Week 6 - Eating disorders, personality disorders, etc Flashcards
Eating Disorders
- 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
Bio/psycho/social/spiritual risk factors for eating disorders
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
Continuum of Eating Experience:
- 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
What is orthorexia?
- Orthorexia – obsessive diet that includes only healthy foods only -> unhealthy obsession w/ specific food and severe weight loss
often can result in malnutrition
Concepts of binge eating and dietary restraint
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.
What is the diagnostic criteria for anorexia nervosa?
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.
What are the types of anorexia nervosa and describe it.
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 ^
Anorexia Nervosa: Diagnostic Criteria (DSM-5, 2013)
- 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
What age range and gender mainly have anorexia nervosa?
Mostly 14-16 years old and females
Anorexia Nervosa: Epidemiology
- 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
Anorexia Nervosa: Bio-psychosocial Aetiologies
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
Anorexia Nervosa: Social Theories
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.
Describe the illness severity BMI ratings for anorexia nervosa.
Mild = BMI > 17
Moderate = BMI 16-16.99
Severe = BMI 15-15.99
Extreme = BMI <15
Interdisciplinary Treatment for Anorexia
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
Epidemiology: Bulimia Nervosa
- 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
What is the weight difference between anorexia and bulimia nervosa?
Bulimia has normal weight.
Bulimia Nervosa
- 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
What is the diagnostic criteria for bulimia nervosa?
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
Clinical Course of Bulimia
- 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
Describe the binge-purge cycle.
Dietary restraint -> hunger <–> binge eating <–> shame/humiliation <–> dieting/purging -> back to dietary restraint
What is the illness severity levels of bulimia nervosa (mild to extreme)?
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
Nursing Management of bulimia
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.
Interdisciplinary Treatment for Bulimia
- 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
Describe binge-eating disorder.
- 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.
What is the diagnostic criteria for binge eating disorder?
- 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
Dialectical Behaviour Therapy for eating disorder
- 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
Dialectical Behaviour Therapy for eating disorder
- 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
Enhanced Cognitive Behavior Therapy (CBT-E)
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
Eating Disorders: Nursing Assessment
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
Personality Disorders
- 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
Personality vs. personality disorder
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
Personality Disorders
- 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
What are the types of personality disorders in the clusters A, B, and C. What describes each category?
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.
What is paranoid personality disorder?
- 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
What is schizoid personality disorder?
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
What is schizotypal personality disorder?
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
What is borderline personality disorder and also problem areas?
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
Aetiology: Biosocial Theories for BPD
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
Describe antisocial personality disorder.
- 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
Describe histrionic personality disorder.
- 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
Describe narcissistic personality disorder.
- 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.
Describe avoidant personality disorder.
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
Describe dependent personality disorder.
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
Describe obsessive-compulsive personality disorder.
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
Pharmacological Treatment of Personality Disorders
- 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.
Personality Disorders: Pharmacological Treatments
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
What is the main non-pharmacological treatment for personality disorders?
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
Nursing Assessment for Personality disorders
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
Disruptive Impulse Control & Conduct Disorders
- 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
What is diagnostic criteria for oppositional defiant disorder?
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
What is diagnostic criteria for conduct disorder?
o Serious violations of rules and social norms
o Aggression to people and animals
o Destruction of property
o Deceitfulness or theft
What is diagnostic criteria for intermittent explosive disorder?
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
What is diagnostic criteria for kleptomania disorder?
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
What is diagnostic criteria for pyromania disorder?
Pyromania
o Repeated impulses or strong desires to set intentional fires
Non-Pharmacological Treatment of Disruptive Impulse Control and Conduct Disorders
- 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
Nursing Screening & Assessment - Disruptive Impulse control & Conduct Disorders
- Screening
o Minnesota Impulsive Disorders Interview (MIDI) - Mental Status Examination
- Suicide Risk Assessment
Mental Disorders: Cultural Perspectives & Experiences
- 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
Nurse Tamara is caring for a client diagnosed with bulimia. The most appropriate initial goal for a client diagnosed with bulimia is to:
Identify anxiety-causing situations.
