chapter 18: eating disorders: anorexia nervosa and bulimia nervosa copyright © 2012, 2007 mosby,...
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Chapter 18:Chapter 18:
Eating Disorders: Anorexia Eating Disorders: Anorexia Nervosa and Bulimia Nervosa and Bulimia
NervosaNervosa
Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
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EtiologyEtiology
Biologic FactorsBiologic Factors GeneticGenetic Serotonin abnormalitySerotonin abnormality
Sociocultural FactorsSociocultural Factors Diet and fitness industryDiet and fitness industry Fashion industryFashion industry Women’s movementWomen’s movement Peer pressurePeer pressure
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Etiology, cont’d. Etiology, cont’d.
Psychologic FactorsPsychologic Factors PerfectionismPerfectionism Social insecuritySocial insecurity Affective insecurityAffective insecurity Interoceptive deficitsInteroceptive deficits AlexithymiaAlexithymia Low self-esteemLow self-esteem
ImmaturityImmaturity ComplianceCompliance Sense of Sense of
ineffectivenessineffectiveness Interpersonal Interpersonal
distrustdistrust
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Etiology, cont’d. Etiology, cont’d.
Familial FactorsFamilial Factors EnmeshmentEnmeshment Poor conflict resolutionPoor conflict resolution Separation, individuationSeparation, individuation
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Figure 18-1 The cycle of eating disorders. Figure 18-1 The cycle of eating disorders.
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EpidemiologyEpidemiology
Sex ratioSex ratio Age of onsetAge of onset Cross-culturalCross-cultural MortalityMortality ComorbidityComorbidity
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Behavioral Symptoms Behavioral Symptoms of Anorexia Nervosaof Anorexia Nervosa
Self-starvationSelf-starvation Compulsive behaviors regarding foodCompulsive behaviors regarding food May use laxatives or diuretics, excessive May use laxatives or diuretics, excessive
exercise, and vomitingexercise, and vomiting Wearing baggy clothesWearing baggy clothes
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Physical Symptoms Physical Symptoms of Anorexia Nervosa of Anorexia Nervosa
Weight loss 15% below idealWeight loss 15% below ideal AmenorrheaAmenorrhea Bradycardia, subnormal body temperatureBradycardia, subnormal body temperature Cachexia, sunken eyes, dry skinCachexia, sunken eyes, dry skin Lanugo on faceLanugo on face ConstipationConstipation Cold sensitivityCold sensitivity
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Psychologic Symptoms Psychologic Symptoms of Anorexia Nervosaof Anorexia Nervosa
Denial of seriousness of low weightDenial of seriousness of low weight Body image disturbanceBody image disturbance Irrational fear of weight gainIrrational fear of weight gain Constant striving for perfect bodyConstant striving for perfect body Self-concept unduly influenced by shape and Self-concept unduly influenced by shape and
weightweight Preoccupation with food, cookingPreoccupation with food, cooking Delayed psychosexual development (little interest Delayed psychosexual development (little interest
in sex, relationships) in sex, relationships)
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Behavioral Symptoms Behavioral Symptoms of Bulimia Nervosaof Bulimia Nervosa
Recurrent episode of binge eatingRecurrent episode of binge eating Purging behavior to compensate Purging behavior to compensate
Self-induced vomiting, use of laxatives, diuretics, Self-induced vomiting, use of laxatives, diuretics, enemas, fasting, excessive exerciseenemas, fasting, excessive exercise
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Physical Symptoms Physical Symptoms of Bulimia Nervosaof Bulimia Nervosa
Fluid and electrolyte imbalancesFluid and electrolyte imbalances Hypokalemia, alkalosis, dehydration, idiopathic edemaHypokalemia, alkalosis, dehydration, idiopathic edema
CardiovascularCardiovascular Hypotension, dysrhythmias, cardiomyopathyHypotension, dysrhythmias, cardiomyopathy
EndocrineEndocrine Hypoglycemia, menstrual dysfunctionHypoglycemia, menstrual dysfunction
GastrointestinalGastrointestinal Constipation, diarrhea, gastroparesis, esophageal Constipation, diarrhea, gastroparesis, esophageal
reflux, esophagitis, esophageal tears, dental enamel reflux, esophagitis, esophageal tears, dental enamel erosion, parotid gland enlargementerosion, parotid gland enlargement
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Psychologic Symptoms Psychologic Symptoms of Bulimia Nervosaof Bulimia Nervosa
Body image disturbanceBody image disturbance Persistent over concern with weight, shape, Persistent over concern with weight, shape,
proportionsproportions Mood swings, irritabilityMood swings, irritability Self-concept unduly influenced by weightSelf-concept unduly influenced by weight
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Discharge CriteriaDischarge Criteria
Be free from self-harm.Be free from self-harm. Achieve minimum normal weight.Achieve minimum normal weight. Consume adequate calories to maintain Consume adequate calories to maintain
normal weight.normal weight. Demonstrate ability to comply with Demonstrate ability to comply with
postdischarge regimen.postdischarge regimen. Verbalize understanding of underlying Verbalize understanding of underlying
psychologic issues.psychologic issues.
