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Chapter 31
Eating Disorders
Copyright © 2014. F.A. Davis Company
Introduction
• The hypothalamus contains the
appetite regulation center within the
brain.
• It regulates the body’s ability to
recognize when it is hungry, when it is
not hungry, and when it has been
sated.
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Introduction (cont.)
• Eating behaviors are influenced by:
– Society
– Culture
• Historically, society and
culture also have influenced
what is considered desirable
in the female body.
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Epidemiological Factors
• The prevalence rate of anorexia nervosa
among young women in the United States
is approximately 1 percent.
• Anorexia nervosa occurs predominantly in
girls and women ages 12
to 30 years.
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Epidemiological Factors (cont.)
• Bulimia nervosa is more prevalent than
anorexia nervosa, with estimates up to
4 percent of young women.
• The onset of bulimia nervosa occurs in
late adolescence or early adulthood.
• It occurs primarily in societies that
emphasize thinness.
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Epidemiological Factors (cont.)
• Obesity has been defined as a body
mass index of 30 or greater.
• The number of adult Americans who
are overweight is 68.5 percent, and 35
percent of these are in the obese range.
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Application of Nursing Process
• Assessment
– Anorexia nervosa
• Characterized by a morbid fear of obesity
• Symptoms include gross distortion of body image,
preoccupation with food, and refusal to eat.
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Anorexia Nervosa (cont.)
• Weight loss is extreme, usually more than 15 percent
of expected weight.
• Other symptoms include hypothermia, bradycardia,
hypotension, edema, lanugo, and a variety of
metabolic changes.
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Anorexia Nervosa (cont.)
• Amenorrhea is typical and may even precede
significant weight loss.
• There may be an obsession with food.
• Feelings of anxiety and depression are common.
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Anorexia Nervosa (cont.)
1. Which is characteristic of the diagnosis of
anorexia nervosa?
A.
B.
C.
D.
Obsession with weight gain
Body image disturbance
Disregard for the feelings of others
Healthy family relationships
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Anorexia Nervosa (cont.)
• Correct answer: B
– The distortion in body image by a client diagnosed
with anorexia nervosa is manifested by thoughts
that they are fat when they are obviously
underweight or even emaciated.
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Nursing Process: Assessment (cont.)
• Bulimia Nervosa
– Bulimia nervosa is an episodic, uncontrolled,
compulsive, rapid ingestion of large quantities of
food over a short period (binging).
– The episode is followed by inappropriate
compensatory behaviors to rid the body of the
excess calories (self-induced vomiting or the
misuse of laxatives, diuretics, or enemas).
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Bulimia Nervosa (cont.)
– Fasting or excessive exercise may also occur.
– Most individuals with bulimia are within a
normal weight range, some slightly
underweight, some slightly overweight.
– Depression, anxiety, and substance abuse
are not uncommon.
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Bulimia Nervosa (cont.)
– Excessive vomiting and laxative or diuretic
abuse may lead to problems with dehydration
and electrolyte imbalances.
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Bulimia Nervosa (cont.)
2. Which assessment finding would the nurse
expect in clients diagnosed with bulimia?
A.
B.
C.
D.
They are below normal weight.
They binge when they experience hunger.
They will be highly motivated to seek help.
They are within their normal weight range.
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Bulimia Nervosa (cont.)
• Correct answer: D
– Clients diagnosed with bulimia nervosa are often
able to maintain a normal weight by purging after
binging.
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Anorexia Nervosa and Bulimia Nervosa
Predisposing Factors
• Biological Influences
– Genetics: A hereditary predisposition to eating
disorders has been hypothesized.
• Anorexia nervosa is more common among sisters and
mothers of those with the disorder than it is among
the general population.
• Possible chromosomal linkage sites have been
suggested.
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Predisposing Factors (cont.)
• Biological Influences (cont.)
– Neuroendocrine abnormalities: There has been
some speculation about a primary hypothalamic
dysfunction in anorexia nervosa.
– Neurochemical influences:
• Bulimia nervosa may be associated with the
neurotransmitters serotonin and norepinephrine.
• Anorexia nervosa may be associated with high levels
of endogenous opioids.
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Predisposing Factors (cont.)
• Psychodynamic Influences
– Psychodynamic influences suggest that eating
disorders result from very early and profound
disturbances in mother-infant interactions
resulting in:
• Delayed ego development
• Unfulfilled sense of separation-individuation
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Predisposing Factors (cont.)
• Family Influences
– Conflict avoidance
• Families may promote and maintain psychosomatic
symptoms, including anorexia nervosa, in an effort to
avoid spousal conflict.
