Week 6 - Eating disorders, personality disorders, etc

Question 1

Eating Disorders

Answer 1

• Approximately 5% of the population will experience an eating disorder at one point in their lives
• Eating disorders are behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions
• For ppl living w/ eating disorders, their self-esteem is primarily determined by their ability to control weight and shape
  o Attempt to follow w/ restrictive dieting  binge-eating episode
• Usually in adolescence or early adulthood
• Preoccupation – excessive thinking about weight or shape
• Fear of becoming fat is a main problem
• Entire mental focus is on one goal: weight loss
  o Ignores body signals or cues such as hunger, and concentrates all efforts on controlling food intake
• Interoceptive awareness – ability to identify and respond to emotional and visceral clues such as hunger
• Types of Eating Disorders (DSM-5, 2013)
  o Anorexia nervosa
  o Bulimia nervosa
  o Binge eating disorder

Question 2

Bio/psycho/social/spiritual risk factors for eating disorders

Answer 2

Spiritual:
* Sense of well-being
* Quality of life
* Attitudes
Social:
* Ideals of beauty
* Media
* Fashion
* Cultural
Biologic:
* Dieting
* Metabolic rate
Psychological:
* Low self-esteem
* Body dissatisfaction
* Ineffectiveness/lack of assertiveness

Question 3

Continuum of Eating Experience:

Answer 3

• Unrestricted eating  watchful eating  increasing weight and shape preoccupation  clinical eating disorders
• Watchful eating – paying attention to food composition and calories, tracking calories, and physical activity
  o May become dissatisfied w/ body appearance and weigh self more than usual
• Increasing weight and shape preoccupation (concern)
  o More rigidly adheres to food selection and eating patterns
  o Insistent calorie counting, preoccupation w/ food composition and exercise
  o May overeat as a response to dietary restriction
  o Tracks weight losses and gains
  o Chemical preparations and supplements to target appearance ideals
  o Binge eating and purging may increase in frequency and duration

Question 4

What is orthorexia?

Answer 4

• Orthorexia – obsessive diet that includes only healthy foods only -> unhealthy obsession w/ specific food and severe weight loss

often can result in malnutrition

Question 5

Concepts of binge eating and dietary restraint

Answer 5

Binge eating
* Rapid, episodic, impulsive, and uncontrollable ingestion of large amount of food over a short period of time (1 to 2 hours)
* Eating followed by guilt, remorse, and severe dieting
o Eating a whole cheesecake or 2 in one short sitting
Dietary restraint
* Restricting intake is believed to explain the relationship between dieting and binge behaviour.
* Restraining intake is predictive of overeating.

Question 6

What is the diagnostic criteria for anorexia nervosa?

Answer 6

Diagnostic Criteria: Anorexia Nervosa
 Restriction of energy intake relative to requirements leading to a significantly low body weight
 Intense fear of gaining weight or of becoming fat or persistent behavior that interferes with weight gain even though at a significantly low weight
 Disturbance in the way in which one’s body weight or shape is experienced/perceived undue influence of body weight, or shape on self-evaluation or persistent lack of recognition of the seriousness of current low body weight
 DSM-5:
 Does not require presence of amenorrhea (absence of period)
 Use of body mass index (BMI) cutoffs to denote severity
R.I.D.

Question 7

What are the types of anorexia nervosa and describe it.

Answer 7

RESTRICTING TYPE
* Dieting
* Fasting
* Excessive exercise
BINGE EATING/PURGING TYPE
* Self-induced vomiting
* Misuse of laxatives
* Misuse of diuretics
* Misuse of enemas
All to lose weight ^

Question 8

Anorexia Nervosa: Diagnostic Criteria (DSM-5, 2013)

Answer 8

• Onset in adolescence or early adulthood.
• Chronic condition with relapses characterized by significant weight loss.
• Higher all-cause mortality than all other psychiatric disorders with the exception of substance abuse and postpartum admission.
• Body image distortion - occurs when the individual perceives his or her body disparately from how the world or society views it.
• Low body weight

Question 9

What age range and gender mainly have anorexia nervosa?

