Anorexia Nervosa Anorexia nervosa is a life-threatening eating disorder characterized by the clients refusal or inability to maintain a minimally normal

body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or even that one exists. Clients with anorexia have a body weight that is 85% less than expected for theirage and height, have experienced amenorrhea for at least three consecutive cycles, and have a preoccupation with food and food-related activities.

Clients with anorexia nervosa can be classified into two subgroups depending on how they control their weight: Binge eating means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less. Purging means the compensatory behaviors designed to eliminate food by means of self-induced vomiting or misuse of laxatives, enemas, and diuretics. Some clients with anorexia do not binge but still engage in purging behaviors after ingesting small amounts of food. The term anorexia is actually a misnomer: these clients do not lose their appetites. They still experience hunger but ignore it and signs of physical weakness and fatigue; they often believe that if they eat anything, they will not be able to stop eating and will become fat. Clients with anorexia often are preoccupied with food-related activities such as grocery shopping, collecting recipes or cookbooks, counting calories, creating fatfree meals, and cooking family meals. They also may engage in unusual or ritualistic food behaviors such as refusing to eat around others, cutting food into minute pieces, or not allowing the food they eat to touch their lips. These behaviors increase their sense of control. Excessive exercise is common; it may occupy several hours a day.

Etiology

Biologic Factors Studies of anorexia nervosa and bulimia nervosa have shown that these disorders tend to run in families. Grise & Kaye found a genetic susceptibility for anorexia nervosa on chromosome 1. Genetic vulnerability also might result from a particular personality type or a general susceptibility to psychiatric disorders. Or it may directly involve a dysfunction of the hypothalamus. A family history of mood or anxiety disorders (e.g., obsessive-compulsive disorder) places a person at risk for an eating disorder. Wade, Bulick, Neale & Kendler attributed 58% of cases of anorexia nervosa to heritability but could not totally discount the influence of a shared environment.

Developmental Factors Onset of anorexia nervosa usually occurs during adolescence or young adulthood. Some researchers believe its causes are related to developmental issues. Two essential tasks of adolescence are the struggle to develop autonomy and the establishment of a unique identity. Autonomy, or exerting control over oneself and the environment, may be difficult in families that are overprotective or in which enmeshment(lack of clear role boundaries) exists. Such families do not support members efforts to gain independence, and teenagers may feel as though they have little or no control over their lives. They begin to control their eating through severe dieting and thus gain control over their weight. Losing weight becomes reinforcing: by continuing to lose, these clients exert control over one aspect of their lives. Two main themes were conforming to a strict diet and fitting into smaller clothes (slim cultural ideal) and feelings of power, control, and even superiority over others by losing weight.

The need to develop a unique identity, or a sense of who one is as a person, is another essential task of adolescence. It coincides with the onset of puberty, which initiates many emotional and physiologic changes. Self-doubt

and confusion can result if the adolescent does not measure up to the person she or he wants to be.

Advertisements, magazines, and movies that feature thin models reinforce the cultural belief that slimness is attractive. Excessive dieting and weight loss may be the way an adolescent chooses to achieve this ideal. Body image is how a person perceives his or her body, i.e., a mental self-image. For most people, body image is consistent with how others view them. For people with anorexia nervosa, however, their body image differs greatly from the perception of others. They perceive themselves as fat, unattractive, and undesirable even when they are severely underweight and malnourished. Body image disturbance occurs when there is an extreme discrepancy between ones body image and the perceptions of others and extreme dissatisfaction with ones body image.

Signs and Symptoms

Fear of gaining weight or becoming fat even when severely underweight Body image disturbance Amenorrhea (absence of menstrual period) Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia Preoccupation with thoughts of food Feelings of ineffectiveness Inflexible thinking Strong need to control environment Limited spontaneity and overly restrained emotional expression Complaints of constipation and abdominal pain Cold intolerance Lethargy ( subjective feeling of weakness)

Emaciation (extreme weight loss) Hypotension, hypothermia, and bradycardia Hypertrophy of salivary glands Elevated BUN (blood urea nitrogen) Electrolyte imbalances Leukopenia and mild anemia Elevated liver function studies

Nursing Interventions: Establishing nutritional eating patterns o Sit with the client during meals and snacks. o Offer liquid protein supplement if unable to complete meal. (to ensure consumption of the total number of prescribed calories.) o Adhere to treatment program guidelines regarding restrictions. o Observe client following meals and snacks for 1 to 2 hours. (to ensure that they do not empty the stomach by vomiting.) o Weigh client daily in uniform clothing. (They may attempt to place objects in their clothing to give the appearance of weight gain.) o Be alert for attempts to hide or discard foodor inflate weight. Helping the client identify emotions and develop nonfood-related coping strategies o Ask the client to identify feelings. o Self-monitoring using a journal o Relaxation techniques o Distraction o Assist client to change stereotypical beliefs. Helping the client deal with body image issues o Recognize benefits of a more near-normal weight. o Assist to view self in ways not related to body image.

o Identify personal strengths, interests, talents. Providing client and family education o Provide emotional support. o o o o Express concern about clients health. Encourage client to seek professional help. Avoid talking only about weight, food intake, calories. Become informed about eating disorders.

o It is not possible for family and friends to force the client to eat. o The client needs professional help from a therapist or psychiatrist.

Psychopharmacology 1. Amitriptyline (Elavil) Amitriptyline is a tricyclic antidepressant. It affects chemicals in the brain that may become unbalanced. You should not use this medication if you are allergic to amitriptyline, or if you have recently had a heart attack. Do not use amitriptyline if you have used an MAO inhibitor such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate) within the past 14 days. Do not drink alcohol. It can cause dangerous side effects when taken together with amitriptyline. This medication may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert. Avoid exposure to sunlight or tanning beds. Amitriptyline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when you are outdoors. 2. antihistamine cyproheptadine (Periactin) can promote weight gain Drowsiness is present in this medication. Warn patient not to do activities that requires to be alert. You should not use this medication if you are allergic to cyproheptadine, or if you have narrow-angle glaucoma, a stomach ulcer or obstruction, an

enlarged prostate or urination problems, if you are having an asthma attack, or if you are elderly or have a debilitating disease. Do not drink alcohol

3. Olanzapine(Zyprexa) has been used with success because of both its antipsychotic effect (on bizarre body image distortions) and associated weight gain Do not administer if particulate matter or cloudiness is noted. Solution should be clear and yellow. Suspension should be yellow and opaque.

4. Fluoxetine(Prozac) has shown some effectiveness in preventing relapse in clients whose weight has been partially or completely restored Avoid taking tryptophan while you are taking fluoxetine. Drinking alcohol can increase certain side effects of fluoxetine. This medication may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be alert