Eating disorders psychiatric nursing disorder

Psychiatric illness

1. Eating disorders

2. Introduction
•Eating disorders describe illnesses that are characterized by
irregular eating habits and severe distress or concern about
weight or shape.
•Describing the emergence of eating disorders in history,
Parry-jones (1991) refers to morbid states involving food
refusal or relentless reduction of food intake and of gorging
followed by Vomiting being mentioned in literature as far back
as ancient Greek and Rome.

3. Classification
F50 Eating disorders (ICD 10)
•F50.0 Anorexia nervosa
•F50.1 Atypical anorexia nervosa
•F50.2 Bulimia nervosa
•F50.3 Atypical bulimia nervosa
•F50.4 Overeating associated with other psychological disturbances
•F50.5 Vomiting associated with other psychological disturbances
•F50.8 Other eating disorders
•F50.9 Eating disorder, unspecified

4. •Under the heading of eating disorders, two important
and clear-cut syndromes are described:
–Anorexia nervosa
–Bulimia nervosa.
Less specific bulimic disorders:
–Overeating when it is associated with psychological
disturbances.
–Vomiting associated with psychological disturbances.

5. Definitions
Anorexia nervosa:
•“Anorexia nervosa is a disorder characterized by
deliberate weight loss, induced and sustained by the
patient”.
•The term anorexia nervosa is derived from the Greek
term for “loss of appetite” and a Latin word implying
nervous origin.

6. Bulimia nervosa:
•“Bulimia nervosa is a syndrome characterized by repeated bouts of
overeating and an excessive preoccupation with the control of
body weight, leading to a pattern of over eating followed by
vomiting or use of purgatives.”
•The term bulimia nervosa derives from the terms for “ox-hunger”
in Greek and “nervous involvement” in Latin. Which means an
excessive insatiable appetite.

7. Body Image:
•A subjective concept of one’s physical appearance
based on the personal perceptions of self and the
reactions of others.

8. Epidemiology
Anorexia nervosa: condition more commonly seen in young
women in whom there is marked distortion of body image,
pathological desire for thinness and self induced weight loss by a
variety of methods.
•Significant mortality: 10-15 % (2/3 physical complications; 1/3
suicide)
•Male to female ratio: 1:10
•Mean age of onset: 16-17 yrs in females (rarely > 30 yrs);
approximately 12 years in males.
•Incidence: approximately 0.5% of adolescents and young women
•Community sample suggest equal distribution across the social
classes but clinical samples shows excess of upper/middle classes

9. Bulimia nervosa: characterized by recurrent
episodes of binge eating, with compensatory
behaviors and overvalued ideas about ‘ideal’ body
weight and shape.
•Often there is a past history of anorexia nervosa
(30-50%) and body weight may be normal.
•Incidence: 1-15% of women, with mid adolescent
onset and presentation in early 20s

10. ETIOLOGY

11. Predisposing Factors (Anorexia Nervosa
and Bulimia Nervosa)
•Genetics: One the basis of family histories recent study
suggests that genetic factors account for 56% of the risk for
developing anorexia nervosa.
• Anorexia nervosa is more common among:
•Sisters and mothers of those with the disorder
•Higher than expected frequency of mood disorders among
first-degree biological relatives of people with anorexia nervosa
and bulimia nervosa
•Substance abuse and dependence in relatives of individuals
with bulimia nervosa among first-degree biological relatives

12. •Neuroendocrine Abnormalities:
Some speculation has occurred regarding a primary
hypothalamic dysfunction in anorexia nervosa.
–Studies consistent with this theory have revealed
elevated cerebrospinal fluid,
–cortisol levels
–possible impairment of dopaminergic regulation in
individuals with anorexia.

13. Neurochemical Influences:
Neurochemical influences in bulimia may be
associated with the neurotransmitters serotonin
and norepinephrine.
Some studies have found high levels of
endogenous opioids in the spinal fluid of clients
with anorexia ( promotes denial of hunger).
Some of these individuals have been shown to
gain weight when given naloxone, an opioid
antagonist.

