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Chapter 11
Eating Disorders
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
1
Concept of Eating Disorders
• Patient experiences severe disruption in
normal eating and disturbance in
perception of body shape/weight
• Several diagnostic categories identified
– Anorexia nervosa
– Bulimia nervosa
– Eating disorder not otherwise specified (NOS)
• Binge-eating disorder
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Eating Disorders: General Information
• Prevalence
– Anorexia: prevalence among women is 1%,
men (0.3%)
– Bulimia: prevalence among women is 1.5%,
men (0.5%)
• Comorbidity
– Eating disorder usually accompanied by other
psychiatric disorders
– History of sexual abuse common
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Biological Theories Related to
Eating Disorders
• Neuroendocrine abnormalities
– Altered serotonin pathway
– Altered serotonin receptors
– Unknown whether the abnormalities occur
first or after development of the eating
disorder
• Genetics
– Female relatives of people with eating
disorders have 12 times the risk
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Other Theories Related to
Eating Disorders
• Psychological (identifies core pathology)
– Low self-esteem and doubts about self-worth
• Harsh self-judgment based on issue of weight
• Family theory
– Anorexia: family system controlling,
emphasize perfection, achievement and
compulsions
– Bulimia: family system chaotic with conflict
and negativity
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Other Theories Related to
Eating Disorders
• Cultural considerations
– Western women driven by ideal of
competence in both career and family roles
• Internalization of societal ideal of thinness
• Eating disorders not common in other
cultures
– Male-dominated societies
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Anorexia Nervosa
• Refusal to maintain normal weight for age
and height
• Intense fear of gaining weight
• Disturbed body image
– Belief that one is fat despite emaciation
• Loss of menses for at least 3 months
• Types of anorexia
– Binge-eating/purging type
– Restricting type
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Anorexia Nervosa:
Physical Complications
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Decreased vital signs (temp, pulse, BP)
Electrolyte imbalances
Leukopenia
Osteoporosis
Amenorrhea
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Anorexia Nervosa:
Physical Complications
• Abnormal thyroid function
• Cardiac abnormalities
• Fatty degeneration of liver, elevated
cholesterol
• Hematuria
• Proteinuria
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Bulimia Nervosa
• Recurrent episodes of binge eating
• Behavior to prevent weight gain
– Self-induced vomiting
– Laxative and diuretic abuse
• Types of bulimia
– Purging type
– Non-purging type
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Bulimia Nervosa:
Physical Complications
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Cardiomyopathy
Cardiac dysrhythmias
Electrolyte imbalances
Dehydration
Loss of dental enamel
Parotid gland enlargement
Esophageal tears
Russell’s sign (callus on knuckles from
self-induced vomiting)
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Eating Disorder Not Otherwise
Specified (NOS)
• Category in DSM-IV-TR assigned for
disorders of eating that do not meet
criteria for a specific eating disorders
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Nursing Process: Assessment
Guidelines for Patient with Anorexia
• Determine if medical/psychiatric condition
warrants hospitalization (appropriate
testing important)
– Severe hypothermia, bradycardia,
hypotension, hypokalemia, cardiac
abnormalities
– Weight loss more than 30% over 6 months
– Suicidal or self-mutilating behaviors
– Severe depression or psychosis
– Out of control use of laxatives, diuretics, street
drugs
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Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
Nursing Process: Assessment
Guidelines for Patient with Anorexia
• Determine level of family understanding
about disorder and where to get support
• Determine level of acceptance of
treatment
• Determine patient and family need for
teaching
• Determine patient’s and family’s desire to
participate in support group
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses assigned
– Imbalanced nutrition: less than body
requirements
– Disturbed body image
– Chronic low self-esteem
– Hopelessness/Powerlessness
• Common outcomes: patient will:
– Normalize eating patterns
– Demonstrate improved self-acceptance
– Address maladaptive beliefs related to eating
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Nursing Process:
Planning and Implementing
• Hospitalization may be necessary for short
time (either medical or psychiatric)
• Long-term treatment with individual, group
and family therapy
• Focus interventions on establishing trust
and monitoring eating patterns
– Weight restoration and monitoring create
opportunities to counter disturbed thought
processes (cognitive distortions)
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Nursing Communication Guidelines for
Patients with Anorexia
• Avoid authoritarianism and assumptions of
parental role
• Build therapeutic alliance
– Frequently acknowledge patient difficulty with
goal of gaining weight
• Address underlying emotions of anxiety,
depression, low self-esteem, and feelings
of lack of control
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Specific Nursing Interventions for
Anorexia
• Weigh patient in minimal clothing, at same
time of day, after voiding and before
drinking or eating
• Monitor patient during meals to prevent
throwing food away/purging
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Specific Nursing Interventions for
Anorexia
• Recognize patient’s distorted body image
without minimizing or challenging patient’s
perception
• Educate patient about ill effects of low
weight
• Work with patient to identify strengths
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Treatment for Anorexia: Milieu Therapy
• Relies on interdisciplinary team approach
– Work for normalization of eating patterns
– Work toward addressing psychological issues
• Use of highly structured setting with close
monitoring to prevent throwing food away,
falsely increasing weight, purging
– During meals
– During weighing
– During bathroom visits
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Treatment for Anorexia: Psychotherapy
• Cognitive-behavioral
– Diminish errors in patient thinking/perceiving
related to eating disordered behaviors
• Psychodynamic
– Address underpinnings of disorder
• Group
– Provide support
• Family
– Does family dysfunction contribute to problem?
