Pathophysiology

The pathophysiology is currently unknown. A person, whether through biology, societal patterns, or behavioral makeup, begins dieting; 35% of those dieting progress to pathological eating habits, and 20% to 25% go on to partial or full-blown eating disorders. Weight loss gives positive reinforcement to continue avoidance of food, intense exercise, or binging and/or purging behaviors. The effect of low weight and starvation leads to nutritional imbalances and psychological changes. Due to the patient's tendency towards obsessive behaviors and rigid thought patterns, the patient maintains the anorexic cycle. The act of starvation and weight loss may provide a sense of pride and positive drive for the patient. Any life stresses, often interpersonal in nature, are avoided with the obsessive focus on food and weight management. A sense of controllable satisfaction and success prompts continuation. The patient gains confidence and resists walking away from the safety of routine. Psychologically speaking, AN relieves generalized anxiety, which takes the form of an easy-to-identify fear of food. The fear of gaining weight leads to avoidance of food, which leads to relief of anxiety through weight loss. Additionally, physiological changes propagate the disease and continual relapses. Corticotrophin-releasing hormone, released during starvation, promotes appetite suppression but this also increases cortisol levels, which in turn increases the risk for osteoporosis. Additionally, vasopressin is high and oxytocin low in cerebrospinal fluid, which is hypothesized to promote the unhealthy thought patterns.

Signs and Symptoms

Physical signs and symptoms of anorexia include: o Extreme weight loss o Thin appearance o Abnormal blood counts o Fatigue o Insomnia o Dizziness or fainting o A bluish discoloration of the fingers o Hair that thins, breaks or falls out o Soft, downy hair covering the body o Absence of menstruation o Constipation o Dry skin o Intolerance of cold o Irregular heart rhythms o Low blood pressure o Dehydration o Osteoporosis o Swelling of arms or legs

Signs and Symptoms cont.

Emotional and behavioral characteristics associated with anorexia include: o Refusal to eat o Denial of hunger o Afraid of gaining weight o Lying about how much food has been eaten o Excessive exercise o Flat mood (lack of emotion) o Social withdrawal o Irritability o Preoccupation with food o Reduced interest in sex o Depressed mood o Possible use of laxatives, diet aids or herbal products

Assessment

Explore the patients understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patients negative body image and negative self-concept are related to overwhelming anxiety. Assess to what degree culture, religion, race, and gender influence the patients negative views of self Determine the family or patients perceptions regarding psychological and physical changes brought about by anorexia Obtain the patients assessment of personal strengths and weaknesses Assess the patients ability to identify here and now emotional states and precipitating events that trigger negative behaviors

Interventions

Encourage reexamination of positive and negative self-perceptions. Encourage the patient to identify the differences between real people and celebrities Encourage recognition, expression, and acceptance of unpleasant feelings Help the patient develop a realistic, acceptable perception of body image and food. Refer the patient to individual counseling and a support group for eating disorders.

Nursing Diagnosis
Disturbed Body Image

Patient Teaching

Reestablish adequate/appropriate nutritional intake. Correct fluid and electrolyte imbalance. Assist patient to develop realistic body image/improve self-esteem. Provide support/involve significant other, if available, in treatment program. Coordinate total treatment program with other disciplines. Provide information about disease, prognosis, and treatment to patient.

Medication Regimen/Adverse Effects

The most common drug which is administered to AN patients is chlorpromazine. If prescribed, it is usually given to severely obsessive-compulsive, anxious, and agitated AN patients. This drug is a neuroleptic or dopamine antagonist in the brain, and the theory which serves as the basis of this treatment revolves around the idea that certain characteristics of anorexia nervosa might reflect central nervous system dopaminergic activity. Some scientists theorize that these dopaminergic activities cause this eating disorder among other things. In certain clinical experiences, chlorpromazine has been shown to be somewhat effective in inducing hunger and weight gain, but others have shown no such effects along with some serious side effects. These include grand mal seizures and in increase in the development of bulimia.

Tricyclic antidepressants, such as clomipramine and amitriptyline, have been prescribed to anorectics. In different studies comparing them to placebo drugs, little significant differences between them were found. When dosages were raised, there was a faster bodyweight gain than with placebo, but the medication produced problematic adverse effect including sedation, tachycardia, constipation, dry mouth and confusion.

Medication Regimen/Adverse Effects cont.

Zinc Supplementation of anorexia nervosa has been reported to increase the weight gain of patients. This theory regarding the supplementation of zinc came about because of its association with weight loss, disorders of appetite and food intake, skin abnormalities, amenorrhea, and depression; the population most at risk for anorexia nervosa. Studies have shown that zinc supplementation of anorexia nervosa patients improved their weight gain and because of its low cost and low potential for side effects, it is a viable supplement to be considered with standard treatment.

Sources
Foundations of Mental Health Care 4th Edition-Morrison-Valfre http://www.vanderbilt.edu/AnS/psychology/health_psychology/a norexia_drugs.htm http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001401/ http://www.mayoclinic.com/health/anorexia/DS00606