Al-Zaytoonah private university of

Jordan
Faculty of nursing
Psychiatric nursing department
Psychiatric health Course practice
(0301358)
Presentation about Eating disorders.

Prepared by: Heba Al-khozae (200711008)

Suha Al-bishawi ( )

Under the supervision of: Dr. Entesar Al-khodary

Mrs. Sawsan
Mr. Hamza Al-shawaheen
Outline:
1- Objectives.

2- Introduction.

3- Etiologies of eating disorders and factors that precipitate that.

4- Implications and prognosis.

5- Anorexia nervosa.

6- Bulimia nervosa.

7- Binge eating disorder.

8- Males eating disorders.

9- Psychotherapeutic management.

10- Nurse-patient relationship.

11- Psychopharmacology.

12- Milieu therapy.

13- Nursing process for eating disorders.

14- Family and client teaching.

15- Conclusion.

16- Questions.

17- References.

Objectives:
After this lecture the students should be able to:
1- Identify eating disorders as an illness, its etiologies, and precipitating
factors, implication and prognosis.

2- Identify each type of eating disorders with its signs and symptoms, and
diagnostic criteria related to (DSM-IV-TR).
3- Describe treatment issues for professionals who deal with eating disordered
patients (psychotherapeutic management, nurse-patient relationship,
psychopharmacology, milieu management).

4- Develop nursing care plans for patients with eating disorders.

 Eating disorders
Healthy people need to regularly consume a rich variety of foods that are sufficient for energy
needs, cellular growth and repair, and maintenance of sufficient weight. Most people normally eat 1,500
– 2,500 calories each day.

Eating is a normal response to hunger should cease when the person attains satiety (comfortable
fullness).

People develop problems related to normal food consumption and satiety which is called eating
disorders.
Eating disorders are most common in females (85%-90%) than males (10%-15%) but recent studies
find that the incidence of eating disorders in males is increasing by incidence ratio of 2women :1 men for
anorexia nervosa and the ratio of 3 women : 1 men for bulimia nervosa, and seems to appear at a later age
than in females.

Eating disorders are those in which eating:

1- Below or above a person’s caloric needs to maintain a healthy weight.

2- Accompanied by anxiety and guilt.

3- Occurs without hunger or fails to produce satiety.

4- Results in physiologic imbalances or medical complications.

The most serious eating disorders are anorexia nervosa and bulimia nervosa.

Anorexia nervosa is a life threatening condition of disturbed body image, emaciation, intense fear of
becoming obese.

Bulimia nervosa is a recurrent pattern of uncontrollable consumption of large amount of food (binge
eating) followed by attempts to eliminate the body of the excess calories (purging).

Etiology and precipitating factors:

Most experts agree that eating disorders have multifactorial causes with significant variance among
individuals developing from complex interaction of individual, family, sociocultural elements.

1- Biologic factors: increase serotonin levels.

2- Cognitive and behavioral factors: environmental contingencies.

3- Psychodynamic factors: modern psychoanalytic theorists have stressed the role of sexuality in
anorexia nervosa, and some researchers have suggested that anorexia involves a regression to a
pre-pubertal state, and another theory has described anorexia nervosa as an obsession with weight
stemming from a fear of being out of control because of the lack of a well-defined self.
 4- Family factors: emotional restraint, enmeshed relationships, rigid organization in the family, tight
control of child behavior by parents, avoidance of conflict, and odd eating habits and emphasis on
appearance and weight by other family members especially mothers and sisters.

5- Sociocultural factors: the increasingly and unrealistically thin body ideal for women, almost a
cultural thinness, and the relational orientation of women, which creates a vulnerability to the
opinions of others particularly during adolescence.

When working with clients and populations who may be at risk for eating disorders, nurses should
remember to discuss the 3Cs:

1- Communication: how to recognize and express feelings.

2- Conflict resolution: how to express needs when they aren’t being met.

