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Flashcards in Eating Disorders Deck (57):

Continuum of Symptoms

1. normal eating

2. develop risk factors: low self esteem, dieting, media ideal bodies

3. partial-syndrome ED: binge eating, serious dieting

4. full-syndrome ED: increase in freq/severity of binge eating, purging, starvation

5. treatment


Nursing Screening for ED

1. Questions:
-Are you satisfied with your eating patterns?
-Do you ever eat in secret?
-BMI & nutritional appearance
-->answers will help decide if further questioning/treatment is necessary

2. Assess diagnostic criteria for specific eating disorders

3. Assess stage of change to determine how to intervene



-Requires effort on the part of teachers, school nurses, parents, coaches and society as a whole
-Educate school nurses and teachers in elementary schools
-Emphasize protective factors that mediate between risk factors and the development of an eating disorder


Prevention: Protective Factors

*EDs considered very preventable

-McKnight Risk Factor Survey --> measures prevalence & degree of risk factors (other tools- See Boyd)

-Evidence Based resources (online: UCLA, NIMH, SAMHSA)

-Education of child, adolescent

-Screen for risk factors & assess for treatment

-Follow-up-Monitor for relapse


Protective Factors: Education for Parents

-Real vs. ideal weight
-Influence of attitudes, behaviors, teasing
-Ways to increase self-esteem
-Role of media: TV, magazines
-Signs & symptoms
-Interventions for obesity
-Boys at risk also
-Observe for food rituals
-Supervision of eating and exercise


Protective Factors: Education for Child

-Peer pressure re’ weight, eating
-Menses, puberty normal weight gain, obesity strategies
-Ways to improve self esteem
-Body image traps: media, retail clothing
-Adapting and coping with problems
-Reporting friends with signs of eating disorders


Continuum of Care

-Outpatient treatment- most treatment takes place outpatient
-Family assessment and intervention
-Emergency care
-Hospitalization (suicide risk, starving to death)


Criteria for Hospitalization

Medical-acute weight loss
-Slow Heart Rate- 40 beats per minute (normal 60-80) & other arrhythmias
-Temp less 36.1 C
-Blood pressure less than 80/50
-Hypokalemia (low potassium, affects heart)
-Hypo-magnesium (low magnesium)

-Poor motivation, failure on outpatient basis

-Risk for suicide (1/2 of fatalities from anorexia), severe depression


Diagnostic Criteria: Anorexia Nervosa

-Refusal to maintain normal body weight
-Intense fear of gaining weight
-Disturbance in body image & self evaluation based on body weight to an extreme
-Perfectionism & does not recognize seriousness
-Severity Rating-BMI-less than or equal to Kg/m2
---Mild- 17
---Moderate- 16-16.99
---Severe- 15- 15.99


Two types of Anorexia

--> must have symptoms for over 3 months

1. Restricting type: rigid dieting, fasting, excessive exercise

2. Binging/Purging type: eating excess food all at once followed by purging by vomiting laxatives, diuretics or enemas (diff from bulimia b/c low BMI)


Clinical Course of Anorexia Nervosa

-Onset in early adolescence
-Chronic condition with relapses characterized by significant weight loss
-Often continue to be obsessed with food
-Many go on to develop bulimia nervosa
-Poor outcome w/initial lower minimum weight, presence of purging, and later age of onset
-May look depressed, but that may be secondary to starvation


Harmful Effects of Anorexia

-hair loss
-thyroid hormone decreases
-low WBC count
-heart failure/death
-rough scaly
-organs deteriorate
-muscles waste away
-hands swell
-period stops
-bone loss
-body fat layer gone


How much larger do anorexics view their bodies than normal?

20% larger


Body image: anorexia

discrepancy between self-perception and others


Drive for thinness: anorexia

an intense physical and emotional process that overrides all physiologic body cues, such as hunger and weakness


Interoceptive awareness: anorexia

sensory response to emotional and visceral cues, such as feeling hunger & defining and understanding their feelings



-0.5 to 1% lifetime prevalence
-Onset is typically between 14 and 16 years
-Female-to-male ratio 10:1
-Familial predisposition
-Co-morbid with depression and anxiety disorders
-Hispanics & whites more common-culturally defined weight expectations (underlined same in bulimia)
-Genetic heritability-50-80%


Men/Boys w/ED

-Later onset around 20 years old
-Athletes in a sport where weight is an issue --> may want thinness and muscle
-Thinner males have less testosterone
-Community samples have much higher rates than reported in clinical samples indicating under-diagnosis
-Risk factors & comorbid conditions similar to women


Interdisciplinary Treatment: Goals

-Initiating nutritional rehabilitation
-Resolving conflicts around body image disturbance
-Increasing effective coping
-Addressing underlying conflicts
-Assisting family with healthy functioning
-Hospitalization usually necessary
-Intensive therapies-supervision of patient and frequency of contact


Interdisciplinary Treatment: Antidepressant

-Fluoxetine (Prozac): helps with depression, obsessive compulsive & perfectionism symptoms
-->FDA approved antidepressant, selective serotonin reuptake inhibitor, (SSRI)-for anorexia and bulimia