14. Psychodynamic Influences
•Psycho analytical theories suggest that eating
disorder results from:
•Fixation at oral stage in females leads to
manifestation of overeating behaviour.
•Psychodynamic theories suggest that eating
disorders result from very early and profound
disturbances in mother– infant interactions

15. Family Influences
a.Conflict Avoidance:
•Psychosomatic symptoms, including anorexia
nervosa, are reinforced in an effort to avoid spousal
conflict.
•Unhealthy involvement between the members;
•Parents retain the child in the dependent position.

16. b.Elements of Power and Control:
These families often consist of a passive father, a
domineering mother, and an overly dependent child.
•A high value is placed on perfectionism.
•The child eventually begins to feel helpless and
ambivalent toward the parents.
•In adolescence, these distorted eating patterns may
represent a rebellion against the parents,
•The symptoms are often triggered by a stressor.

17. CLINICAL FEATURES
•Anorexia nervosa is a syndrome
characterized by three essential criteria.
•The first is a self-induced starvation to a
significant degree—a behavior.
•The second is a relentless drive for thinness or a
morbid fear of fatness—a psychopathology.
•The third criterion is the presence of medical
signs and symptoms resulting from starvation
—a physiological symptomatology.

18. Physical consequences: mostly due to effects of starvation
•Oral: dental caries
•Cardiovascular: hypertension, cardiomyopathy, arrhythmias
•Gastrointestinal: delayed gastric emptying, altered antral
motility, gastric atrophy, decreased intestinal motility,
constipation
•Endocrine and metabolic: hypokalemia, hyponatremia,
hypoglycemia, hypothermia, altered thyroid function,
amenorrhea, arrested growth, osteoporosis, delay in puberty
•Renal: renal calculi
•Reproductive: infertility, LBW baby
•Dermatological: dry scaly skin, brittle hair, lanugo
•Neurological: peripheral neuropathy, cerebral atrophy, loss of
brain volume, ventricular enlargement
•Hematologic: Anaemia, leucopaenia, thrombocytopaenia

19. Complications
•Cardiac (most common cause for death):
significant bradycardia, hypotension, marked
ECG changes, decreased heart size, decreased
left ventricular mass
•Amenorrhoea
•Osteopenia

20. •Bulimia nervosa is characterized by
•Episodes of binge eating combined with
inappropriate ways of stopping weight gain.
•Physical discomfort for example, abdominal
pain or nausea terminates the binge eating,
which is often followed by feelings of guilt,
depression, or self-disgust.
•Unlike patients with anorexia nervosa, those
with bulimia nervosa typically maintain a
normal body weight.

21. Physical signs:
•May be similar to anorexia nervosa tend to be less
severe, specific problems related to ‘purging’ include:
•Arrhythmias
•Cardiac failure
•Electrolyte disturbances (decresed Na, K, Cl levels,
metabolic acidosis or alkalosis)
•Esophageal erosions/ perforations
•Gastric/duodenal ulcers
•Pancreatitis
•Constipation/steatorrhea
•Dental erosions
•Leucopenia / lymphocytosis

22. DIAGNOSIS

23. Diagnosis: F50.0 Anorexia nervosa
•Diagnostic guidelines: For a definite diagnosis, all the
following are required:
(a)Body weight is maintained at least 15% below that
expected (either lost or never achieved)
(b)The weight loss is self-induced by avoidance of
"fattening foods". One or more of the following may
also be present: self-induced vomiting; self-induced
purging; excessive exercise; use of appetite
suppressants and/or diuretics.
(c)There is body-image distortion in the form of a specific
psychopathology whereby a dread of fatness persists
as an intrusive, overvalued idea and the patient
imposes a low weight threshold on himself or herself.

24. (d)A widespread endocrine disorder involving the
hypothalamic - pituitary - gonadal axis is manifest
in women as amenorrhoea and in men as a loss of
sexual interest and potency.
(e)If onset is pre pubertal, the sequence of pubertal
events is delayed or even arrested (growth ceases; in
girls the breasts do not develop and there is a primary
amenorrhoea; in boys the genitals remain juvenile).
With recovery, puberty is often completed normally,
but the menarche is late.