3- Coping: what to do when the client can’t directly solve a problem.

Implications and prognosis:

 Peoples with eating disorders rarely seek help, typically aren’t motivated to change, and often
leave treatment.

 Bulimia nervosa has higher rate of recovery than does anorexia nervosa.

 In a 10 years follow-up study of clients with bulimia approximately 30% continued to engage in
binge eating or purging behaviors.

 Care management is complex and frequently lengthy because these clients may resist treatment
because of denial is typically strong.

 Nurses, physicians, psychotherapists, social workers, dietitians, occupational therapists collaborate

to form a treatment plan.

Anorexia nervosa:
A life threatening condition characterized by a refusal to maintain body weight at or above a
minimally normal weight for age and height, an intense few of becoming fat, a distorted body image, and
amenorrhea or irregular menstrual cycles in women and low testosterone hormone levels in men.

Anorexia is less common than bulimia, 85% of cases developing between the ages of 13 and 20 years,
onset varies from preadolescence to early adulthood, these ages correspond with transitional stages in
people lives, and the disease have the mortality rate of 5-20%.

The anorectics suppress their appetite in an effort to remain thin or get thinner but they don’t lose their
appetite, and they have ritualistic eating patterns and compulsive behaviors, often feel hopeless, helpless,
and depressed.

The anorexia affects menstruation by causing amenorrhea, irregular and spotty menstruation, and
affects cardiac muscles (atrophy) and decrease cardiac output.

The course of anorexia varies from:

1- A single episode with weight and psychological recovery.

 2- Nutritional rehabilitation with relapses.

3- An unremitting course resulting in death.

Patients with anorexia nervosa are into two types:

1- Restrictors:

 They are young people in the normal or slightly above normal weight for height.

 This group views losing weight as more probable if they simply eat less and avoid social
situations in which they are expected to eat. Withdraw to their rooms and avoid family and
friends.

 They could be competitive, compulsive, and obsessive about their activities, highly anxious and
unable to relax, become hyperactive.

2- Vomiters- purgers:

 They are more often fluctuating and overweight before the eating disorder begins.

 This group use dangerous methods of weight reduction, such as induction of vomiting or
excessive use of laxatives or diuretics.

 The amount of food isn’t excessive as it with bulimics,

 These patients complain of dental problems, substance abuse, and open family conflict than
restricting anorectics.

Signs and symptoms of anorexia nervosa:

 Psychosocial: extreme fear of gaining weight, poor social adjustment, odd food habits,
hyperactivity, mood and\or sleep disturbances, obsessive compulsive behaviors, perfectionist,
introverted, denies feeling of sadness or anger and will often appear pleasant and complaint,
families often have rigid rules, and have high expectations for their members.

 Physiologic and endocrine symptoms: emaciated physical appearance, changes in cardiac status
(bradycardia, HTN, dysrhythmia), dry yellowish skin, amenorrhea, infertility, hair loss, possible
presence of lanugo, decreased metabolic rate, chronic constipation, fatigue and lake of energy,
insomnia, loss of bone mass, osteoporosis, enlarged salivary glands, decayed tooth, dehydration,
edema, laboratory abnormalities and medical complications.

DSM-IV-TR diagnostic criteria for anorexia nervosa:

1- Refusal to maintain body weight at or above a minimum normal weight for age and height.

2- Intensive fear of gaining weight or becoming fat, although significantly underweight.

3- Disturbance in the way in which one’s body weight or shape is experienced, overvaluing of low
weight or weight loss.

4- In women and female adolescents, the absence of at least three consecutive menstrual cycles.
  Restricting type: during an episode of anorexia nervosa, individuals don’t engage in recurrent
episodes of binge eating or purging.

 Binge eating or purging type: during an episode of anorexia nervosa, individuals engage in
recurrent episodes of binge eating or purging.

Favorable prognostic indicators:

1- Earlier age at onset.

2- Return of menses.

3- Good pre-morbid school\work history.