-Adult dose for eating disorders usually 40-60 mg/day. Take 2X daily if over 20 mg/day.
-May take up to 4 weeks for full antidepressant effects, may increase after a few weeks if needed.
-->Boxed warning: increased risk suicidal thoughts & behaviors in children, adolescents & young adults.
-May cause dizziness or drowsiness avoid driving
-Small frequent meals if causes nausea & vomiting
-Avoid taking while breastfeeding & pregnant


Anorexia Priority Care Issues

-Mortality rate 7-10%
-Long duration of illness
-Binging and purging
-Co-morbid illnesses
---Substance abuse
---Depression (suicide using highly lethal means)
---Anxiety disorders


Anorexia Nursing Assessment

Evaluation of body and social systems:
-School attendance
-Family interaction
-Careful history (patient and family interactions)

Determine BMI

Body distortion:
-Fear of weight gain

Unrealistic expectations and thinking

Ritualistic behaviors

Difficulty expressing negative feelings

Inability to experience visceral cues and emotions

Suicide ideation-50% of deaths are suicide

Family Assessment:
-Enmeshment-low autonomy
-Unrealistic attitudes towards weight & appearance with teasing and criticism


Anorexia Nursing Diagnosis

-Imbalanced nutrition: less than body requirements
-Disturbed body image
-Ineffective coping


Anorexia Nursing Intervention

1. Therapeutic relationship
-Be firm, accepting, and patient
-Provide a rationale for all interventions
-Avoid power struggles over eating

2. Understanding feelings
-Challenge cognitive distortions
-Imagery and relaxation

3. Interpersonal therapy
-Focus on role transitions, control, and ineffective feelings
-Change distortions about food and interactions with others

4. Education
-Clarify misinformation about food with patient
-Family education

5. Weight-increasing protocols
-usually a behavioral plan with positive and negative reinforcements)
-strict monitoring and recording of intake

6. Exercise
-generally not permitted during refeeding
-any exercise needs to be monitored

7. Sleep
structured, healthy routine

8. Facilitate transition to school

9. Family therapy



Overestimation of the significance of undesirable events (gained 2 pounds can’t wear shorts)


Superstitious thinking

Believing in the cause-effect relationship of noncontingent events (If I eat a sweet it will instantly turn into stomach fat)


Dichotomous or all-or-none thinking

Thinking in extreme or absolute terms such as that events can only be black or white, right or wrong, good or bad (If I eat one piece of candy I blew it and might as well eat all the candy)


Defense Mechanisms

Automatic psychological processes protecting the patient from unwanted anxiety, generally the patient is unaware of using them and of the stresses that precipitate their use. Some are adaptive and some maladaptive.



use food to avoid intimacy & other fears



in anorexia this gets stronger as others express more concern about the ED


Isolation of affect

inability to recognize their feelings



use of excessive reasoning or logic to deal with situations rather than feeling their emotions



Extracting a rule on the basis of one event and applying it to other dissimilar situations (I used to be a normal weight & I wasn’t happy so I know gaining weight will not help)


Selective Abstraction

Basing a conclusion on isolated details while ignoring contradictory and more important evidence (eating is the only thing that will make me happy)



Egocentric interpretations of impersonal events or over-interpretation of events related to the self (those people were talking and laughing about how fat I am)


Bulimia Nervosa: Diagnostic Criteria

1. Recurrent episodes of binge eating
a. Rapid, episodic, impulsive, and uncontrollable ingestion of large amounts of food over a short period of time (up to 2 hours)
b. Feelings of lack of control
---Restriction of total calories between binges
---Undue influence of body weight or shape or denial of current low weight

2. Recurrent episodes of binge eating & compensatory purging: vomiting/laxatives, diuretics/emetics, fasting or over-exercising

3. These episodes must occur at least once a week for a period of at least 3 months

4. Eating --> guilt, remorse, and severe dieting. Self evaluation unduly influenced by weight. Ashamed and often conceal their eating.


Bulimia Nervosa: Key Concepts

Two types of bulimia nervosa:
1. Restricting type:
Similar to anorexia nervosa-restricting is followed by binge eating, which is then followed by another period of restricting
2. Purging type- vomiting or using laxatives, diuretics, or emetics, fasting or over-exercising

Dietary restraint
-Restricting intake is believed to explain the relationship between dieting and binge behavior
-Restraining intake is predictive of overeating

Usually normal weight- generally not life-threatening

Present as overwhelmed and overly committed individuals who have difficulty setting limits and establishing boundaries (“social butterflies”)

Treatment is usually outpatient therapy


Epidemiology of Bulimia

-Lifetime prevalence 1 to 2.3% (more prevalent than anorexia nervosa)
-Onset is between 15-24 years (older than anorexia nervosa)
-Females to males 10:1
-Related to social values of Western culture
-Co-morbid conditions-substance use disorder, depression, and Obsessive Compulsive Disorder (OCD)
-1 to 4% of females; 4 to 15% in high school & college females, & 20% of nursing students and female medical students


