PSYCHIATRIC NURSING
EATING DISORDERS
Chapter 21
OBJECTIVES
• Identify the difference among the various
eating disorders
• Describe symptomatology associated with
anorexia nervosa and bulimia nervosa
• Identify the etiological implications in the
development of eating disorders
• Discuss various modalities relevant to
treatment of eating disorders
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Introduction
• What part of the body is responsible of the
appetite regulation (appestat?
• Hypothalamus
• Society and culture have a major influence on
eating behaviors.
• BMI
• Below 18.5
Underweight
• 18.5 - 24.9
Normal
• 25.0 - 29.9
Overweight
• 30.0 and Above
Obese
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Effect of Culture
• Cultural stereotypes
• Preoccupation with the body
• Cultural ideal of thinness
• Identity and self-esteem are
dependent on physical appearance
• Changing male ideals of the body
Biologic Theory
• There may be a genetic
predisposition for anorexia.
• Relatives of clients with eating
disorders are 5 to 10 times more
likely to develop an eating disorder.
The Effect of Serotonin On
Eating Disorders
Low serotonin
levels decrease
satiety
High serotonin
levels increase
satiety
Increase food
intake
Decrease food
intake
Other Neurotransmitters
Affect Eating Disorders
• Increase eating behavior:
– Norepinephrine
– Neuropeptide Y
• Suppresses food intake:
– Dopamine
Eating Disorders
•Eating is a social activity; almost every
social event has food while it occurs.
• Eating disorders are those associated
with under-eating and over-eating.
•Why do we include eating disorders to
psychiatric nursing?
•Because psychological and behavioral
factors play a potential role in the
presentation of these disorders.
Eating Disorders
• There are basically two psychological or behavioral
eating disorders: Anorexia Nervosa (AN), and
Bulimia Nervosa (BN).
• Obesity is not classified as a psychiatric problem in
DSM-IV.
• AN occurs more in females 12-30 years
(approximately 90% vs. 10%);
• BN is more prevalent than AN, occurs mostly in late
adolescence or early adulthood;
• Obesity is a BMI of 30 or greater, with an inverse
relationship with level of education; morbid obesity is a
BMI>40 kg/m².
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Anorexia nervosas
• is a life-threatening eating disorder
• characterized by the client’s 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
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Anorexia Nervosa
• Characterized by a morbid fear of obesity.
1. Gross distortion in body image (they perceive self
as “fat” when obviously underweight or
emaciated). Weight loss is accomplished by
reduction in food intake and extensive exercising.
They use self-induced vomiting, abuse of
laxatives and diuretics. Marked weight loss.
2. Other symptoms include hypothermia,
bradycardia, hypotension, edema, lanugo,
metabolic changes, and amenorrhea that usually
follows weight loss or sometimes precedes it.
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Anorexia Nervosa
3. Preoccupation with food: there may be an
obsession with food (hoard or conceal food, talk
about food at great length only to restrict
themselves to limited amount of low-calorie food
intake), refusal to eat.
4. Compulsive behaviors, such as hand washing.
5. Psychosexual development is delayed.
6. Feelings of depression and anxiety usually
combine this disorder. Studies suggested
possible interrelationship between eating
disorders and affective disorders.
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Anorexia Nervosa
• Age at onset is early to late adolescence. Occurs in
approximately 0.5-1% of adolescent females and is 1020 times more common in females than in males.
• There are two types
• Restricting type; lose weight primarily through dieting,
fasting, or excessive exercising
• Binge-eating/Purging type. engage regularly in binge
eating followed by purging. 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 involves compensatory
behaviors designed to eliminate food by means of selfinduced vomiting or misuse of laxatives, enemas, and
diuretics.
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Physical Manifestation
of Anorexia Nervosa
• Reduction in the following:
– Heart rate
– Blood pressure
– Metabolic rate
– Production of estrogen or testosterone
Hallmarks of Anorexia
Nervosa
• Rigidity and control
• Rigid rules
• Obsessive rituals
Bulimia nervosa,
• often simply called bulimia, is an eating
disorder characterized by recurrent
episodes (at least twice a week for 3
months) of binge eating followed by
inappropriate compensatory behaviors to
avoid weight gain, such as purging,
fasting, or excessively exercising
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Bulimia Nervosa
•
•
•
•
BN is an episodic, uncontrolled, compulsive,
rapid ingestion of large amounts of food
(binging) followed by inappropriate
compensation to rid the body from the excess
calories.
Food consumed during binge has high calorie,
sweet taste, soft or smooth texture that can be
eaten rapidly without chewing.
Binging occurs in secret and usually
terminated by abdominal discomfort, sleep,
social interruption, or self-induced vomiting.
Self-degradation and depressed mood are
common despite feelings of pleasure during
eating binges.
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Bulimia Nervosa
• To get rid of excessive calories, purging
behaviors are engaged in (self-induced
vomiting; misuse of laxatives, diuretics, or
enemas), or other inappropriate
compensatory behaviors (fasting or
excessive exercise).