Negative prognostic indicators:

1- Recurrent illness.

2- Multiple hospitalizations.

3- Male.

4- Family pathology.

5- Pre-morbid personality difficulties and poor social adjustment in childhood.

Bulimia nervosa:
Is a condition of uncontrolled rapid ingestion of large quantities of food followed by self-induced
vomiting, obsessive exercise, use of laxatives and diuretics, or all of these behaviors. Its maybe occurs
alone or in conjunction with the food restriction of anorexia.

They may consume an incredible number of calories (an average of 39415 per binge) then in a short
period induce vomiting, and perhaps repeat this behavior several times a day.

Bulimia nervosa frequently exist with major depression, substance abuse, personality disorders,
primarily those with impulsive traits.

Clients with bulimia may develop:

 Dental caries from the frequent contact of tooth enamel with food and acidic gastric fluids.

 ECG changes.

 Parotid gland enlargement.

 Esophagitis.

 Gastric dilation.

 Menstrual irregularity.
  Electrolyte imbalance.

DSM-IV-TR diagnostic criteria for bulimia nervosa:

1. Recurrent episodes of binge eating in a short time period, with intake much greater than average.

2. A feeling of lack of control over eating behaviors during eating binges.

3. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as induced
vomiting, use of laxatives, enemas, or diuretics, strict dieting or fasting, vigorous exercise, or
taking diet pills.

4. Binge eating and inappropriate compensatory behaviors both occurring, on average, at least twice a
week for 3 months.

5. Self-evaluation unduly influenced by body shape and weight.

 Purging type: regularly engages in self-induced vomiting or the use of laxatives, diuretics, or
enemas.

 Non-purging type: regularly uses strict diet, fasting, or vigorous exercise, but doesn’t regularly
engage in purging.

Treatment:

Clinical and dialectical-pharmacologic behavioral therapies (CBT) for those with bulimia appear to
have good response in conjunction with interpersonal psychotherapy and pharmacotherapy.

Pharmacologic: 1- fluoxetine 60 mg\day for 6-18 weeks reduces the symptoms of binging and
purging. 2- tricyclic antidepressant is also found useful in treating bulimia nervosa.

Comparing between anorexia nervosa and bulimia nervosa:

Shared features:

 Restriction of intake at times, especially anorectics.

 Bingeing overeating at times, especially bulimics.

 Purging through vomiting, laxatives, or diuretics.

 Over exercise.

 Extreme concern about appearance.

  Perfectionist traits-dissatisfaction with appearance and performance in aspects of life such as work
or school.

 Belief that their worth is based solely on appearance.

 Discomfort in social settings, especially with the opposite gender.

 Misperception of their size, shape, and level of fat.

 Low-self esteem.

Differentiation of behaviors:

Anorexia Bulimia

Early onset later onset

Very low weight more normal weight

Amenorrhea for some patient’s menstrual irregularities but not amenorrhea

Hormonal imbalance fluid and electrolyte imbalance

Constipation if not using laxatives GI problems related to bingeing and purging

Binge eating disorder:

Is one of the most challenging current epidemics in western countries involves overweight and obesity,
conditions that result from the regular overconsumption of calories and sedentary life styles.

BED shares many criteria of bulimia nervosa (lack of control over intake, patient distress, and guilt
over bingeing) but without the regular compensation for excess intake through purging, laxatives, fasting,
or over exercise.

Patient’s with BED tends to be overweight to a moderate or greater degree and their weight tends to
fluctuate more compared with those with anorexia or bulimia.

As with bulimia, the onset of this disorder tends to be later than anorexia, generally beginning in late
adolescence to early adulthood, but currently isn’t considered a psychiatric disorder in the DSM-IV-TR
because of the rapidly growing numbers of obese people of all ages.

Many researchers view obesity as the result of compulsive eating behavior and it certainly associated
with morbidity.

Characteristics of BED include:

1- Recurrent eating binges.