• The sick child becomes the problem, and focus on the
conflict is diverted.
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Predisposing Factors (cont.)
• Family Influences (cont.)
– Elements of power and control
• Power and control may become the overriding
elements within the family.
• Parental criticism promotes an increase in obsessive
and perfectionistic behavior on the part of the child
who continues to seek love, approval, and recognition.
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Predisposing Factors (cont.)
• Family Influences (cont.)
– Elements of power and control (cont.)
• Ambivalence toward the parents develops, and
distorted eating patterns may represent rebellion
against the parents.
• Eating disorder is seen as a way to gain control.
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Nursing Process: Assessment
• Obesity
– A body mass index of 30 is considered obese.
– Obesity can contribute to increases in morbidity
and mortality.
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Obesity (cont.)
– Obese people are at higher risk for:
• Hyperlipidemia
•
•
•
•
Diabetes mellitus
Osteoarthritis
Angina
Respiratory insufficiency
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Obesity (cont.)
• The DSM-5 identifies binge eating disorder
(BED) as an eating disorder than can lead to
obesity.
– The individual binges on large amounts of food, as
in bulimia nervosa.
– BED differs from bulimia nervosa in that the
individual does not engage in behaviors to rid the
body of the excess calories.
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Predisposing Factors: Obesity (cont.)
• Biological Influences
– Genetics: 80 percent of children born of two
obese parents will also be obese.
– Twin studies have also supported a hereditary
factor.
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Predisposing Factors: Obesity (cont.)
• Biological Influences (cont.)
– Physiological factors
• Lesions in the appetite and satiety centers of the
hypothalamus
• Hypothyroidism
• Decreased insulin production
• Increased cortisone production
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Predisposing Factors: Obesity (cont.)
• Biological Influences (cont.)
– Lifestyle factors
• Increased caloric intake
• Sedentary lifestyle
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Predisposing Factors: Obesity (cont.)
• Psychosocial Influences
– Unresolved dependency needs
– Fixation in the oral stage of psychosexual
development
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Predisposing Factors (cont.)
3. The nurse is teaching a class on obesity
prevention. Which statement by a student
indicates that learning about obesity has
occurred?
A. “Obesity is classified as a psychiatric disorder in
the DSM-5.”
B. “Obesity is defined as a body mass index (BMI) of
25.0 to 29.9.”
C. “Eighty percent of offspring of two obese parents
are obese.”
D. “Lesions in the appetite center in the thalamus
may contribute to obesity.”
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Predisposing Factors (cont.)
• Correct answer: C
– Genetics have been implicated in the
development of obesity. Research indicates that
80 percent of offspring of two obese parents are
obese.
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Nursing Process
• Nursing Diagnoses
– Imbalanced nutrition: less than body
requirements related to refusal to eat
– Deficient fluid volume (risk for or actual)
related to decreased fluid intake, self-induced
vomiting, and laxative and/or diuretic abuse
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Nursing Process (cont.)
• Ineffective denial related to delayed ego
development and fear of losing the only
aspect of life over which he or she
perceives some control (eating)
• Imbalanced nutrition: more than body
requirements related to compulsive
overeating
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Nursing Diagnoses (cont.)
• Disturbed body image/low self-esteem
related to retarded ego development,
dysfunctional family system, or feelings of
dissatisfaction with body appearance
• Anxiety (moderate to severe) related to
feelings of helplessness and lack of control
over life events
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Nursing Process (cont.)
4. A client is 5’8’’ tall and weighs 105 pounds.
The client has been taking laxatives daily, an
self-induces vomiting after eating. Which is
the priority nursing diagnosis for this client?
A.
B.
C.
D.
Ineffective denial
Disturbed body image
Low self-esteem
Imbalanced nutrition: less than body
requirements
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Nursing Process (cont.)
• Correct answer: D
– This client is malnourished and underweight due
to self-induced vomiting and laxative abuse.
Nutritional status is compromised and this
problem must be prioritized to establish
physiological integrity.
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Outcomes
• The Client:
– Has achieved and maintained at least 80
percent of expected body weight
– Has vital signs, blood pressure, and
laboratory serum studies within normal limits
– Verbalizes importance of adequate nutrition
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Outcomes (cont.)
• The Client:
– Verbalizes knowledge regarding consequences
of fluid loss caused by self-induced vomiting
(or laxative/diuretic abuse) and importance of
adequate fluid intake
– Verbalizes events that precipitate anxiety and
demonstrates techniques for its reduction
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Outcomes (cont.)