Answer 9

Mostly 14-16 years old and females

Question 10

Anorexia Nervosa: Epidemiology

Answer 10

• 0.3% to 1% prevalence
• Mostly in 14- to 16-year-olds
• Female-to-male ratio: 10:1
• Culturally defined body weight expectations
• Vulnerable b/c of stressors associated w/ body image, autonomy, peer pressure, media, etc.
• Familial predisposition
• Comorbid with mood or anxiety disorders, alcohol abuse/dependence, and depression

Question 11

Anorexia Nervosa: Bio-psychosocial Aetiologies

Answer 11

Spiritual distress
Biologic:
* Increased genetic vulnerability
* Dieting  starving
* Overexercising
* Decreased awareness of hunger
* OCD
* Decreased serotonin activity
Social:
* Idealization of thinness – media
* Pursuit of thinness
* Enmeshment with family
o Too involved with family and no personal boundaries
* Overprotective family
Psychological:
* Separation – individuation struggle
* Sexuality conflicts
* Decreased awareness of emotional cue
* Feminist view  role pressures
* Negative body image – body dissatisfaction

Question 12

Anorexia Nervosa: Social Theories

Answer 12

Social expectations:
o Societal norms and expectations.
o Media influence, fashion industry, peer pressure
 Media exposure are strong predictors of girls’ dietary restraint
o Body dissatisfaction is related to low self-esteem, depression, dieting, binging, and purging.
Family responses
o Enmeshment – no personal boundaries
 Leads to poor autonomy and higher severity of anorexia nervosa (AN)
 refers to an extreme form of intensity in family interactions.
 Can lead to self-esteem issues due to lack of identity
o Overprotectiveness – acting on high degree of concern for another
Spiritual
o Core struggles in eating disorders are spiritual in nature.
o Individuals tend to lose the ability to acknowledge their self-worth and identity.
o Feeling distant and disconnected from family and friends.

Question 13

Describe the illness severity BMI ratings for anorexia nervosa.

Answer 13

Mild = BMI > 17
Moderate = BMI 16-16.99
Severe = BMI 15-15.99
Extreme = BMI <15

Question 14

Interdisciplinary Treatment for Anorexia

Answer 14

Goals
o Initiating nutritional rehabilitation
o Resolving conflicts around body image disturbance
o Increasing effective coping
o Addressing underlying conflicts
o Assisting family with healthy functioning and communication
o For full recovery:
 Weight restoration alone is not sufficient goal
 Must address distorted body image, thoughts/behaviours, etc.
 Restoring weight influences symptom remission more than medications
Treatment modalities
o Hospitalization necessary if health deteriorates
o Interdisciplinary approach
o Pharmacologic approaches
Refeeding syndrome
o Body not used to process a lot of food at once after being anorexic and should build on the amount consumed

Question 15

Epidemiology: Bulimia Nervosa

Answer 15

• Approximately 1% to 3% of young women develop BN in their lifetime.
• Onset is in adolescence or early adulthood (older than anorexia nervosa).
• In the community setting, 1 case in 4 of BN is a male.
• Related to Western culture social values.
• First-degree relatives more likely to develop.
• Comorbid conditions include substance abuse and anxiety disorders.
  Risk factors for BN is dieting
  o Can turn into dietary restraint -> binge eating and purging
  o Others include body dissatisfaction and anxiety stressors

Question 16

What is the weight difference between anorexia and bulimia nervosa?

Answer 16

Bulimia has normal weight.

Question 17

Bulimia Nervosa

Answer 17

• Recurrent episodes of binge eating.
• Does not come to the attention of parents and peers as quickly as AN.
• Treatment is outpatient therapy.
• Usually normal weight.
• Dietary restraint can lead to excessive hunger  binge eating

Question 18

What is the diagnostic criteria for bulimia nervosa?