25. F50.1 Atypical anorexia nervosa
•This term should be used for those individuals in
whom one or more of the key features of anorexia
nervosa (F50.0), such as amenorrhoea or significant
weight loss, is absent, but who otherwise present a
fairly typical clinical picture.
•Such people are usually encountered in psychiatric
liaison services in general hospitals or in primary care.
Patients who have all the key symptoms but to only
a mild degree may also be best described by this
term.
•This term should not be used for eating disorders that
resemble anorexia nervosa but that are due to known
physical illness.
•

26. F50.2 Bulimia nervosa: Diagnostic
guidelines
•For a definite diagnosis, all the following are required:
(a)There is a persistent preoccupation with eating, and an
irresistible craving for food; (large amounts of food
are consumed in short periods of time).
(b)The patient attempts to counteract the "fattening"
effects of food by one or more of the following:
self-induced vomiting; purgative abuse, alternating
periods of starvation; use of drugs such as appetite
suppressants, thyroid preparations or diuretics. When
bulimia occurs in diabetic patients they may choose to
neglect their insulin treatment.

27. (c)The psychopathology consists of a morbid dread of
fatness and the patient sets herself or himself a
sharply defined weight threshold, well below the
premorbid weight that constitutes the optimum or
healthy weight in the opinion of the physician.

28. F50.3 Atypical bulimia nervosa
•This term should be used for those individuals in
whom one or more of the key features listed for
bulimia nervosa (F50.2) is absent, but who otherwise
present a fairly typical clinical picture. Most
commonly this applies to people with normal or even
excessive weight but with typical periods of overeating
followed by vomiting or purging.

29. F50.4 Overeating associated with other
psychological disturbances
•Overeating that has led to obesity as a reaction to
distressing events should be coded here.
Bereavements, accidents, surgical operations, and
emotionally distressing events may be followed by a
"reactive obesity", especially in individuals
predisposed to weight gain.
•Note: Obesity as a cause of psychological
disturbance should not be coded here. Obesity may
cause the individual to feel sensitive about his or her
appearance and give rise to a lack of confidence in
personal relationships; the subjective appraisal of
body size may be exaggerated.

30. F50.5 Vomiting associated with other
psychological disturbances
•Apart from the self-induced vomiting of bulimia
nervosa, repeated vomiting may occur in
dissociative disorders (F44.-), in hypochondriacal
disorder (F45.2).
F50.8 Other eating disorders
•Includes: pica of nonorganic origin in adults
•psychogenic loss of appetite
F50.9 Eating disorder, unspecified the disorders
which does not meet the criteria given above
comes as eating disorders unspecified.

31. COURSE and PROGNOSIS
Anorexia nervosa:
•The course of anorexia nervosa varies greatly:
•Spontaneous recovery without treatment,
•Recovery after a variety of treatments,
•A fluctuating course of weight gains followed by
relapses
•A gradually deteriorating course resulting in death.
• If untreated, it carries one of the highest mortality
figures in psychiatric disorders i.e. 10-15%
•If treated ‘rule of third’ (1/3 full recovery, 1/3
partial recovery, 1/3 chronic problems)

32. Indicators of favorable outcome:
•admission of hunger,
•lessening of denial and immaturity,
•Improved self-esteem.
Indicators of poor outcome:
•childhood neuroticism, parental conflict, bulimia nervosa,
vomiting, laxative abuse, and various behavioral
manifestations (e.g., obsessive-compulsive, hysterical,
depressive, psychosomatic, neurotic, and denial
symptoms), males, poor parental relationships, late age of
onset, excessive weight loss.

33. Bulimia nervosa: Bulimia nervosa is
characterized by higher rates of partial and full
recovery compared with anorexia nervosa.
•Patients who are untreated tend to remain
chronic.
•Approximately 30% continued to engage in
recurrent binge eating or purging behaviors.
•A h/o of substance use problems and a longer
duration of the disorder at presentation predicted
worse outcome. Approximately 40% of women
were fully recovered at follow-up.