2- Guilt, shame, and disquiet about bingeing.

3- Marked psychological distress.

Males eating disorders:
The incidence of eating disorders among males is currently 10%-15% of the eating-disordered
population. And the diagnosis, etiologies, and treatment is similar to eating disorders among females, but
there appear to be differences in onset, presentation, and assessment.

Males seem to have more difficulty than females in expressing their feelings so the therapeutic
relationship could be instrumental in the recovery of them.

Males are more likely than females with eating disorders to have a history of obesity before the onset
of symptoms of an eating disorder and to have a later and higher initial BMI before becoming eating-
disordered.

Males also tend to feel less guilt than in females about episodes of bingeing and purging. And dieting
or bingeing is more often related to a desire to build a lean body for participation in sports.

There is three areas need particular focus with males for treatment of eating disorder:

1- The excessive attention that adolescent boys can place on attaining a masculine physique and its
effect on their body image.

2- Dietary habits to promote health fitness, and muscle mass without using disordered eating patterns.

3- The expression of feelings and the exploration of any underlying sexual identity concerns.

Manifestations of cognitive distortions in clients with eating disorders:

Distortion Explanation
Catastrophizing\ Giving an event or its consequences
magnification more merit than is realistic
Dichotomous Reasoning by extremes, seeing
thinking everything as ‘black or white’
Emotional reasoning Relying on emotions to determine
reality
Overgeneralization Basing beliefs on one or a few, not
necessarily related, considerations.
personalization Over interpreting an event as
having personal significance.
Selective abstraction Focusing on only some information
while choosing to ignore other
information.
Psychotherapeutic management:
The psychotherapeutic management of each disorder will vary, depending on the period of treatment
being considered and whether the focus is on short or long term treatment.
Example
These jeans feel tight today. I know
everyone can tell that I’ve gained 3 lb.
If I’m thin, I must be fat;
I’ve already eaten two slices of pizza and
wrecked my diet. I might as well eat the
whole thing.
I know I’m fat because I feel fat.
I don’t have a boyfriend. It must be
because I’m fat.
Liz is so thin and has the perfect life. I
should lose weight so my life can be better
Dad made a face when I grabbed a piece
of candy from the jar, he must think I’m
overweight.
I’ve lost 10 lb. but I still can’t fit into a
size 8 I’m a failure.
Management of anorexia is geared toward three primary objectives:

1- Increasing weight to at least 90% of the average body weight for the patient’s height.

2- Helping the patient to establish appropriate eating behavior.

3- Increasing self-esteem, so the patient doesn’t need to attain the perfection that they believe
thinness provides.

For bulimics, the objectives are similar but rather than the need for weight increase, are more likely to
focus on stabilizing weight without purging, because bulimics are more likely to be of normal weight. And
pharmacotherapy is used as an adjunct to psychotherapy for bulimics when indicated.

A stepped care approach might be useful, in which patient first participate in a simple treatment such
as guided self-help or a psycho educational group with their families and if they don’t respond are referred
for cognitive-behavior therapy, and if don’t improve will be referred for a more intensive form of
treatment, such as interpersonal psychotherapy, partial or full hospitalization, and possibly antidepressants
medication.

Cognitive-behavioral therapy has the greatest research support, although limited evidence exist
suggesting that interpersonal psychotherapy might have similar effectiveness.

Effective therapeutic modalities for people suffering from eating disorders:

1- Behavioral therapy: using apparent conditioning paradigm, effective in inducing short-term

weight gain.

2- Cognitive therapy: examining underlying assumptions, modifying basic assumptions,

reinterpreting body image misperceptions, help client to challenge the validating of distorted
beliefs and perceptions that are perpetuating their illness.

3- Family therapy: interventions focus on fostering open, healthy interaction patterns among
members. Behavior family systems therapy (BFST) is an approach that blends behavior
modification, cognitive therapy, and family therapy. It relies on empirically tested behavioral and
cognitive techniques. And consist of four stages:

 Assessment.

