Eating Disorders

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  • Anorexia and bulimia are complex disorders, and no specific factors have been identified as the cause. Research findings indicate a variety of possible causes, which include but are not restricted to Familial Sociocultural Biological Trauma
  • Kenny (1991) suggested that a person with anorexia: comes from a family, which discourages him or her from making outside contact Is expected to succeed and achieve Is oppressed by domineering parents Palazzoli (1974) has looked at familial factors in more detail and has found these factors to be involved: A rejection of communicated messages Poor conflict resolution A covert alliance of family members Munichin (1978) also found these factors: Enmeshment over-protectiveness Rigidity Lack of conflict resolution
  • Concerns have been raised about the media and how it may have contributed to the image of a slim to under-weight figure being socially acceptable. It is believed that adolescents view under-weight rock stars, models and actresses as being more happy, popular, wealthy and acceptable. More research is required before one can say that the media is a definite influence. Relationship between eating disorders and cultural/religious values Social acceptance and social norms regarding body size, food Australasian studies have indicated a trend towards thinness (Nowak et al. 1996). In some cultures not only is it acceptable, but a symbol of wealth to be overweight. New Zealand is a young country and its culture is still developing and is no doubt under the influence of other cultures. More research is required to highlight the sociocultural factors relevant to New Zealand
  • There are many factors that play a role in the development of anorexia nervosa and it is important that clinicians screen the person with anorexia and their family for the following conditions: Inflammatory bowel disease Malignancies/cancer Thyroid disease Diabetes mellitus Chronic infections Genetic influence such as a familial history of Obesity/overweight Eating disorder Dieting Depression Bipolar Ellen et al. (2003) discuss the recent awareness of familial transmission as a result of current research findings. There appears to be emerging evidence that children who have close relatives with an eating disorder are more at risk of developing an eating disorder themselves.
  • Refusal to maintain body weight at or above minimally normal weight for age and height. Intense fear of gaining weight or becoming fat, even though underweight. BMI <17.5 In post-menarcheal females, amenorrhea (3 consecutive months) Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. Restrictive Type = Restricting diet Binge/Purge Type = Laxatives, self-induced vomiting
  • Recurrent episodes of binge eating characterised by eating in a discrete period of time, an amount that is definitely larger than most people would eat during a similar period of time and under similar circumstances. And a sense of lack of control over eating during the episode (e.g., feeling that one cannot stop eating or control what or how much one is eating). This occurs at least 2 times per week for the duration of 3 months. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, or other medications, fasting or excessive exercise. This occurs at least 2 times per week for the duration of 3 months. Self-evaluation is unduly influenced by body shape and weight. So low self-esteem when weight increases. Purging Type = Regularly engaging in self-induced vomiting or the misuse of laxatives. Non purging = inappropriate compensatory behaviours such as exercise or fasting
  • Treat co-morbid illness. Mortality rate higher for those with co-morbid illness. Check suicidality.
  • Weight restoration – this is especially important if BMI is low and any changes occurring in vital signs. If you ever come across anyone who is malnourished, say with a BMI of 16 or less, you will notice a deterioration in there cognitive functioning and their Anorectic thoughts are stronger. Weight restoration is complexed, if it happens too quickly it can cause death (Re-feeding Syndrome), other complications include pain can be due to mouth ulcers, dental erosion, irritated osophegus, reduced bowel motility, constipation, bloating. Normalisation ED behaviours – So what kinds of ED behaviours are we/family likely to see?? Isolates self at meal times, exercising, preparing family meals and dishing up meals, doing the grocery shopping
  • BP and pulse lying and standing. Ask about dizziness or feeling faint. Note the rhythm and rate and strength of pulse, take pulse for full 60 seconds. Not uncommon to have very low diastolic and postural drop and also common to have a weak thready pulse, bradycardia and arrhythmias. Body temp, Why do we check this??? advise them to wear warm clothes, heater in bedroom. Hydration, tongue, skin, cap refill
  • Brainstorm signs of BN with class…
  • Nurses who participated in a study ‘caring for adolescent females with anorexia nervosa: registered nurses’ perspective’ did not have any formal mental health training. Living with frustration overwhelmed the nurses, they reached a point where they’d just had enough. The warring, frustration, being hurt and lack of success eroded their resilience so much they couldn’t cope with the situation any more and ‘turned off’. They distanced themselves from their patients and spent less time with them, they did this to protect themselves. Maintenance of optimal relationships between people with eating disorders and nursing staff is difficult. People with eating disorders are unique and challenging.