34. Assessment of eating disorders
Full psychiatric history:
•Establish the context in which the problems
have arisen (to plan appropriate care)
•Confirm the diagnosis of an eating disorder
•Assess risk for self-harm/suicide
Full medical history:
•Focus on the medical complications of altered
nutrition
•Focus on weight changes, dietary patterns,
excessive exercises

35. Physical examination:
•Determine weight and height (calculate BMI)
•Assess physical signs of starvation and vomiting
•Routine and focused blood tests
•ECG
Blood investigations:
•Full blood count, Erythrocyte Sedimentation
Rate, Urea and Electolytes estimation, blood
glucose estimation, Liver and Thyroid function
tests, Albumin / total protein testing,
cholesterol testing, testing for endocrine
hormonal alterations are indicated.

36. Treatment modalities

37. ANOREXIA NERVOSA:
•In view of the complicated psychological and medical
implications of anorexia nervosa, a comprehensive
treatment plan, including hospitalization when
necessary and both individual and family therapy, is
recommended.
•Behavioral, interpersonal, and cognitive approaches are
used and, in many cases, medication may be indicated.

38. Hospitalization
•The first consideration in the treatment of anorexia
nervosa is to restore patients’ nutritional state. In
general, patients with anorexia nervosa who are 20
percent below the expected weight for their height
are recommended for inpatient programs, and
patients who are 30 percent below their expected
weight require psychiatric hospitalization for 2 to 6
months.

39. 1.Hospital Management:
•Patients should be weighed daily, early in the
morning after emptying the bladder.
•The daily fluid intake and urine output should be
recorded.
•If vomiting is occurring, hospital staff members
must monitor serum electrolyte levels regularly and
watch for the development of hypokalemia.
•Because food is often regurgitated after meals, see
that bathroom inaccessible for at least 2 hours after
meals or by having an attendant in the bathroom to
prevent the opportunity for vomiting.

40. •Constipation in these patients is relieved when they
begin to eat normally. Stool softeners may occasionally
be given, but never laxatives.
•Give patients about 500 calories over the amount
required to maintain their present weight (usually 1,500
to 2,000 calories a day). It is wise to give these calories
in six equal feedings throughout the day.
•Giving patients a liquid food supplement may be
advisable, because they may be less apprehensive about
gaining weight slowly with the formula than by eating
food.
•Once patients are discharged from the hospital, it is
necessary to continue outpatient supervision.

41. 2. Psychotherapy
a.Cognitive-Behavioral Therapy:
b.Monitoring is an essential component of
cognitive-behavioral therapy. Patients are taught to
monitor their food intake, their feelings and
emotions, their binging and purging behaviors,
and their problems in interpersonal relationships.
•Patients are taught cognitive restructuring to
identify automatic thoughts and to challenge their
core beliefs.
•Problem solving is a specific method whereby
patients learn how to think through and devise
strategies to cope with their food-related and
interpersonal problems.

42. b. Dynamic Psychotherapy:
• Dynamic expressive-supportive psychotherapy is
used in the treatment of anorexia nervosa.
•The opening phase of the psychotherapy process
must be geared toward building a therapeutic
alliance.
•Patients may experience early interpretations as
though someone else were telling them what they
really feel and thereby minimizing and
invalidating their own experiences.

43. c. Family Therapy:
•A family analysis should be done for all patients
with anorexia nervosa who are living with their
families, which is used as a basis for a clinical
judgment on what type of family therapy or
counseling is advisable.
•If family therapy is not possible; however, issues
of family relationships can then be addressed in
individual therapy.

44. 3. Pharmacotherapy
•Pharmacological studies have not yet identified any
medication that yields definitive improvement of the
core symptoms of anorexia nervosa.
•Some reports support the use of cyproheptadine
(Periactin), a drug with antihistaminic and
antiserotonergic properties.
•Amitriptyline (Elavil) has also been reported to have
some benefit.
•Other medications include clomipramine (Anafranil),
pimozide (Orap), and chlorpromazine (Thorazine).
Trials of fluoxetine (Prozac) have resulted in some
reports of weight gain.
•In patients with anorexia nervosa and coexisting
depressive disorders, the depressive condition should
be treated.

45. BULIMIA NERVOSA:
•Most patients with uncomplicated bulimia nervosa do
not require hospitalization. In general, patients with
bulimia nervosa are not as secretive about their
symptoms as patients with anorexia nervosa.
•In some cases—when eating binges are out of control,
outpatient treatment does not work, or a patient exhibits
such additional psychiatric symptoms as suicidality and
substance abuse hospitalization may become necessary.
•In addition, electrolyte and metabolic disturbances
resulting from severe purging may necessitate
hospitalization.