• People having this binge and purge
syndrome are within a normal weight
range, with weight fluctuations because of
alternating binges and fasts.
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Bulimia Nervosa
• Excessive vomiting and laxative/diuretic abuse
lead to dehydration and electrolyte imbalance.
• Gastric acid of vomitus causes erosion of tooth
enamel.
• Mood disorders, anxiety disorders, and substance
abuse or dependence, on amphetamines or
alcohol, are common.
• There are two specific types:
1.Purging type.
2.Nonpurging type.
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Etiological implications for AN & BN
1.
2.
3.
4.
5.
Genetics
Neuroendocrine abnormalities
Neurochemical influences
Psychodynamic influences
Family influences (conflict avoidance;
elements of power and control)
Nursing diagnoses:
1. Imbalanced nutrition: less or more than body
requirements
2. Disturbed body image/low self-esteem
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Binge-Eating Disorder
• Eating significantly larger-thannormal amounts in a discrete time
period, until uncomfortably full
• Sense of lack of control
• No compensatory purging
Obesity
• Thought to represent
overcompensation for unmet oral
needs in infancy
• Defense against intimacy with the
opposite sex
• Treatment includes motivational
enhancement therapy and
psychotherapy aimed at relapse
prevention
Contributing Psychosocial
Theories
• Psychoanalytic
• Family systems
• Cognitive/behavioral
• Sociocultural
• Biologic
Female Attractiveness
• Equated with thinness, physical
fitness
• Media glamorizes thinness
• Thinness equated with success and
happiness
• Prejudice against overweight
• Self-esteem enhanced for those
considered attractive
Male Attractiveness
• Ideal body type is lean and muscular
• Emphasis on strength and
athleticism
• Less popular if they do not have the
ideal body type
Psychosocial Pressures
• Frequent exposure to articles about
dieting is significantly associated
with lower self-esteem, depressed
mood, and lower levels of body
satisfaction.
Psychosocial Considerations
• Use of anabolic steroids
• Increased risk for gay or bisexual
males
• Predominately an issue in
industrialized, developed countries
• Not solely a problem of specific
cultural groups
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Assessing Clients
• Dramatic weight loss or gain
• Medical history and physical
examination
• Client conception/misperceptions
about food
• Denial
• Blurred boundaries
• Physical symptoms
Family Dynamics
• Families seriously affected
• Anorexia nervosa
– Enmeshed
– Blurred boundaries
• Bulimia nervosa
– Less enmeshed
– Isolate from one another
Prevention and Treatment
• Anorexia nervosa
• Bulimia nervosa
• Binge-eating disorders
Goals (cont'd)
• The overall goal of treatment for the
individual with anorexia nervosa is
gradual weight restoration.
• A target weight is usually chosen by
the treatment team in collaboration
with a dietitian.
• Target weight for discharge from
treatment is usually 90% of average
for age and height.
Goals (cont'd)
• The goal of nursing interventions
with anxious clients with bulimia is to
help them:
– Recognize events that create anxiety
– Avoid binge eating and purging in
response to anxiety
– Verbalize acceptance of normal body
weight without intense anxiety
Goals (cont'd)
• Providing basic nutritional education
is the goal of interventions with
clients that have a knowledge deficit
in this area.
Nursing Interventions:
Client with Anorexia
Nervosa
• Ensure that the client survives.
• Help the client to learn more
effective ways of coping with the
demands of life.
Anorexia Nervosa: Specific
Interventions
• Tube feeding
• Intravenous therapy
• Weighing the client daily
• Observing bathroom behavior
• Recording intake and output
• Observing the client during meals
Medications
• Antidepressants
– Reduce binge
eating and vomiting
• Symptom control
–
–
–
–
Anxiety
Depression
Obsessions
Impulse control
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Prevention
• Nurses in community-based settings
can play a valuable role in:
– Education
– Support
– Referral
Screening and Education
• Nurses can provide screening and
education in schools, clinics, homes,
health fairs, health clubs
• Individuals at risk: low self-esteem,
irrational behavior related to food,
excessive exercise, and other factors
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Prevention and Screening
• Important to understand cultural
factors contributing to eating
disorders
• Nurses can implement primary
prevention and secondary screening
measures
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Treatment modalities
•
•
•
•
Behavior modification
Individual therapy
Family therapy
Psychopharmacology
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Cognitive–Behavioral
Therapy
• Strategies designed to change the client’s
thinking (cognition) and actions (behavior)
about food focus on interrupting the cycle
of dieting, binging, and purging and
altering dysfunctional thoughts and beliefs
about food, weight, body image, and
overall self concept.
• CBT enhanced with assertiveness training
and self-esteem enhancement has
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produced positive results
Psychopharmacology
• The antidepressants were more effective
than were the placebos in reducing binge
eating.
• They also improved mood and reduced
preoccupation with shape and weight.
• Most of the positive results, however, were
short term, with about one third of clients
relapsing within a 2-year period
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THANK YOU
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