Download bulimia nervosa

EATING DISORDER
By
Ni Ketut Alit A
Faculty Of Nursing Airlangga University
Slide 1
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Smeltzer, S.C., & Bare, B. (2003). Brunner and Suddarth's Textbook of
Medical-Surgical Nursing (10th ed.). Philadelphia: Lippincott Williams
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Philadelphia: W.B. Saunders Company.
Luckman & Sorensen. (2000). Medical Surgical Nursing. Philadelphia:
W.B. Saunders Company.
Journals and article related to..
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
Slide 3
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
Slide 4
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
Slide 5
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
Slide 6
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
Slide 7
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
Slide 8
Anorexia Nervosa: The Clinical Picture
 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.
Slide 9
Anorexia Nervosa: The Clinical Picture
 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”
Slide 10
Anorexia Nervosa: The Clinical Picture
 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
Slide 11
Anorexia Nervosa: Problems
 Caused by starvation:
• Amenorrhea
• Slow heart rate
• Low body temperature
• Metabolic and
electrolyte imbalance
• Low blood pressure
• Body swelling
• Reduced bone density
• Dry skin, brittle nails
• Poor circulation
• Lanugo
Slide 12
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
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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”
Slide 19
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
Slide 20
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…
Slide 21
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
Slide 22
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
Slide 23
Bulimia Nervosa vs.
Anorexia Nervosa
 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
Slide 24
Bulimia Nervosa vs.
Anorexia Nervosa
 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
Slide 25
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
Slide 26
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
Slide 27
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
Slide 28
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
Slide 29
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
Slide 30
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
Slide 31
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
Slide 32
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
Slide 33
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
Slide 34
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
Slide 35
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
Slide 36
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
Slide 37
Causes Eating Disorders : Biological Factors
 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)
Slide 38
Causes Eating Disorders :
Biological Factors
 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
Slide 39
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
Slide 40
Treatments for Anorexia Nervosa
 The initial aims of treatment for anorexia
nervosa are to:
• Restore proper weight
• Recover from malnourishment
• Restore proper eating
Slide 41
Treatments for Anorexia Nervosa
 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
Slide 42
Treatments for Anorexia Nervosa
 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
Slide 43
Treatments for Anorexia Nervosa
 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
Slide 44
Treatments for Anorexia Nervosa
 Another focus of treatment is changing family
interactions
• Family therapy is important for anorexia
• The main issues are often separation and
boundaries
Slide 45
Treatments for Anorexia Nervosa
 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
Slide 46
Treatments for Anorexia Nervosa
 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
Slide 47
Treatments for Anorexia Nervosa
 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
Slide 48
Treatments for Bulimia Nervosa
 Treatment programs are relatively new but
have risen in popularity
 Treatment is frequently offered in specialized
eating disorder clinics
Slide 49
Treatments for Bulimia Nervosa
 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
Slide 50
Treatments for Bulimia Nervosa
 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
Slide 51
Treatments for Bulimia Nervosa
 Several treatment strategies:
• 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
Slide 52
Treatments for Bulimia Nervosa
 Several treatment strategies:
• 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
Slide 53
Treatments for Bulimia Nervosa
 Several treatment strategies:
• 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
Slide 54
Treatments for Bulimia Nervosa
 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
Slide 55
Treatments for Bulimia Nervosa
 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
Slide 56
Slide 57