46. Psychotherapy
a.Cognitive Behavioral Therapy: CBT should be
considered the benchmark, first-line treatment for
bulimia nervosa. Include about 18 to 20 sessions over
5 to 6 months.
CBT implements a number of cognitive and behavioral
procedures to:
(1)interrupt the self maintaining behavioral cycle of
binging and dieting
(2)Alter the individual’s dysfunctional cognitions;
beliefs about food, weight, body image; and overall
self-concept.

47. •Other Modalities: Controlled trials have
shown that a variety of novel ways of
administering and facilitating
cognitive-behavioral therapy. Some have been
incorporated in “stepped-care” programs and
including Internet based platforms, computer
facilitated programs, email enhanced
programs, and administration of
cognitive-behavioral therapy via telemedicine
to remote areas.

48. Pharmacotherapy
•Antidepressant medications have been shown to be helpful
in treating bulimia. This includes the SSRIs, such as
fluoxetine (Prozac).
❖Antidepressant medications can reduce binge eating and
purging independent of the presence of a mood disorder.
•Imipramine (Tofranil), desipramine (Norpramin), trazodone
(Desyrel), and monoamine oxidase inhibitors (MAOIs) have
been helpful.
•Medication is helpful in patients with comorbid depressive
disorders and bulimia nervosa. Evidence indicates that the
use of antidepressants alone results in a 22 percent rate of
abstinence from binging and purging; other studies show
that CBT and medications are the most effective
combination.

49. CLIENT/FAMILY EDUCATION
•The role of client teacher is important in the
psychiatric area, as it is in all areas of nursing. A list of
topics for client/family education relevant to eating
disorders is presented below.
Nature of the Illness
1. Symptoms of anorexia nervosa
2. Symptoms of bulimia nervosa
3. Causes of eating disorders
4. Effects of the illness or condition on the body

50. Client education (Contd..)
Management of the Illness
1. Principles of nutrition (foods for maintenance of wellness)
2. Ways client may feel in control of life (aside from eating)
3. Importance of expressing fears and feelings, rather than
holding them inside.
4. Alternative coping strategies (to maladaptive eating
behaviors)
5. Correct administration of prescribed medications (e.g.,
antidepressants, anorexiants)
6. Indication for and side effects of prescribed medications
7. Relaxation techniques
8. Problem-solving skills

51. NURSING DIAGNOSIS AND NURSING CARE PLAN
Nursing diagnosis I
Imbalanced Nutrition: Less than Body Requirements/Deficient
Fluid Volume (Risk for or Actual) related to refusal to eat/drink, self
induced vomiting; abuse of laxatives/diuretics evidenced by loss of
body weight
Short-Term Goals
● The client will gain weight within a week (at least 500gms)
● The client will drink 125 ml of fluid each hour during waking hours.
Long-Term Goal
● By the time of discharge from treatment, the client will exhibit no signs
or symptoms of malnutrition or dehydration.

52. Interventions
● For the client who is emaciated and is unable or unwilling to
maintain an adequate oral intake, liquid diet to be administered
via nasogastric tube. Nursing care of the individual receiving tube
feedings should be administered according to established hospital
protocals.
● For the client who is able and willing to consume an oral diet,
dietitian should determine the appropriate number of calories
required to provide adequate nutrition and weight gain.
● Explain the program of behavior modification to client and family.
Explain that privileges and restrictions will be based on
compliance with treatment and direct weight gain.
● Do not focus on food and eating specifically. Instead, focus on the
emotional issues that have precipitated these behaviors.

53. ● Do not discuss food or eating with the client once protocol has
been established. Do, however, offer support and positive
reinforcement for obvious improvements in eating behaviors.
● Keep a strict record of intake and output. Weigh the client daily
immediately on arising and following first voiding. Always use
the same scale, if possible.
● Assess skin turgor and integrity regularly. Assess moistness and
color of oral mucous membranes. The condition of the skin and
mucous membranes provides valuable data regarding client
hydration. Discourage the client from bathing every day if the
skin is very dry.
● Sit with the client during mealtimes for support and to observe
the amount ingested. A limit (usually 30 minutes) should be
imposed on time allotted for meals.
● The client should be observed for at least 1 hour following meals.
The client may use this time to discard food that has been
stashed from the food tray or to engage in self-induced vomiting.