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Treatment of Anorexia: Medications
• Medications not recommended until weight
has been restored
• SSRI antidepressants
– Fluoxetine (Prozac): to reduce relapse
• Atypical antipsychotics
– Olanzapine (Zyprexa): helpful in improving
mood and decreasing obsessional behaviors
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Nursing Process: Evaluation
• Anorexia nervosa is a chronic illness:
relapse common
• Evaluation criteria
– Percentage of weight restored
– Extent to which self-worth no longer
dependent on weight and shape
– Decreased disruption in patient’s life
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Nursing Process: Assessment
Guidelines for Patient with Bulimia
• Patient may be at or slightly above or
below ideal weight
• Typical signs: enlarged parotid glands,
dental caries, enamel loss, Russell’s sign
• Review patient history for impulsive
behaviors (stealing) or compulsions
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Nursing Process: Assessment
Guidelines for Patient with Bulimia
• Determine if family relationships are
chaotic
• Review medical evaluation to determine
abnormalities warranting medical
hospitalization
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Nursing Process: Diagnosis and
Outcomes Identification
• Common nursing diagnoses assigned
– Decreased cardiac output
– Disturbed body image
– Chronic low self-esteem
– Powerlessness
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Nursing Process: Diagnosis and
Outcomes Identification
• Common outcomes: the patient will (in
specified time period)
– Refrain from binge/purge behaviors
– Maintain normal electrolyte balance
– Express feelings in non-food–related way
– Name personal strengths
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Nursing Process:
Planning and Implementing
• May require hospitalization in either
medical or psychiatric facility for short time
• Long-term outpatient treatment expected
• Implementations directed toward
examining underlying conflicts and
distorted perceptions of shape and weight
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Nursing Communication Guidelines for
Patient with Bulimia
• Patient may readily form therapeutic
alliance with nurse
– Eating behaviors are ego-dystonic
• Nurse needs to understand patient’s
sensitivity toward perceptions of others
– May feel shame and out of control
• Accepting, nonjudgmental approach
guides communication
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Treatment of Patient with Bulimia:
Milieu Therapy
• Highly structured inpatient unit has goal of
interrupting binge/purge cycle
– Close observations during and after meals
(similar to patient with anorexia)
• Teaching focused on:
– Healthy diet
– Coping skills
– Physical and emotional effects of bingeing
and purging
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Treatment of Patient with Bulimia:
Psychotherapy and Medications
• Psychotherapy
– Cognitive-behavioral approach recommended
• Medications
– SSRI antidepressant, fluoxetine (Prozac)
• Reduces binge eating and vomiting episodes
• Treats comorbid depression
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Nursing Process: Evaluation
• Evaluation process is ongoing
– Short-term and intermediate goals revised as
necessary
– Specific outcomes identified reviewed for level
of achievement
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Concept of Binge-Eating Disorder
• May be variant of compulsive overeating
– Binge eating reported as being soothing and
helpful with mood regulation
• May be related to depression (overeating
is frequently a sign of this disorder)
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Concept of Binge Eating Disorder
• Controversy over whether this proposed
disorder is a separate eating disorder
– 20%-30% of obese individuals seeking
treatment report binge eating
• DSM-IV-TR appendix identifies research
criteria for further study of binge-eating
disorder
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