 Control rationale.

 Weight gain.

 Weight maintenance.

4- Individual psychotherapy: successful psychotherapy needs to be highly interactive, explore

relevant issues, educate, negotiate, challenge assumptions underlying anorectic behavior, and
encourage the client directly and openly.
Nurse-patient relationship:
Specific therapeutic communication techniques helpful for eating-disordered patients include the
following:

1- Convey warmth and sincerity.

2- Listen empathically.

3- Be honest.

4- Set appropriate behavioral limits.

5- Assist patient in identifying their positive qualities.

6- Collaborate with patients.

7- Teach patients about their disorders.

8- Determine the anorectic’s ability to be weighted in the early stages of treatment.

9- Initiate a behavior modification program with patient input that rewards weight gain or lack of
purging with meaningful privileges or rewards.

10- Model and teach appropriate social skills.

11- Help patient identify and express bodily sensations and feelings related to their disorders.

12- Identify non-weight-related interests of the patient.

Psychopharmacology:
Currently, no psychopharmacologic agent is approved specifically for anorexia nervosa; medication
management of anxiety, depression, somatic disturbances, or other co-morbid conditions is appropriate
and might assist in treatment of the patient anorexia.

Generally, psychotherapy is recommended before a trial of an antidepressant, antidepressants are

considered when the patient has failed to respond adequately to psychotherapy alone or when there is co-
morbidity with severe clinical depression.

Low dose imipramine in conjunction with dietary counseling and psychological support is also
associated with decreases in binge eating and weight loss.

 Anxiolytics: to decrease anxiety that fuel’s a bulimic’s bingeing and purging.

 Antidepressants: to reduce bingeing, purging, and depression in bulimic patients.

 Atypical antipsychotic olanzepine (zyprexa): has been tried to promote weight gain.

 Antihistamine: effective in emaciated anorectic in decreasing depression.

 Lithium: to improve mood.

Milieu management:
1- Provide an orientation to the sitting to prepare the patient for inpatient or outpatient treatment so
that fears will be reduced.

2- Provide a warm, nurturing atmosphere.

3- Closely observe patients.

4- Encourage the patient to approach a team member if feeling the need to purge.

5- Involve the patient’s family in treatment when appropriate.

6- Respond with consistency.

7- Encourage participation in art, recreation, and other types of therapy.

8- Involve a dietitian in the treatment plan who can teach proper nutrition while providing patients
with an opportunity to select menus.

9- Encourage patient attendance at group therapy sessions.

10- Recommend follow-up psychotherapeutic groups and support groups for patients and their families
and individual psychotherapy for patients with a qualified therapist.

Nursing process:
 Assessment:

1- Health history: nutrition, elimination, reproduction and hormones, activity and rest,
psychosocial.

2- Physical examination: body weight, skin, nutritional state examination, cardiac examination,
GI examination.

3- Laboratory testing: electrolyte abnormalities and cardiac dysfunction.

4- Diagnostic procedure: ECG, endoscopy.

 Nursing diagnosis:

1- Imbalanced nutrition less than body requirements related to refusal to ingest or retain ingested
food, physical excess of caloric intake.

2- Disturbed thought process related to intellectualization, obsessions, overgeneralization and

malnutrition.

3- Disturbed body image related to unresolved psychosocial conflicts.

4- Chronic low self-esteem related to unrealistic expectations from self or others, lack of positive
feedback, striving to please others to gain acceptance.

5- Powerlessness related to belief that one’s actions will not result in desired outcome.
 6- Ineffective coping related to unmet developmental tasks (trust, autonomy), dysfunctional
family system.

7- Interrupted family process related to ineffective communication patterns, denial of problems

and conflict, unresolved issues of control, inability to manage conflict.

 Planning:

1- Body image enhancement.

2- Emotional support.

3- Nutrition management.

4- Weight gain assistance.