54. •If weight loss occurs, use restrictions. Restrictions and limits
must be established and carried out consistently to avoid
power struggles and to encourage client compliance with
therapy.
•Ensure that the client and family understand that if nutritional
status deteriorates, tube feedings will be initiated. This is
implemented in a matter-of-fact, nonpunitive way, for the
client’s safety and protection from a life-threatening condition.
● Encourage the client to explore and identify the true feelings
and fears that contribute to maladaptive eating behaviors.
Emotional issues must be resolved if these maladaptive
responses are to be eliminated.

55. Nursing diagnosis II
Ineffective Denial related to retarded ego
development and fear of losing the only aspect of life over
which the client perceives some control (eating)
Short-Term Goal
● The client will verbalize understanding of the correlation
between emotional issues and maladaptive eating
behaviors).
Long-Term Goal
● By discharge from treatment, the client will demonstrate the
ability to discontinue use of maladaptive eating behaviors
and to cope with emotional issues in a more adaptive
manner.

56. Interventions
● Establish a trusting relationship with the client
● Acknowledge the client’s anger at feelings of loss of control
brought about by the established eating regimen associated with
the program of behavior modification.
● Avoid arguing or bargaining with the client who is resistant to
treatment. State matter-of-factly which behaviors are
unacceptable and how privileges will be restricted for
noncompliance.
● Encourage the client to verbalize feelings regarding his or her
role within the family and issues related to
dependence/independence, the intense need for achievement, and
sexuality.
- Help the client recognize how maladaptive eating behaviors may
be related to these emotional issues. Discuss ways in which he or
she can gain control over these problematic areas of life without
resorting to maladaptive eating behaviors.

57. Nursing diagnosis III
Imbalanced Nutrition: More than Body Requirements
related to compulsive overeating evidenced by BMI >
30; weight of more than 20% of expected
Short-Term Goal
● The client will verbalize understanding of what must be
done to lose weight.
Long-Term Goal
● The client will demonstrate a change in eating patterns
that results in a steady weight loss.

58. Interventions:
● Encourage the client to keep a diary of food intake.
● Discuss feelings and emotions associated with eating.
● With input from the client, formulate an eating plan that includes
food from the required food groups, low-fat intake.
● Identify realistic increment goals for weekly weight loss.
Reasonable weight loss (1 to 2 pounds per week) results in more
lasting effects.
● Plan a progressive exercise program tailored to individual goals and
choice.
● Discuss the probability of reaching plateaus when weight remains
stable for extended periods.
● Provide instruction about medications to assist with weight loss if
ordered by the physician. Appetite suppressant drugs (e.g.,
sibutramine) and others that have weight loss as a side effect (e.g.,
fluoxetine; topiramate) may be helpful.

59. Nursing diagnosis IV
Disturbed Body Image/Low Self-Esteem related to
retarded ego development and dysfunctional family system
evidenced by distorted body image, depressed mood etc
Short-Term Goal
● The client will verbally acknowledge misperception of body
image as “fat” within specified time (depending on severity
and chronicity of condition).
Long-Term Goal
● By the time of discharge from treatment, client will
demonstrate an increase in self-esteem as manifested by
verbalizing positive aspects of self and exhibiting less
preoccupation with own appearance as a more realistic body
image is developed.

60. Interventions:
● Help the client to develop a realistic perception of body image
and relationship with food. Compare specific measurement of
the client’s body with the client’s perceived calculations.
● Promote feelings of control within the environment through
participation and independent decision making. Through positive
feedback, help the client learn to accept self as it is, including
weaknesses as well as strengths.
● Help the client realize that perfection is unrealistic, and explore
this need with him or her. As the client begins to feel better
about self, identifies positive self attributes, and develops the
ability to accept certain personal inadequacies, the need for
unrealistic achievement should diminish.