eating disorder

EATING DISORDER

By

Ni Ketut Alit A

Faculty Of Nursing Airlangga University

Slide 1

REFERENCES

Black, J.M. & Matassarin E, (1997). Medical Surgical Nursing: Clinical Management for continuity of care. J.B. Lippincott.co.

Barbara C.L & Wilma J.P. (2006). Essentials of Medical Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

Smeltzer, S.C., & Bare, B. (2003). Brunner and Suddarth's Textbook of Medical-Surgical Nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

Ignativicius & Bayne. (2001). Medical and Surgical Nursing. Philadelphia: W.B. Saunders Company.

Luckman & Sorensen. (2000). Medical Surgical Nursing. Philadelphia: W.B. Saunders Company.

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Slide 2

EATING DISORDERS

Current Western beauty standards equate thinness with health and beauty

There has been a rise in eating disorders in the past three decades• The core issue is a morbid fear of weight gain

Two main diagnoses:• Anorexia nervosa

• Bulimia nervosa

ANOREXIA NERVOSA

The main symptoms of anorexia nervosa are:

• A refusal to maintain more than 85% of normal body weight

• Intense fears of becoming overweight

• A distorted view of body weight and shape

• Amenorrhea

Anorexia Nervosa

There are two main subtypes:

• Restricting type• Lose weight by restricting “bad” foods, eventually

restricting nearly all food

• Show almost no variability in diet

• Binge-eating/purging type• Lose weight by vomiting after meals, abusing laxatives

or diuretics, or engaging in excessive exercise• Like those with bulimia nervosa, people with this subtype

may engage in eating binges

Anorexia Nervosa

About 90–95% of cases occur in females

The peak age of onset is between 14 and 18 years

Around 0.5% of females in Western countries develop the disorder

• Many more display some symptoms

Anorexia Nervosa

The “typical” case:

• A normal to slightly overweight female has been on a diet

• Escalation to anorexia nervosa may follow a stressful event

• Separation of parents

• Move or life transition

• Experience of personal failure

• Most patients recover

• However, about 2 to 6% become seriously ill and die as a result of medical complications or suicide

Anorexia Nervosa: The Clinical Picture

The key goal for people with anorexia nervosa is thinness

• The driving motivation is FEAR:

• Of becoming obese

• Of losing control of body shape and weight


Despite their dietary restrictions, people with anorexia are extremely preoccupied with food

• This includes thinking and reading about food and planning for meals

• This relationship is not necessarily causal

• It may be the result of food deprivation, as evidenced by the famous.


People with anorexia nervosa also demonstrate distorted thinking:

• Often have a low opinion of their body shape

• Tend to overestimate their actual proportions

• Adjustable lens assessment technique – overestimate size by 20%

• Hold maladaptive attitudes and beliefs

• “I must be perfect in every way”

• “I will be a better person if I deprive myself”

• “I can avoid guilt by not eating”


People with anorexia may also display certain psychological problems:• Depression (usually mild)

• Anxiety

• Low self-esteem

• Insomnia or other sleep disturbances

• Substance abuse

• Obsessive-compulsive patterns

• Perfectionism

Anorexia Nervosa: Problems

Caused by starvation:

• Amenorrhea

• Low body temperature

• Low blood pressure

• Body swelling

• Reduced bone density

• Slow heart rate

• Metabolic and electrolyte imbalance

• Dry skin, brittle nails

• Poor circulation

• Lanugo

BULIMIA NERVOSA

Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges:

• Bouts of uncontrolled overeating during a limited period of time

• Often objectively more than most people would/could eat in a similar period

Bulimia Nervosa

The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition:

• Purging-type bulimia nervosa• Vomiting

• Misusing laxatives, diuretics, or enemas

• Nonpurging-type bulimia nervosa• Fasting

• Exercising excessively

Bulimia Nervosa

Like anorexia nervosa, about 90–95% of bulimia nervosa cases occur in females

The peak age of onset is between 15 and 21 years

Symptoms may last for several years with periodic letup

Bulimia Nervosa

Patients are generally of normal weight

• May be slightly overweight

• Often experience weight fluctuations

“Binge-eating disorder” may be a related diagnosis

• Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting)

• This condition is not yet listed in the DSM

Bulimia Nervosa

Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media

In one study:

• 50% of college students reported periodic binges

• 6% tried vomiting

• 8% experimented with laxatives at least once

Bulimia Nervosa: Binges

For people with bulimia nervosa, the number of binges per week can range from 2 to 40

