other aspects of life
- Binge and purge in secret
- Treatment often delayed for years
- Treatment initiated when control of eating is lost
Bulimia Nursing Assessment
Imbalanced nutrition
- Current eating patterns
- Number of times a day of binging and purging
- Dietary restraint practices
Sleep patterns
Exercise habits
Cognitive distortions
Knowledge deficits
Body dissatisfaction
Impulsivity
Harmful Effects of Bulimia
- depression, seizures, addiction
- swollen salivary glands
- teeth decay
- swollen/sore throat
- irregular heart beat
- stomach ulcers
- liver/kidney damage
- muscle weakness
- constant bloating/ab pain
- bowel muscle damage
Nursing Diagnosis of Bulimia
- Disturbed thought processes
- Powerlessness
- Knowledge deficient
- Imbalanced nutrition
- Disturbed sleep pattern
Bulimia Nursing Intervention
Encourage regular sleep patterns
Cognitive Behavioral Therapy & Interpersonal Therapy
- Behavioral techniques
- –Cue elimination
- –Self-monitoring
- –Strictly monitor food intake
- –Bathroom visits should be supervised
- Group therapy
- –Concentrate on interpersonal issues
- –Understand the binge–purge cycle
Monitoring and administration of medication-Selective Serotonin Reuptake Inhibitors (SSRI)
Bulimia Interdisciplinary Treatment: Goals
- Stabilizing and normalizing eating
- Restructuring dysfunctional thoughts and attitudes
- Teaching healthy boundary setting
- Resolving conflicts about separation-individuation
Bulimia Interdisciplinary Treatment: Multifaceted Approach
- Cognitive behavioral therapy (CBT)
- Antidepressants: SSRIs-Fluoxetine (Prozac) most research
- Nutrition counseling
Bulimia Priority Care Issues
- Co-morbid depression and suicide
- Risk for self-mutilation
- Impulsive behavior (shoplifting, overspending, etc.)
Binge Eating Disorder
consume large amounts of calories during binges & feel a lack of control & distress but do NOT try to lose weight. Most are obese. Interventions similar to bulimia nervosa.
Motivation is a problem with ED
Anorexia-denial of a problem even when life threatening
Bulimia-this varies some clients do not want to change and others are motivated
Use Motivational Interviewing (MI) & stages of change when the client is not motivated. Use traditional action oriented strategies and some MI techniques during times the client is motivated
Motivation: Case Study
Recent research shows that MI and Stages of Change are useful in treating the motivational problems in patients with ED.
Internal vs external motivation- ex. doing well in inpatient treatment but not after discharge
101 clients in 16 groups, not ready to change-12 week group program without any pressure to change –> 41% moved into therapy involving action
Therapist presented the assignment and left the room-90 minute sessions
Topics-
- Psychoeducation
- Function of illness
- Impact of illness
- Change, fear & recovery
- Evaluations and termination
Motivational Interviewing in ED
Cognitive Behavioral Treatment (CBT) is generally action-oriented.
- It is the main treatment for Bulimia and used with anorexia as well.
- Anorexia has the behavioral components of structure to gain weight during hospitalizations.
Nurses using MI at the Weight Disorder Clinic in Australia decreased the premature discharge rate from 41% to 14%.
Common Roadblocks to Successful Treatment
Admission to action oriented inpatient programs when patient is not interested in change
Primary reason for enrolling is to satisfy other people
Failure to explore ambivalence
Non-negotiable treatment actions that are not understood, not applied consistently
Repeating treatment approaches that failed in the past
Bypassing Roadblocks to Treatment
Ex: patient with anorexia being committed, how patient became willing
- Focus on patient desire to avoid commitment instead of focus on weight gain or symptoms
- Pt agreed to attend outpt. meal support weekly & decrease exercise. Later agreed to admission.
Nursing Approach to Treatment of ED
- curious, non-judgmental,
- clarifying dilemmas but not trying to solve them,
- validating the position of deciding not to change,
- respecting that eating disorders are difficult
Self-help programs
NOT recommended until maintenance stage of change as they may cause a delay in seeking treatment
How to motivate the client w/ED
- -> Show empathy to the clients situation & use reflective listening to determine stage of change. Ask client to tell you about how their eating affects their life.
1. raise subject and ask permission
2. feedback
3. advice
4. enhance motivation (OARS, Readiness Ruler, Pros/Cons) - -> REDS:
- rolling with resistance
- express empathy
- develop discrepancy between goals/behaviors
- support self efficacy
5. Negotiate a plan