Bulimia Etiology: Biologic Theories

Neuropathologic-brain changes seen in Magnetic Resonance imaging(MRI) are result of eating dysregulation not the cause

Genetic and familial predispositions-twin studies show genetic influences are stronger than environmental

Biochemical-chronic depletion of plasma tryptophan (serotonin precursor)


Bulimia Etiology: Psychological and Social Theories

Cognitive theory-cognitive distortions maintain illness instead of creating it

Family-separation/individuation-difficulty with healthy boundaries


Clinical Course of Bulimia

-Few outward signs: do great in other aspects of life
-Binge and purge in secret
-Treatment often delayed for years
-Treatment initiated when control of eating is lost


Bulimia Nursing Assessment

Imbalanced nutrition
-Current eating patterns
-Number of times a day of binging and purging
-Dietary restraint practices

Sleep patterns

Exercise habits

Cognitive distortions

Knowledge deficits

Body dissatisfaction



Harmful Effects of Bulimia

-depression, seizures, addiction
-swollen salivary glands
-teeth decay
-swollen/sore throat
-irregular heart beat
-stomach ulcers
-liver/kidney damage
-muscle weakness
-constant bloating/ab pain
-bowel muscle damage


Nursing Diagnosis of Bulimia

-Disturbed thought processes
-Knowledge deficient
-Imbalanced nutrition
-Disturbed sleep pattern


Bulimia Nursing Intervention

Encourage regular sleep patterns

Cognitive Behavioral Therapy & Interpersonal Therapy
-Behavioral techniques
---Cue elimination
---Strictly monitor food intake
---Bathroom visits should be supervised
-Group therapy
---Concentrate on interpersonal issues
---Understand the binge–purge cycle

Monitoring and administration of medication-Selective Serotonin Reuptake Inhibitors (SSRI)


Bulimia Interdisciplinary Treatment: Goals

-Stabilizing and normalizing eating
-Restructuring dysfunctional thoughts and attitudes
-Teaching healthy boundary setting
-Resolving conflicts about separation-individuation


Bulimia Interdisciplinary Treatment: Multifaceted Approach

-Cognitive behavioral therapy (CBT)
-Antidepressants: SSRIs-Fluoxetine (Prozac) most research
-Nutrition counseling


Bulimia Priority Care Issues

-Co-morbid depression and suicide
-Risk for self-mutilation
-Impulsive behavior (shoplifting, overspending, etc.)


Binge Eating Disorder

consume large amounts of calories during binges & feel a lack of control & distress but do NOT try to lose weight. Most are obese. Interventions similar to bulimia nervosa.


Motivation is a problem with ED

Anorexia-denial of a problem even when life threatening

Bulimia-this varies some clients do not want to change and others are motivated

Use Motivational Interviewing (MI) & stages of change when the client is not motivated. Use traditional action oriented strategies and some MI techniques during times the client is motivated


Motivation: Case Study

Recent research shows that MI and Stages of Change are useful in treating the motivational problems in patients with ED.

Internal vs external motivation- ex. doing well in inpatient treatment but not after discharge

101 clients in 16 groups, not ready to change-12 week group program without any pressure to change --> 41% moved into therapy involving action

Therapist presented the assignment and left the room-90 minute sessions

1. Psychoeducation
2. Function of illness
3. Impact of illness
4. Change, fear & recovery
5. Evaluations and termination


Motivational Interviewing in ED

Cognitive Behavioral Treatment (CBT) is generally action-oriented.
-It is the main treatment for Bulimia and used with anorexia as well.
-Anorexia has the behavioral components of structure to gain weight during hospitalizations.

Nurses using MI at the Weight Disorder Clinic in Australia decreased the premature discharge rate from 41% to 14%.


Common Roadblocks to Successful Treatment

Admission to action oriented inpatient programs when patient is not interested in change

Primary reason for enrolling is to satisfy other people

Failure to explore ambivalence

Non-negotiable treatment actions that are not understood, not applied consistently

Repeating treatment approaches that failed in the past


Bypassing Roadblocks to Treatment

Ex: patient with anorexia being committed, how patient became willing
-Focus on patient desire to avoid commitment instead of focus on weight gain or symptoms
-Pt agreed to attend outpt. meal support weekly & decrease exercise. Later agreed to admission.


Nursing Approach to Treatment of ED

-curious, non-judgmental,
-clarifying dilemmas but not trying to solve them,
-validating the position of deciding not to change,
-respecting that eating disorders are difficult


Self-help programs

NOT recommended until maintenance stage of change as they may cause a delay in seeking treatment


How to motivate the client w/ED

--> Show empathy to the clients situation & use reflective listening to determine stage of change. Ask client to tell you about how their eating affects their life.
1. raise subject and ask permission
2. feedback
3. advice
4. enhance motivation (OARS, Readiness Ruler, Pros/Cons)
--> REDS:
-rolling with resistance
-express empathy
-develop discrepancy between goals/behaviors
-support self efficacy
5. Negotiate a plan