  • What is a healthy BMI? (20-25) for adults, refer to chart for youth
  • Eating Disorders

    1. 1. Eating Disorders Anorexia Nervosa & Bulimia Nervosa Power Point Presentation for Nursing Students By Katrina Tyne (2005)
    2. 2. Presentation overview <ul><li>Prevalence </li></ul><ul><li>Influencing factors for developing Eating Disorders </li></ul><ul><li>Signs & Symptoms of Eating Disorders </li></ul><ul><li>Diagnostic Criteria and comorbidity </li></ul><ul><li>Treatment of Eating Disorders </li></ul>
    3. 3. Prevalence <ul><li>Anorexia Nervosa </li></ul><ul><li>0.5% of women between 15 and 40 years </li></ul><ul><li>3-5% mild sub clinical form of anorexia </li></ul><ul><li>Bulimia Nervosa </li></ul><ul><li>2% of women between 15 and 45years </li></ul><ul><li>5-10% have mild sub clinical form of bulimia </li></ul>Up to 40% of 9-10 year old girls are worried about becoming fat.
    4. 4. Influencing Factors <ul><li>Familial </li></ul><ul><li>Sociocultural </li></ul><ul><li>Biological </li></ul><ul><li>Trauma </li></ul>
    5. 5. Familial <ul><ul><li>Kenny (1991) suggested that a person with anorexia: </li></ul></ul><ul><ul><li>comes from a family, which discourages him or her from making outside contact </li></ul></ul><ul><ul><li>Is expected to succeed and achieve </li></ul></ul><ul><ul><li>Is oppressed by domineering parents </li></ul></ul><ul><ul><li>Palazzoli (1974) has looked at familial factors in more detail and has found these factors to be involved: </li></ul></ul><ul><ul><li>A rejection of communicated messages </li></ul></ul><ul><ul><li>Poor conflict resolution </li></ul></ul><ul><ul><li>A covert alliance of family members </li></ul></ul><ul><ul><li>Munichin (1978) also found these factors: </li></ul></ul><ul><ul><li>Enmeshment </li></ul></ul><ul><ul><li>over-protectiveness </li></ul></ul><ul><ul><li>Rigidity </li></ul></ul><ul><ul><li>Lack of conflict resolution </li></ul></ul>
    6. 6. Sociocultural <ul><li>adolescents view under-weight rock stars, models and actresses as being more happy, popular, wealthy and acceptable. </li></ul><ul><li>Relationship between cultural and religious values </li></ul>
    7. 7. Biological <ul><ul><li>Medical illness </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Malignancies/cancer </li></ul></ul><ul><ul><li>Thyroid disease </li></ul></ul><ul><ul><li>Diabetes mellitus </li></ul></ul><ul><ul><li>Chronic infections </li></ul></ul><ul><li>Family history </li></ul><ul><li>Eating disorder </li></ul><ul><li>Dieting </li></ul><ul><li>Mood disorders </li></ul><ul><li>Alcoholism in 1 st degree relatives </li></ul>
    8. 8. Physical Signs & Symptoms of an Eating Disorder <ul><li>Anorexia Nervosa </li></ul><ul><li>Weight loss </li></ul><ul><li>Failure to gain weight in proportion to height </li></ul><ul><li>primary or Secondary amenorrhea </li></ul><ul><li>Low blood Glucose </li></ul><ul><li>Liver function changes </li></ul><ul><li>Bradycardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Hypothermia </li></ul><ul><li>Peripheral cyanosis </li></ul><ul><li>Hair loss, brittle hair </li></ul><ul><li>Lanugo </li></ul><ul><li>Hyperactivity </li></ul><ul><li>Dry skin </li></ul><ul><li>constipation </li></ul><ul><li>Bulimia Nervosa </li></ul><ul><li>Swollen or tender parotid glands </li></ul><ul><li>Dental enamel erosion </li></ul><ul><li>Large number of new caries </li></ul><ul><li>Calloused scarred area on back of hand </li></ul><ul><li>Perioral irritation </li></ul><ul><li>Mouth ulcers </li></ul><ul><li>Edema </li></ul><ul><li>diarrhoea </li></ul><ul><li>Yo-yo weight pattern </li></ul><ul><li>Metabolic Alkalosis </li></ul><ul><li>Electrolyte changes </li></ul>