Answer 18

Recurrent episodes of binge eating and purging at least once a week for 3 months.
Lack of control during eating and concern for body weight

Diagnostic Criteria: Bulimia Nervosa
 Recurrent episodes of binge eating
 A sense of lack of control over eating during the episode
 Recurrent compensatory behaviors to prevent weight gain including self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, excessive exercising
 Binge eating and compensatory behaviors occur at least once a week for three months
 Excessive Concern with body shape and weight
RBP CC

Question 19

Clinical Course of Bulimia

Answer 19

• Few outward signs
• Binge and purge (expelling food) in secret
• Treatment often delayed for years b/c might not come to attention to parents
• Treatment initiated when control of eating is lost
• Treatment is outpatient therapy.
• Usually normal weight.
• Complete recovery after treatment initiated

Question 20

Describe the binge-purge cycle.

Answer 20

Dietary restraint -> hunger <–> binge eating <–> shame/humiliation <–> dieting/purging -> back to dietary restraint

Question 21

What is the illness severity levels of bulimia nervosa (mild to extreme)?

Answer 21

Mild = 1-3 episodes of compensatory behaviours/week
Moderate = 4-7 episodes of compensatory behaviours/week
Severe = 8-13 episodes of compensatory behaviours/week
Extreme = 14+ episodes of compensatory behaviours/week

Question 22

Nursing Management of bulimia

Answer 22

Assessment
o Similar to anorexia nervosa
o Binging/purging behaviour
Diagnosis
Interventions
o Biologic
 Nutritional counselling/management
 Pharmacologic
o Psychosocial
 CBT and IPT can be used.
 Behavioural interventions (cue elimination, self-monitoring).
 Self-monitoring.
Identifying disordered eating patterns.
 Interrupting binge–purge cycle.
 Education.
 Group therapy and family intervention.

Question 23

Interdisciplinary Treatment for Bulimia

Answer 23

• Usually takes place in an outpatient setting
• Focuses on psychological issues including:
  o Boundary setting and separation–individuation conflicts (not being able to pursue goals that differ from family and friends)
  o Changing problematic behaviours and dysfunctional thought patterns and attitudes
  o Spiritual component
• Nutritional counselling

Question 24

Describe binge-eating disorder.

Answer 24

• Ingestion of a large amount of food in a short period of time.
• Sense of loss of control during the binge.
• Distress regarding the binge.
• Eating until uncomfortably full.
• Feelings of guilt or depression following the binge.
• Purging does not occur with BED.

Question 25

What is the diagnostic criteria for binge eating disorder?

Answer 25

• Recurrent episodes of binge eating that occur on average at least once a week for a period of 3 months
• Influenced by such cues as dietary restraint, hunger, and negative affective states

Question 26

Dialectical Behaviour Therapy for eating disorder

Answer 26

• Combines numerous cognitive–behavioural approaches
• Requires monitoring and commitment by the patient
• Individual therapy
• Building skills through skills group
  o Mindfulness
  o Interpersonal effectiveness
  o Emotion regulation
  o Distress tolerance skills

Question 27

Dialectical Behaviour Therapy for eating disorder

Answer 27

• Combines numerous cognitive–behavioural approaches
• Requires monitoring and commitment by the patient
• Individual therapy
• Building skills through skills group
  o Mindfulness
  o Interpersonal effectiveness
  o Emotion regulation
  o Distress tolerance skills

Question 28

Enhanced Cognitive Behavior Therapy (CBT-E)

Answer 28

An empirically supported staged treatment designed specifically to help individuals with eating disorder achieve their personal recovery goals
Staged Treatment
o Stage1 focused on understanding eating problem
o Stage 2 understanding processes that are maintaining the eating problem
o Stage 3 Addressing concerns about shape and eating, enhancing ability to deal with day to day events and moods, addressing extreme dietary restraint
o Stage 4 Dealing with setbacks and maintaining gains