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Discharge Criteria, cont’d.Discharge Criteria, cont’d.
Use improved coping strategies. Use improved coping strategies. Exhibit more functional behaviors within Exhibit more functional behaviors within
family system.family system. Attend group therapy.Attend group therapy. Interact with helpful peers.Interact with helpful peers. Keep appointments to monitor behaviors and Keep appointments to monitor behaviors and
medications.medications.
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AssessmentAssessment
Therapeutic alliance is vital. Therapeutic alliance is vital.
Assess:Assess: Willingness for treatmentWillingness for treatment Treatment historyTreatment history Patterns and perceptions regarding weightPatterns and perceptions regarding weight Body dissatisfactionBody dissatisfaction Body image distortionBody image distortion
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Assessment, cont’d.Assessment, cont’d.
Assess:Assess: Dieting historyDieting history Binge eatingBinge eating Feelings regarding binge behaviorsFeelings regarding binge behaviors Food cravingsFood cravings Purging behaviorsPurging behaviors Menstrual historyMenstrual history Medical side effects of eating disorderMedical side effects of eating disorder Comorbidity factorsComorbidity factors
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Nursing DiagnosesNursing Diagnoses
Anorexia NervosaAnorexia Nervosa AnxietyAnxiety Disturbed body imageDisturbed body image Nutrition imbalance: less than body requirementsNutrition imbalance: less than body requirements Social isolationSocial isolation
Bulimia NervosaBulimia Nervosa Ineffective copingIneffective coping Deficient fluid volumeDeficient fluid volume Chronic low self-esteemChronic low self-esteem
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Outcome IdentificationOutcome Identification
Participate in therapeutic contact with staff. Participate in therapeutic contact with staff. Consume adequate calories for age, height, and Consume adequate calories for age, height, and
metabolic need.metabolic need. Maintain fluid and electrolyte balance.Maintain fluid and electrolyte balance. Demonstrate more effective coping strategies.Demonstrate more effective coping strategies. Manage family dysfunction more effectively.Manage family dysfunction more effectively. Verbalize awareness of underlying psychologic Verbalize awareness of underlying psychologic
issues.issues. Perceive normal body weight and shape as Perceive normal body weight and shape as
acceptable.acceptable.
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PlanningPlanning
Avoid power strugglesAvoid power struggles Need consistent, collaborative efforts by Need consistent, collaborative efforts by
client, family, interdisciplinary staffclient, family, interdisciplinary staff
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ImplementationImplementation
Ensure safe, nonthreatening environmentEnsure safe, nonthreatening environment Prevent self-harmPrevent self-harm Therapeutic allianceTherapeutic alliance Behavioral program to restore weight, nutritionBehavioral program to restore weight, nutrition Structured environment with clear limitsStructured environment with clear limits Behavioral plan to reward complianceBehavioral plan to reward compliance Encourage expression of feelingsEncourage expression of feelings
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Nursing InterventionsNursing Interventions
Help increase client understanding of body Help increase client understanding of body image distortion.image distortion.
Emphasize client capability to eat small Emphasize client capability to eat small portions without binging.portions without binging.
Maintain clear boundaries.Maintain clear boundaries. Avoid power struggles.Avoid power struggles. Intervene in anxiety.Intervene in anxiety.
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Nursing Interventions, cont’d.Nursing Interventions, cont’d.
Give positive feedback for adherence to plan.Give positive feedback for adherence to plan. Engage in group therapy.Engage in group therapy. Assist to identify issues (e.g., esteem, identity Assist to identify issues (e.g., esteem, identity
disturbance).disturbance). Teach adaptive strategies.Teach adaptive strategies. Collaborate with dietician to teach nutrition.Collaborate with dietician to teach nutrition. Collaborate with interdisciplinary staff.Collaborate with interdisciplinary staff.
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Biologic and Pharmacologic Biologic and Pharmacologic Treatment ModalitiesTreatment Modalities
BiologicBiologic Medical monitoring/hospitalizationMedical monitoring/hospitalization Correcting deficiencies/imbalancesCorrecting deficiencies/imbalances
PharmacologicPharmacologic SSRIsSSRIs Specific drugs for medical side effects of Specific drugs for medical side effects of
the disordersthe disorders
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Psychotherapeutic Psychotherapeutic Treatment ModalitiesTreatment Modalities
Individual psychotherapyIndividual psychotherapy BehavioralBehavioral
ContractsContracts Exposure and response preventionExposure and response prevention
CognitiveCognitive ReframingReframing Cognitive restructuringCognitive restructuring
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Psychotherapeutic Psychotherapeutic Treatment Modalities, cont’d.Treatment Modalities, cont’d.
Family therapyFamily therapy Decrease secondary gainDecrease secondary gain Uncover family dysfunctionUncover family dysfunction
Group therapyGroup therapy Safe disclosureSafe disclosure Minimize manipulation and secondary gainMinimize manipulation and secondary gain
Expressive therapies Expressive therapies
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Adjunctive TherapyAdjunctive Therapy
Occupational therapyOccupational therapy Nutrition education and counselingNutrition education and counseling Interdisciplinary treatment teamInterdisciplinary treatment team Community support groupsCommunity support groups