    9. 9. DSM-IV Criteria for Anorexia Nervosa <ul><li>BMI < 17.5 or less than 85% of expected weight </li></ul><ul><li>Intense fear of gaining weight or becoming fat </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Distorted body image </li></ul><ul><li>Restricting or binge/purging type </li></ul>
    10. 10. DSM-IV Criteria for Bulimia Nervosa <ul><li>Recurrent episodes of binge eating </li></ul><ul><li>Recurrent compensatory behaviour to prevent weight gain </li></ul><ul><li>Self-evaluation unduly influenced by body shape and weight </li></ul><ul><li>Purging or non-purging </li></ul>
    11. 11. DSM-IV Criteria for Eating Disorders (NOS) <ul><li>The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. </li></ul><ul><li>Examples include: </li></ul><ul><li>For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses. </li></ul><ul><li>All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual’s current weight is in the normal range. </li></ul><ul><li>All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less frequently. </li></ul><ul><li>The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies). </li></ul>
    12. 12. Common Comorbid Psychiatric Disorders <ul><li>Mood Disorders – Major depression and Dysthymic disorder </li></ul><ul><li>Anxiety Disorders – Obsessive-Compulsive Disorders, Generalised Anxiety Disorder </li></ul><ul><li>Personality Disorders – </li></ul><ul><li>AN = Obsessive-Compulsive, Avoidant </li></ul><ul><li>BN = Borderline, Narcissistic, Histrionic </li></ul>
    13. 13. Treatment Goals <ul><li>To become free of eating disorder symptoms </li></ul><ul><li>To become free of preoccupation with food </li></ul><ul><li>To have healthy weight for height, age, ethnicity </li></ul><ul><li>To develop adequate self esteem </li></ul><ul><li>To develop appropriate social skills </li></ul><ul><li>To develop good body image </li></ul><ul><li>To develop the ability to deal with emotions </li></ul>
    14. 14. Management of Adolescents with Anorexia Nervosa <ul><li>Medical Management </li></ul><ul><li>Psychoeducation </li></ul><ul><li>Individual Therapy </li></ul><ul><li>Family Therapy </li></ul>
    15. 15. Outpatient Medical Management <ul><li>Weekly weight monitoring (see tips for weighing , BMI ) </li></ul><ul><li>Blood Pressure and Pulse </li></ul><ul><li>Body Temperature </li></ul><ul><li>Hydration </li></ul><ul><li>Blood Tests </li></ul><ul><li>Cardiac Examination (ECG) (see starvation process) </li></ul><ul><li>Dental Examination </li></ul><ul><li>Abdominal Examination </li></ul><ul><li>Advise limits on exercise </li></ul>
    16. 16. Indications for hospitalisation <ul><li>Rapid weight loss (>7kg in 4 weeks) </li></ul><ul><li>Potassium below 2.5mmol/l and/or with significant ECG changes </li></ul><ul><li>Prolonged QT interval </li></ul><ul><li>Dysrhythmias </li></ul><ul><li>Unstable vital signs </li></ul><ul><li>Severe malnutrition (BMI<13) </li></ul><ul><li>Severe dehydration </li></ul><ul><li>Rapidly diminishing exercise tolerance </li></ul><ul><li>Frequent exercise induced chest pain </li></ul><ul><li>Fainting or black outs </li></ul><ul><li>Renal dysfunction or low urine output (<400ml/day) </li></ul><ul><li>Low phosphate during initial refeeding </li></ul><ul><li>Any significant medical condition that would require hospitalisation with a non-anorexic patient </li></ul>
    17. 17. Eating Disorders and the Mental Health Act (1992) <ul><li>In New Zealand application can be sought for involuntary assessment under the Mental Health Act for a patient with a dieting disorder if it is believed that the patient has a mental disorder of such a degree that it </li></ul><ul><li>Poses a serious danger to the health and safety of that person or of others </li></ul><ul><li>Seriously diminishes the capacity of that person to take care of himself or herself. </li></ul><ul><li>“ Mental disorder ” in this situation is defined as an abnormal state of mind characterised by delusions, or by disorder of mood, perception, volition or cognition. </li></ul>