• The Client:
– Verbalizes ways in which he or she may gain
more control of the environment and thereby
reduce feelings of powerlessness
– Expresses interest in welfare of others and less
preoccupation with own appearance
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Outcomes (cont.)
• The Client:
– Verbalizes that image of body as “fat” was
misperception and demonstrates ability to take
control of own life without resorting to
maladaptive eating behaviors (anorexia
nervosa).
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Outcomes (cont.)
• The Client (with obesity):
– Has established a healthy pattern of eating for
weight control, and weight loss toward a
desired goal is progressing
– Verbalizes plans for future maintenance of
weight control
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Planning and Implementation
• Nursing care of the client with an eating
disorder is aimed at restoring nutritional
balance.
• Emphasis is also placed on helping the
client gain control over life situations in
ways other than inappropriate eating
behaviors.
• Self-esteem and positive self-image are
promoted in ways that relate to aspects
other than appearance.
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Client/Family Education
• Nature of the Illness
– Symptoms of anorexia nervosa and bulimia
nervosa
– What constitutes obesity?
– Causes of eating disorders
– Effects of the illness or condition on the body
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Client/Family Education (cont.)
• Management of the Illness
– Principles of nutrition
– Ways client may feel in control of life
– Importance of expressing fears and feelings,
rather than holding them inside
– Alternative coping strategies
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Client/Family Education (cont.)
• Management of the Illness (cont.)
– Correct administration of prescribed medications
– Indication for and side effects of prescribed
medications
– Relaxation techniques
– Problem-solving skills
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Client/Family Education (cont.)
• For the Obese Client
– How to:
•
•
•
•
Plan a reduced-calorie, nutritious diet
Read food content labels
Establish a realistic weight loss plan
Establish a planned program of physical activity
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Client/Family Education (cont.)
• Support Services
– Weight Watchers International
– Overeaters Anonymous
– National Association of Anorexia Nervosa
and Associated Disorders
– National Eating Disorders Association
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Evaluation
• Evaluation of the client with an eating
disorder requires reassessment of the
behaviors for which the client sought
treatment.
• Behavioral change will be required by
client and family members.
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Treatment Modalities
• Behavior Modification
– Issues of control are central to the etiology of
these disorders.
– For the program to be successful, the client
must perceive that he or she is in control of
the treatment.
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Treatment Modalities (cont.)
• Behavior Modification (cont.)
– Successes have been observed when the client:
• Is allowed to contract for privileges based on weight
gain
• Has input into the care plan
• Clearly sees what the treatment choices are
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Treatment Modalities (cont.)
• Behavior Modification (cont.)
– The client has control over:
• Eating
• Amount of exercise pursued
• Whether to induce vomiting
– Staff and client agree about:
• Goals
• System of rewards
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Treatment Modalities (cont.)
• Behavior Modification (cont.)
– The client has a choice whether to:
• Abide by the contract
• Gain weight
• Earn the desired privilege
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Treatment Modalities (cont.)
• Individual Therapy
– Helpful when underlying psychological
problems are contributing to the
maladaptive behaviors.
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Treatment Modalities (cont.)
• Family Therapy
– Involves educating the family about the disorder
– Assesses the family’s impact on maintaining the
disorder
– Assists in methods to promote adaptive
functioning by the client
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Treatment Modalities (cont.)
• Psychopharmacology
– No medications are specifically indicated for eating
disorders.
– Various medications have been prescribed for
associated symptoms such as:
• Anxiety
• Depression
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
• Medications that have been tried with some
success include:
– Anorexia nervosa
•
•
•
•
•
Fluoxetine (Prozac)
Clomipramine (Anafranil)
Cyproheptadine (Periactin)
Chlorpromazine (Thorazine)
Olanzapine (Zyprexa)
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
• Medications that have been tried with some
success include:
– Bulimia nervosa
•
•
•
•
•
•
Fluoxetine (Prozac)
Imipramine (Tofranil)
Desipramine (Norpramine)
Amitriptyline (Elavil)
Nortriptyline (Aventyl)
Phenelzine (Nardil)
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
• Medications that have been tried with some
success include:
– Binge eating disorder with obesity
• Topiramate (Topamax)
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Treatment Modalities (cont.)
• Psychopharmacology (cont.)
• Medications that have been tried with some
success include:
– Obesity
•
•
•
•
Fluoxetine (Prozac)
Various anorexiants (CNS stimulants)
Lorcaserin (Belviq)
Phentermine/topiramate (Qsymia)
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