Question 29

Eating Disorders: Nursing Assessment

Answer 29

Screening
o SCOFF eating disorders screening tool
o CAGE screen for alcohol disorders
Assessment
o Head-to-toe assessment
o Vital signs
o Weight
o BMI
o Laboratory tests
Mental Status Examination
Suicide Risk Assessment

The following physical signs and laboratory findings are common:
* marked weight loss
* bradycardia and hypotension
* amenorrhea or light, irregular periods
* impaired temperature regulation
* acrocyanosis
* delayed gastric emptying
* hair loss, dry skin and growth of lanugo hair
* hypokalemic, hypochloremic metabolic alkalosis
* elevated salivary amylase
* parotid hypertrophy
* anemia
* EKG findings of low voltage, T-wave inversion, prolonged QTc interval
* osteoporosis at a young age

Question 30

Personality Disorders

Answer 30

• Approximately 7.8% of the population is diagnosed have a personality disorder (APA, 2022)
• Individuals with personality disorders represent 20% of emergency department and 25% of inpatient mental health hospital admissions (Barr, Jewell & Townsend, 2020)
• Regrettably, individuals living with personality disorders often experience stigmatizing responses from health care providers when they seek health care services including:
  o Poor communication
  o Inappropriate treatment
  o Not having concerns taken seriously
• Highly unusual for children to be diagnosed w/ PD
• BPD diagnosis can be given to adolescent

Question 31

Personality vs. personality disorder

Answer 31

Personality:
* Complex pattern of characteristics, largely outside of the person’s awareness
* Distinctive patterns of perceiving, feeling, thinking, coping, and behaving
* Emerges within biopsychosocial framework

Personality Disorder:
* An enduring pattern of deviant inner experiences and behaviour
* Differs from cultural expectations
* Pervasive, inflexible, and stable
* Leads to distress or impairment

Question 32

Personality Disorders

Answer 32

• No sharp division exists between normal and abnormal personality functioning.
• Ten personality disorders are recognized as psychiatric diagnoses and are organized into three clusters.
• To receive a DSM-5 diagnosis of PD, an individual must demonstrate the criteria behaviours persistently and to such an extent that they impair the ability to function socially and occupationally.
• Psychological and psychosocial interventions are primary approaches to treatment of PDs, with psychopharmacology used adjunctively and on a short-term basis

Question 33

What are the types of personality disorders in the clusters A, B, and C. What describes each category?

Answer 33

Cluster A – Social Aversion
* Paranoid personality disorder
* Schizoid personality disorder
* Schizotypal personality disorder
* P.S.S.
Cluster B – Dysregulation in emotions and behaviour
* Narcissistic personality disorder
* Antisocial personality disorder
* Histrionic personality disorder
* Borderline personality disorder
* N.A.H.B.
Cluster C – Fearfulness
* Obsessive-compulsive personality disorder
* Dependent personality disorder
* Avoidant personality disorder
* O.D.A.

Question 34

What is paranoid personality disorder?

Answer 34

• Features
  o Mistrustful, avoid relationships that they cannot control
   Even w/ family and close friends
  o Persistent ideas of self-importance
   E.g., important enough to be a target of harmful intentions of others
  o Will be hypervigilant to any environmental changes
  o Difficulty with developing and maintaining relationships

Question 35

What is schizoid personality disorder?

Answer 35

Features
o Expressively impassive and interpersonally unengaged
o Introverted and reclusive, engage in solitary activities
o Communication sometimes confused and lacks focus
o Incapable of forming social relationships
o Minimum introspection, self-awareness, and interpersonal experiences

Question 36

What is schizotypal personality disorder?

Answer 36

Features
o Eccentric (odd person) or peculiar
o Pattern of social and interpersonal deficits
o Void of close friends, don’t form friendships easily
o Odd beliefs
o Ideas of reference
 false belief that random events relate to them
* E.g., “everyone on the passing bus is talking about them”
o When psychotic, symptoms mimic schizophrenia

Question 37

What is borderline personality disorder and also problem areas?