    18. 18. Communication <ul><li>How should I talk to someone with an eating disorder? </li></ul><ul><li>What’s it like for a child with Anorexia Nervosa? </li></ul><ul><li>What’s it like for their family? </li></ul><ul><li>What’s it like for the health clinician? </li></ul>
    19. 19. Communication Style <ul><li>Be direct but non-confrontational </li></ul><ul><li>Be encouraging and supportive </li></ul><ul><li>Defuse feelings of shame, blame and guilt (externalise the disorder) </li></ul><ul><li>Understand eating disorder as a coping mechanism against internal and/or external stressors </li></ul><ul><li>Collaborative therapeutic relationship </li></ul><ul><li>Try to engage with “healthy side” of patient while acknowledging part of them wants/needs to continue with eating disorder </li></ul><ul><li>Use medical information to enhance motivation for change in client in a non-critical but concerned manner </li></ul><ul><li>Recommendations from Dr R Mysliwiec (Feb, 2002) Auckland Eating Disorders Service </li></ul>
    20. 20. A Child’s Perspective of AN <ul><li>“ It’s no coincidence that I obtained the starring role in my school play in the midst of my weight loss. The more I suffered from AN the more determined I became to be the best.” </li></ul><ul><li>“ If I maintained my weight that was acceptable; if I lost weight I was satisfied and relieved. But if I put on even a fraction of a kilo, I was miserable” </li></ul><ul><li>“ I feel as though I’m in a box with a lid shut as tightly as can be, open and shut, open and shut, but the lid never opens for me” </li></ul><ul><li>“ I was convinced that the thinner I was the more loveable I would be to the rest to the world” </li></ul><ul><li>“ I made a silent vow to myself that I would become like her (celebrity)” </li></ul><ul><li>“ I believe that love is the keyword in recovery from anorexia nervosa. Inside I loathed myself and not eating was a way of expressing my unworthiness” </li></ul><ul><li>“ For a long time I simply drew but said nothing. It took a while before I trusted my therapist enough to speak. Sometimes I felt frustrated by the long lapses of silence. I often wished that we could have a real conversation together not based on theory…” </li></ul>
    21. 21. Parent’s Perspective of AN <ul><li>“ It’s to ask yourself all day and half the night what went wrong?” </li></ul><ul><li>“ It’s to read everything you can find on AN and try to understand and help your child – then read it’s your fault” </li></ul><ul><li>“ It’s to have everything about you rejected by your child - your food, your body, your personality, your achievements” </li></ul><ul><li>“ I felt wooden and empty and afraid to speak for fear I would cry” </li></ul><ul><li>“ I didn’t know what I was supposed to say or do” </li></ul><ul><li>“ Some explanation of therapeutic goals would be helpful” </li></ul><ul><li>Getting help is difficult “my doctor laughed me out of the office and told me I was an anxious mother…when I mentioned her periods, he said “what does she want periods for anyway?” </li></ul><ul><li>“ waiting for admission is a time of indescribable anxiety” </li></ul>
