1. Chapter 18: Eating Disorders: Anorexia Nervosa and Bulimia Nervosa Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. 2 Etiology Biologic Factors  Genetic  Serotonin abnormality Sociocultural Factors  Diet and fitness industry  Fashion industry  Women’s movement  Peer pressure

3. 3 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Etiology, cont’d. Psychologic Factors  Perfectionism  Social insecurity  Affective insecurity  Interoceptive deficits  Alexithymia  Low self-esteem  Immaturity  Compliance  Sense of ineffectiveness  Interpersonal distrust

4. 4 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Etiology, cont’d. Familial Factors  Enmeshment  Poor conflict resolution  Separation, individuation

5. 5 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Figure 18-1 The cycle of eating disorders.

6. 6 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Epidemiology  Sex ratio  Age of onset  Cross-cultural  Mortality  Comorbidity

7. 7 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Behavioral Symptoms of Anorexia Nervosa  Self-starvation  Compulsive behaviors regarding food  May use laxatives or diuretics, excessive exercise, and vomiting  Wearing baggy clothes

8. 8 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Physical Symptoms of Anorexia Nervosa  Weight loss 15% below ideal  Amenorrhea  Bradycardia, subnormal body temperature  Cachexia, sunken eyes, dry skin  Lanugo on face  Constipation  Cold sensitivity

9. 9 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychologic Symptoms of Anorexia Nervosa  Denial of seriousness of low weight  Body image disturbance  Irrational fear of weight gain  Constant striving for perfect body  Self-concept unduly influenced by shape and weight  Preoccupation with food, cooking  Delayed psychosexual development (little interest in sex, relationships)

10. 10 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Behavioral Symptoms of Bulimia Nervosa  Recurrent episode of binge eating  Purging behavior to compensate  Self-induced vomiting, use of laxatives, diuretics, enemas, fasting, excessive exercise

11. 11 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Physical Symptoms of Bulimia Nervosa  Fluid and electrolyte imbalances  Hypokalemia, alkalosis, dehydration, idiopathic edema  Cardiovascular  Hypotension, dysrhythmias, cardiomyopathy  Endocrine  Hypoglycemia, menstrual dysfunction  Gastrointestinal  Constipation, diarrhea, gastroparesis, esophageal reflux, esophagitis, esophageal tears, dental enamel erosion, parotid gland enlargement

12. 12 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychologic Symptoms of Bulimia Nervosa  Body image disturbance  Persistent over concern with weight, shape, proportions  Mood swings, irritability  Self-concept unduly influenced by weight

13. 13 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Discharge Criteria  Be free from self-harm.  Achieve minimum normal weight.  Consume adequate calories to maintain normal weight.  Demonstrate ability to comply with postdischarge regimen.  Verbalize understanding of underlying psychologic issues.

14. 14 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Discharge Criteria, cont’d.  Use improved coping strategies.  Exhibit more functional behaviors within family system.  Attend group therapy.  Interact with helpful peers.  Keep appointments to monitor behaviors and medications.

15. 15 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment Therapeutic alliance is vital. Assess:  Willingness for treatment  Treatment history  Patterns and perceptions regarding weight  Body dissatisfaction  Body image distortion

16. 16 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment, cont’d. Assess:  Dieting history  Binge eating  Feelings regarding binge behaviors  Food cravings  Purging behaviors  Menstrual history  Medical side effects of eating disorder  Comorbidity factors

17. 17 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Diagnoses Anorexia Nervosa  Anxiety  Disturbed body image  Nutrition imbalance: less than body requirements  Social isolation Bulimia Nervosa  Ineffective coping  Deficient fluid volume  Chronic low self-esteem

18. 18 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Outcome Identification  Participate in therapeutic contact with staff.  Consume adequate calories for age, height, and metabolic need.  Maintain fluid and electrolyte balance.  Demonstrate more effective coping strategies.  Manage family dysfunction more effectively.  Verbalize awareness of underlying psychologic issues.  Perceive normal body weight and shape as acceptable.

19. 19 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Planning  Avoid power struggles  Need consistent, collaborative efforts by client, family, interdisciplinary staff

20. 20 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation  Ensure safe, nonthreatening environment  Prevent self-harm  Therapeutic alliance  Behavioral program to restore weight, nutrition  Structured environment with clear limits  Behavioral plan to reward compliance  Encourage expression of feelings

21. 21 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Interventions  Help increase client understanding of body image distortion.  Emphasize client capability to eat small portions without binging.  Maintain clear boundaries.  Avoid power struggles.  Intervene in anxiety.

22. 22 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Interventions, cont’d.  Give positive feedback for adherence to plan.  Engage in group therapy.  Assist to identify issues (e.g., esteem, identity disturbance).  Teach adaptive strategies.  Collaborate with dietician to teach nutrition.  Collaborate with interdisciplinary staff.

23. 23 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Biologic and Pharmacologic Treatment Modalities Biologic  Medical monitoring/hospitalization  Correcting deficiencies/imbalances Pharmacologic  SSRIs  Specific drugs for medical side effects of the disorders

24. 24 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychotherapeutic Treatment Modalities  Individual psychotherapy  Behavioral  Contracts  Exposure and response prevention  Cognitive  Reframing  Cognitive restructuring

25. 25 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Psychotherapeutic Treatment Modalities, cont’d.  Family therapy  Decrease secondary gain  Uncover family dysfunction  Group therapy  Safe disclosure  Minimize manipulation and secondary gain  Expressive therapies

26. 26 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Adjunctive Therapy  Occupational therapy  Nutrition education and counseling  Interdisciplinary treatment team  Community support groups