• Average: 10 per week

Binges are often carried out in secret

• Binges involve eating massive amounts of food rapidly with little chewing

• Binge-eaters commonly consume more than 1500 calories (often more than 3000 calories) per binge episode

Bulimia Nervosa: Binges

Binges are usually preceded by feelings of tension and/or powerlessness

Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery”

Bulimia Nervosa: Compensatory Behaviors

After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects

The most common compensatory behaviors:

• Vomiting

• Affects ability to feel satiated greater hunger and bingeing

• Laxatives and diuretics

• Almost completely fail to reduce the number of calories consumed

Bulimia Nervosa: Compensatory Behaviors

Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating

• Over time, however, a cycle develops in which purging bingeing purging…

Bulimia Nervosa

The “typical” case:

• A normal to slightly overweight female has been on an intense diet

• Research suggests that even among normal subjects, bingeing often occurs after strict dieting

• For example, a study of binge-eating behavior in a low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment

Bulimia Nervosa vs. Anorexia Nervosa

Similarities:• Onset after a period of dieting

• Fear of becoming obese

• Drive to become thin

• Preoccupation with food, weight, appearance

• Elevated risk of self-harm or attempts at suicide

• Feelings of anxiety, depression, perfectionism

• Substance abuse

• Disturbed attitudes toward eating


Differences:

• People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships

• People with bulimia tend to be more sexually experienced

• People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia

• People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping


Differences:

• People with bulimia tend to be controlled by emotion – may change friendships easily

• People with bulimia are more likely to display characteristics of a personality disorder

• Different medical complications:

• Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia

• People with bulimia suffer damage caused by purging, especially from vomiting and laxatives

Causes Eating Disorders

Most theorists subscribe to a multidimensional risk perspective:

• Several key factors place individuals at risk

• More factors = greater risk

• Leading factors:

• Sociocultural conditions (societal and family pressures)

• Psychological problems (ego, cognitive, and mood disturbances)

• Biological factors

Causes Eating Disorders: Societal Pressures

Many theorists argue that current Western standards of female attractiveness have contributed to the rise of eating disorders

• Standards have changed throughout history toward a thinner ideal

Causes Eating Disorders: Societal Pressures

Certain groups are at greater risk from these pressures:

• Models, actors, dancers, and certain athletes

• Of college athletes surveyed, 9% met full criteria for an eating disorder while another 50% had symptoms

• 20% of surveyed gymnasts met full criteria for an eating disorder

Causes Eating Disorders:Societal Pressures

The socially-accepted prejudice against overweight people may also add to the “fear” and preoccupation about weight

• About 50% of elementary and 61% of middle school girls are currently dieting

Causes Eating Disorders : Family Environment

Families may play a critical role in the development of eating disorders

• As many as half of the families of those with eating disorders have a long history of emphasizing thinness, appearance, and dieting

• Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves

Causes Eating Disorders : Family Environment

Abnormal family interactions and forms of communication within a family may also set the stage for an eating disorder

• Minuchin cites “enmeshed family patterns” as causal factors of eating disorders

• These patterns include overinvolvement in, and overconcern about, family member’s lives

• Such families can be affectionate and loyal but can also foster clinginess and dependency

• Children are allowed little room for individuality and independence

Causes Eating Disorders Ego Deficiencies and Cognitive Disturbances

Bruch : eating disorders are the result of disturbed mother–child interactions which lead to serious ego deficiencies in the child and to severe cognitive disturbances

Causes Eating Disorders :Ego Deficiencies and Cognitive Disturbances

Bruch : parents may respond to their children either effectively or ineffectively• Effective parents accurately attend to a child’s biological

and emotional needs

• Ineffective parents fail to attend to child’s internal needs; they feed when the child is anxious, comfort when the child is tired, etc.

• Children who receive such parenting may grow up confused and unaware of their own internal needs; they are unable to identify their own emotions

Causes Eating Disorders: Ego Deficiencies and Cognitive Disturbances

There is some empirical support for Bruch’s theory from clinical sources

• People with bulimia eat in response to emotions; many mistakenly think they are also hungry

• People with eating disorders rely excessively on the opinions, wishes, and views of others

• They are more likely to worry about how they are viewed, to seek approval, to be conforming, and to feel a lack of life control

Causes Eating Disorders : Mood Disorders

Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression

• Theorists believe mood disorders may “set the stage” for eating disorders

Causes Eating Disorders Mood Disorders

There is some empirical support for the claim that mood disorders set the stage for eating disorders• Many more people with an eating disorder qualify for a

clinical diagnosis of major depressive disorder than do people in the general population