Answer 37

Instability of AIRS
* Pervasive patterns of instability of interpersonal relationships, self-image, and affects, as well as marked impulsivity that begins by early adulthood and is present in a variety of contexts

CARDIS

Cognitive dysfunctions
o Maladaptive schemas
o Dichotomous thinking – only thinks of things in two opposite categories
 E.g., good or bad, success or failure (does not think in between those ideas)
o Dissociation – thoughts and ideas can split off from consciousness
 E.g., driving familiar road, get lost in thoughts and suddenly not remember what happened during that trip
 Kind of like daydreaming

Affective instability—rapid and extreme shifts in moods
o E.g., greet person w/ intense affection, then later be distant from them

Unstable interpersonal relationships
o Fear of abandonment
o Unstable, insecure attachments
o Overidealize/intense relationships

Dysfunctional behaviours
o Impaired problem solving
o Impulsivity
o Self-injurious behaviours (parasuicidal behaviour)
 Compulsive
 Episodic
 Repetitive

Identity disturbance (loss of your sense of self/personal identity)
o Role absorption—narrow definition of self within a single role
o Painful incoherence—distressed internal disharmony
o Inconsistency in thoughts, feelings, and actions
o Lack of commitment

Risk for suicide

Risk Factors
o Physical and sexual abuse
o Childhood neglect

Aetiology of BPD:
o Genetics – 5x more common w/ first-degree relatives

Question 38

Aetiology: Biosocial Theories for BPD

Answer 38

Millon
o Distinct disorder that develops as a result of both biologic and psychological factors.
o Due to biologically based patterns and behaviour:
 Personality is shaped by (a) active–passive behaviour, (b) pleasure–pain, and (c) sensitivity to self or others.
Linehan
o Focus on biologic and social learning influences:
 Emotional vulnerability, self-invalidation, unrelenting crises, inhibited grieving, active passivity, and apparent competence

Question 39

Describe antisocial personality disorder.

Answer 39

• Disregard for and violation of the rights of others
• Behaviourally impulsive, often criminal behaviour
• Interpersonally irresponsible, deceitful
  o E.g., trying to get nurses to break rules for them
• Fail to adapt to the ethical and social standards of community
• Interpersonally engaging, but in reality, lack empathy
• Easily irritated, often aggressive
• Comorbid with alcohol and drug abuse

Question 40

Describe histrionic personality disorder.

Answer 40

• Attention seeking, life of the party, uncomfortable with single relationship (need multiple)
• Lively and dramatic and draw attention to themselves by their enthusiasm, dress, and apparent openness
• Become depressed when not centre of attention
• Culturally influenced
• May co-occur with BPD, DPD, and ASPD, as well as anxiety disorders, substance abuse, and mood disorders

Question 41

Describe narcissistic personality disorder.

Answer 41

• Grandiose degree of self-love and self-importance
• Lacks empathy for others
• Inexhaustible need for attention
• Fantasies about power, unlimited success
• Experiences personal insecurities
• Aetiology—unknown
• A.E.G.I.S.

Question 42

Describe avoidant personality disorder.

Answer 42

Cluster C.
Avoidant personality disorder
o Intense fear of social rejection
o Avoiding interpersonal contacts and social situations
o Perceiving themselves as socially inept (awkward), timid, shy
 Only engage in interpersonal relationships when certain they will receive approval

Question 43

Describe dependent personality disorder.

Answer 43

Dependent personality disorder
o Submissive pattern, desperate to keep others close
o Cling to others to be taken care of
o Prevalent in clinical samples

Question 44

Describe obsessive-compulsive personality disorder.

Answer 44

Obsessive–compulsive personality disorder
o Different than OCD
o Not as many obsessions and compulsions, less when anxiety decreases
o E.g., orderliness, details rules, lists
 Have difficulty working w/ others who do not do things exactly as they do
o Functioning is not impacted

Question 45

Pharmacological Treatment of Personality Disorders

Answer 45

• Requires the entire health care team.
• There is evidence that BPD symptoms can be alleviated in the short term by mood stabilizers (e.g., topiramate; for emotional dysregulation and impulse-aggressive symptoms) and some second-generation antipsychotics (e.g., olanzapine; for cognitive–perceptual and impulsive–aggressive symptoms).
• Psychotherapy.