5- Fluid and electrolyte management.

6- Mood management.

7- Hope instillation.

8- Self-esteem enhancement.

9- Values clarification.

10- Cognitive restructuring.

 Nursing interventions:

1- Monitor daily caloric intake and electrolyte status while in the hospital, patient shouldn’t gain
too much weight too quickly.

2- Observe patients for signs of purging or other compensation for food consumed.

3- Monitor activity level and encourage appropriate levels of activity for patients.

4- Weight daily while in hospital, but encourage patients to diminish focus on weight after re-
feeding.

5- Plan for a dietitian to meet with patients and families to provide accurate information on
nutrition, discuss a realistic and healthy diet, and assist the nurse in monitoring the nutritional
intake of the patient.

6- Encourage use of therapies or support groups to attain healthy weight and prevent relapse.

7- Promote patient decision making concerning issues other than food.

8- Promote positive self-concept and perceptions of body, as well as interactions with others.

 Indicators of expected outcomes:

1- Verbalizes satisfaction with appearance.

2- Reports a positive internal picture of self.

 3- Moves toward congruence between self-perception and reality.

4- Improved food and fluid intake.

5- Improved weight-to-height ratio.

6- Stabilized vital signs.

7- Stabilized fluid and electrolyte levels.

8- Reports positive feelings of self-worth.

9- Describes self positively.

10- Verbalizes strengths and limitations.

Family teaching:
Do’s and don’ts of helping someone recover from an eating disorder (provided by ANAD):

Do’s:

1- Gently encourage the patient to eat properly.

2- Express your love and support.

3- Try to understand, although this seems impossible.

4- Take time to listen.

5- Try to see how the patient perceives the situation.

6- Realize that the patient is terrified of gaining weight.

7- Emphasize the patient positive.

8- Encourage the patient to accept support and honestly express his feelings.

9- Talk honestly and sincerely with love and understanding.

10- Recognize that other, nonfood factors are at the heart of the problem.

11- Help the patient find someone to support him.

12- Realize that, although he must have help from others, he must want to get better and he needs to
love himself.

Don’ts:

1- Try to force the patient to eat or stop exercising.

2- Get angry or punish the patient.

3- Be impatient.

4- Lecture.
 5- Bee too busy, even you have to give up important things.

6- Jump to conclusions or see things only through your eyes and mind.

7- Make the patient feel bad or guilty for having an eating disorder.

8- Spy on the patient.

9- Place the blame on anyone,

10- Be afraid to talk about the problems.

11- Pretend it will all just go away.

12- Expert an instant recovery.

13- Let the patient feel that he is the only one with this problem.

Conclusion:
1- Anorexia nervosa and bulimia nervosa share many etiologic factors. Although multiple theories
exist. Most experts agree that eating disorders develop from a complex interaction of individual,
family, sociocultural, and physiologic factors.

2- Clients with eating disorders exhibit disturbances in many or all of the functional health patterns.

3- Treatment of clients with eating disorders occurs in community-based and inpatient settings and is
a complex and often lengthy process.

4- Desired client outcomes include normalization of weight and eating patterns, improved self-
esteem, and development of realistic thought process, adaptive coping mechanisms, and
constructive family processes.

5- Most clients require follow-up treatment to reinforce behavioral changes and prevent a return of
disordered eating.

References:
1- Elizabeth M. varcarolis, 2006, manual of psychiatric nursing care plans, third edition, Elsevier Inc,
p:348-384.

2- Wanda K. Mohr, 2006, psychiatric-mental health nursing, seventh edition, Philadelphia, Lippincott
Williams and wilkins, p: 504-528.

3- Norman l. keltner, lee halyard schwecke, carol E. bostrom, 2007, psychiatric nursing, 5th edition,
USA, mosby, p:544-561.

4- www.ANAD.org.

5- www.edreferral.com.

6- www.anred.com.
7- www.something-fishy.org

8- www.scribd.com.