• Close relatives of those with eating disorders seem to have higher rates of mood disorders

• People with eating disorders, especially those with bulimia nervosa, have low levels of serotonin

• Symptoms of eating disorders are helped by antidepressant medications

Causes Eating Disorders : Biological Factors

Biological theorists suspect that some people inherit a genetic tendency to develop an eating disorder

• Consistent with this model:• Relatives of people with eating disorders are 6 times

more likely to develop the disorder themselves

• These findings may be related to low serotonin


Other theorists believe that eating disorders may be related to dysfunction of the hypothalamus

• Researchers have identified two separate areas that control eating:

• Lateral hypothalamus (LH)

• Ventromedial hypothalamus (VMH)


Some theorists believe that the LH and VMH are responsible for weight set point – a “weight thermostat” of sorts

• Set by genetic inheritance and early eating practices, this mechanism is responsible for keeping an individual at a particular weight level

• If weight falls below set point: hunger, metabolism binges

• If weight rises above set point: hunger, metabolism

• Dieters end up in a fight against themselves to lose weight

Treatments for Eating Disorders

Eating disorder treatments have two main goals:

• Correct abnormal eating patterns

• Address broader psychological and situational factors that have led to and are maintaining the eating problem

• This often requires the participation of family and friends

Treatments for Anorexia Nervosa

The initial aims of treatment for anorexia nervosa are to:

• Restore proper weight

• Recover from malnourishment

• Restore proper eating


In the past, treatment took place in a hospital setting; it is now often offered in an outpatient setting

In life-threatening cases, clinicians may force tube and intravenous feeding

• This may breed distrust in the patient and create a power struggle

Most common technique now is the use of supportive nursing care and high calorie diets


Therapists use a mixture of therapy and education to achieve this broader goal

• One focus of treatment is building autonomy and self-awareness

• Therapists help patients recognize their need for independence and control

• Therapists help patients recognize and trust their internal feelings


Another focus of treatment is correcting disturbed cognitions, especially client misperceptions and attitudes about eating and weight

• Using cognitive approaches, therapists correct disturbed cognitions and educate about body distortions


Another focus of treatment is changing family interactions

• Family therapy is important for anorexia

• The main issues are often separation and boundaries

The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa

• But even with combined treatment, recovery is difficult

The course and outcome of the disorder vary from person to person



Positives of treatment:

• Weight gain is often quickly restored

• 83% of patients still showed improvements after several years

• Menstruation often returns with return to normal weight


Negatives of treatment:

• Close to 20% of patients remain troubled for years

• Even when it occurs, recovery is not always permanent

• Relapses are usually triggered by stress

• Many patients still express concerns about body shape and weight

Treatments for Bulimia Nervosa

Treatment programs are relatively new but have risen in popularity

Treatment is frequently offered in specialized eating disorder clinics


The initial aims of treatment for bulimia nervosa are to:

• Eliminate binge-purge patterns

• Establish good eating habits

• Eliminate the underlying cause of bulimic patterns

Programs emphasize education as much as therapy


Several treatment strategies:

• Individual insight therapy

• The insight approach receiving the most attention is cognitive therapy, which helps clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape

• As many as 65% stop their binge-purge cycle

• If cognitive therapy isn’t effective, interpersonal therapy (IPT), a treatment that seeks to improve interpersonal functioning, may be tried

• A number of clinicians also suggest self-help groups or self-care manuals



• Behavioral therapy

• Behavioral techniques are often included in treatment as a supplement to cognitive therapy

• Diaries are often a useful component of treatment

• Exposure and response prevention (ERP) is used to break the binge-purge cycle



• Antidepressant medications

• During the past decade, antidepressant drugs have been used in bulimia treatment

• Most common is fluoxetine (Prozac), an SSRI

• Drugs help 25 to 40% of patients

• Medications are best when used in combination with other forms of therapy



• Group therapy

• Provides an opportunity for patients to express their thoughts, concerns, and experiences with one another

• Helpful in as many as 75% of cases, especially when combined with individual insight therapy


Left untreated, bulimia can last for years

Treatment provides immediate, significant improvement in about 40% of cases

• An additional 40% show moderate improvement

Follow-up studies suggest that 10 years after treatment, about 90% of patients have fully or partially recovered


Relapse can be a significant problem, even among those who respond successfully to treatment• Relapses are usually triggered by stress

• Relapses are more likely among persons who:• Had a longer history of symptoms

• Vomited frequently

• Had histories of substance use

• Have lingering interpersonal problems

Finally, treatment may also help improve overall psychological and social functioning

eating disorder

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