Question 46

Personality Disorders: Pharmacological Treatments

Answer 46

Antidepressants
o can be useful if an individual has depressed mood, anger impulsivity, irritability or hopelessness associated with personality disorders
Anxiolytics
o can help with impulsive behavior
Antipsychotics
o can help with psychotic symptoms and anger
Mood stabilizers
o can help with mood swings, reduce irritability, impulsivity and aggression

Question 47

What is the main non-pharmacological treatment for personality disorders?

Answer 47

Dialectical Behaviour Therapy
* Combines numerous cognitive–behavioural approaches
* Requires monitoring and commitment by the patient
* Individual therapy
* Building skills through skills group
o Mindfulness
o Interpersonal effectiveness
o Emotion regulation
o Distress tolerance skills

Question 48

Nursing Assessment for Personality disorders

Answer 48

Screening
o McLean Screening Instrument for BPD (MSI-BPD)
Assessment
o Structured Clinical Interview for DSM V Axis II Personality Disorders-Patient Questionnaire
Mental Status Examination
Suicide Risk Assessment
A single, definitive personality disorder test does not exist

Question 49

Disruptive Impulse Control & Conduct Disorders

Answer 49

• Approximately 10.5% of the population is diagnosed have a disruptive impulse control disorders
• Problematic issues with self-control are typically first observed in childhood and often persist into adulthood
• Types of Impulse Control Disorders:
  o Oppositional defiant disorder
  o Intermittent explosive disorder
  o Conduct disorder
  o Kleptomania – desire to steal
  o Pyromania – desire to set fires

Question 50

What is diagnostic criteria for oppositional defiant disorder?

Answer 50

o Angry/irritable mood (aggressive)
o Argumentative and defiant
o Blames others for mistakes and misbehaviour
o Vindictiveness – vengeful, seeks revenge
o E.g., getting into trouble at school and not following rules
o Disruption at school or work and in relationships with others

Question 51

What is diagnostic criteria for conduct disorder?

Answer 51

o Serious violations of rules and social norms
o Aggression to people and animals
o Destruction of property
o Deceitfulness or theft

Question 52

What is diagnostic criteria for intermittent explosive disorder?

Answer 52

o Outbursts of verbal or physical aggressiveness, out of proportion, that result in an assault of persons, animals, or property
o Event triggers them and can cause problems at work, home, etc.
 E.g., told you can’t go to party and you break everything in the house out of anger
o Risk for suicide can be high

Question 53

What is diagnostic criteria for kleptomania disorder?

Answer 53

o Involuntary, impulsive and irresistible stealing of objects that are not needed for personal use or other forms of use
o E.g., they can afford and don’t even want it

Question 54

What is diagnostic criteria for pyromania disorder?

Answer 54

Pyromania
o Repeated impulses or strong desires to set intentional fires

Question 55

Non-Pharmacological Treatment of Disruptive Impulse Control and Conduct Disorders

Answer 55

• Parent management training – how to relate to children better and how to change the frequency of bad activities
• Cognitive behaviour therapy
• Family therapy
• Functional family therapy
• Cognitive therapy

Question 56

Nursing Screening & Assessment - Disruptive Impulse control & Conduct Disorders

Answer 56

• Screening
  o Minnesota Impulsive Disorders Interview (MIDI)
• Mental Status Examination
• Suicide Risk Assessment

Question 57

Mental Disorders: Cultural Perspectives & Experiences

Answer 57

• Culture affects the way we express our thoughts, emotions and behaviors
• There are cultural differences in the way illness is manifested and treated
• One of the main differences seen across cultures is the way illness is expressed

Question 58

Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:

Answer 58

Identify anxiety-causing situations.