    22. 22. Staff perspectives on AN <ul><li>“ You can put frustrating, in capital letters. And…it can be pleasurable. When they reach the bottom of the barrel and start coming up and you see them blossom.” </li></ul><ul><li>“ we could not get through to them. They never trusted us enough to confide in us…all of us were really, really tired of fighting with these girls…” </li></ul><ul><li>“ You think you’ve done a good job in getting them up to a healthy weight and good at getting them to eat a healthy diet. And then… within weeks, they’ll just lose the weight and just come back , and keep coming back. </li></ul><ul><li>“… a good learning experience for me. I’ve become more open in my thoughts…and gained a lot of knowledge” </li></ul><ul><li>“ Now I just look after them like any other patient, no special treatment really…just stick to the rules and maintain the care…I’ve just switched off” </li></ul>
    23. 23. Treatment Outcomes for Adults with Eating Disorder <ul><li>Anorexia Nervosa </li></ul><ul><li>After 5 years: 1/3 recovered, 1/3 improved, 1/3 not improved </li></ul><ul><li>After 10-20 years: 50% recovered, 30% improved, 10% chronic, 10% mortality. </li></ul><ul><li>Bulimia Nervosa </li></ul><ul><li>After 5 years: 50% recovered, 20-35% improved, 15% not improved </li></ul><ul><li>Among 15 % not improved a high number of comorbid psychiatric diagnoses (especially borderline personality disorder) exist. </li></ul>
    24. 24. The End Thank you for your time
    25. 25. Tips for weighing <ul><li>When weighing individuals use the same scales each time. </li></ul><ul><li>Make sure that the scales are calibrated accurately at zero before use. </li></ul><ul><li>Ask individual to void prior to weighing. </li></ul><ul><li>Remove excess clothing (if suspect that individual is strapping weights to body, use hospital gown). </li></ul><ul><li>Weigh at the same time of the day, preferably in the morning as reduces the possibility of using fluids to increase weight. </li></ul><ul><li>Back to medical management </li></ul>
    26. 26. Body Mass Index (BMI) <ul><li>A calculation of BMI is the best way to measure how much the individual is over/underweight </li></ul><ul><li>The BMI is calculated by dividing the individual’s weight by their height squared </li></ul><ul><li>BMI = weight (kg) </li></ul><ul><li> [height (m)]sq. </li></ul><ul><li>Plot the BMI on the appropriate BMI chart </li></ul><ul><li>Back to outpatient medical management </li></ul>
    27. 27. The Starvation Process <ul><li>The body uses carbohydrates to maintain metabolic functioning. Carbohydrates are stored in the liver and muscles. Storage is minimal and may be depleted within 18hrs. </li></ul><ul><li>Once carbohydrate stores are depleted, protein begins to be converted to energy. </li></ul><ul><li>After 5-9 days, body fat is mobilized to supply energy. Fat stores are generally used up within 4-6 weeks. </li></ul><ul><li>Once fat stores are used, protein is the only remaining energy source. </li></ul><ul><li>Liver function is reduced </li></ul><ul><li>Formation of plasma proteins decreased </li></ul><ul><li>Fluid shifts occur </li></ul><ul><li>Sodium-Potassium pump fails </li></ul><ul><li>Back to medical monitoring </li></ul>
    28. 28. Externalising the Disorder <ul><li>Get them to name the disorder, perhaps “Anna” for anorexia or “Billy” for Bulimia </li></ul><ul><li>“ Anna is trying really hard to make you eat less” </li></ul><ul><li>“ Billy tells you it’s okay to eat a whole tub of ice cream, 2 blocks of chocolate, 5 mince pies, and a chicken all at once…” </li></ul><ul><li>“ Anna wants you to keep losing weight, that’s how she stays alive” </li></ul><ul><li>“ Billy knows when you’re upset, that’s when he is able to get you to …” </li></ul><ul><li>Back to Communication Styles </li></ul>
    29. 29. BMI Chart <ul><li>Back to medical monitoring </li></ul>

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