Transcript EATING DISORDER - Universitas Airlangga

By
Ni Ketut Alit A
Faculty Of Nursing Airlangga University
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Black, J.M. & Matassarin E, (1997). Medical Surgical Nursing:
Clinical Management for continuity of care. J.B. Lippincott.co.
Barbara C.L & Wilma J.P. (2006). Essentials of Medical Surgical
Nursing. Philadelphia: Lippincott Williams & Wilkins.
Smeltzer, S.C., & Bare, B. (2003). Brunner and Suddarth's
Textbook of Medical-Surgical Nursing (10th ed.). Philadelphia:
Lippincott Williams & Wilkins.
Ignativicius & Bayne. (2001). Medical and Surgical Nursing.
Philadelphia: W.B. Saunders Company.
Luckman & Sorensen. (2000). Medical Surgical Nursing.
Philadelphia: W.B. Saunders Company.
Journals and article related to..
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REVIEW
Body Weight
 Body Mass Index ( BMI)
 Daily Calori Need - Haris Benedict
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Current Western beauty standards equate
thinness with health and beauty
There has been a rise in eating disorders in
the past three decades
◦ The core issue is a morbid fear of weight gain
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Two main diagnoses:
◦ Anorexia nervosa
◦ Bulimia nervosa
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The main symptoms of anorexia nervosa are:
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A refusal to maintain more than 85% of normal
body weight
Intense fears of becoming overweight
A distorted view of body weight and shape
Amenorrhea
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There are two main subtypes:
◦ Restricting type
 Lose weight by restricting “bad” foods, eventually
restricting nearly all food
 Show almost no variability in diet
◦ Binge-eating/purging type
 Lose weight by vomiting after meals, abusing laxatives
or diuretics, or engaging in excessive exercise
 Like those with bulimia nervosa, people with this subtype
may engage in eating binges
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About 90–95% of cases occur in females
The peak age of onset is between 14 and 18
years
Around 0.5% of females in Western countries
develop the disorder
◦ Many more display some symptoms
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The “typical” case:
◦ A normal to slightly overweight female has been
on a diet
◦ Escalation to anorexia nervosa may follow a
stressful event
 Separation of parents
 Move or life transition
 Experience of personal failure
◦ Most patients recover
 However, about 2 to 6% become seriously ill and die as a
result of medical complications or suicide
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The key goal for people with anorexia
nervosa is thinness
◦ The driving motivation is FEAR:
 Of becoming obese
 Of losing control of body shape and weight
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Despite their dietary restrictions, people with
anorexia are extremely preoccupied with food
◦ This includes thinking and reading about food and
planning for meals
◦ This relationship is not necessarily causal
 It may be the result of food deprivation, as evidenced
by the famous.
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People with anorexia nervosa also
demonstrate distorted thinking:
◦ Often have a low opinion of their body shape
◦ Tend to overestimate their actual proportions
 Adjustable lens assessment technique – overestimate size
by 20%
◦ Hold maladaptive attitudes and beliefs
 “I must be perfect in every way”
 “I will be a better person if I deprive myself”
 “I can avoid guilt by not eating”
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People with anorexia may also display
certain psychological problems:
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Depression (usually mild)
Anxiety
Low self-esteem
Insomnia or other sleep disturbances
Obsessive-compulsive patterns
Perfectionism
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Caused by starvation:
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Amenorrhea
Low body temperature
Low blood pressure
Body swelling
Reduced bone density
◦ Slow heart rate
◦ Metabolic and
electrolyte imbalance
◦ Dry skin, brittle nails
◦ Poor circulation
◦ Lanugo
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Bulimia nervosa, also known as “binge-purge
syndrome,” is characterized by binges:
◦ Bouts of uncontrolled overeating during a limited
period of time
 Often objectively more than most people would/could
eat in a similar period
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The disorder is also characterized by
compensatory behaviors, which mark the
subtype of the condition:
◦ Purging-type bulimia nervosa
 Vomiting
 Misusing laxatives, diuretics, or enemas
◦ Nonpurging-type bulimia nervosa
 Fasting
 Exercising excessively
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Like anorexia nervosa, about 90–95% of
bulimia nervosa cases occur in females
The peak age of onset is between 15 and 21
years
Symptoms may last for several years with
periodic letup
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Patients are generally of normal weight
◦ May be slightly overweight
◦ Often experience weight fluctuations
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“Binge-eating disorder” may be a related
diagnosis
◦ Symptoms include a pattern of binge eating with
NO compensatory behaviors (such as vomiting)
◦ This condition is not yet listed in the DSM
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Teens and young adults have frequently
attempted binge-purge patterns as a means
of weight loss, often after hearing accounts
of bulimia from friends or the media
In one study:
◦ 50% of college students reported periodic binges
◦ 6% tried vomiting
◦ 8% experimented with laxatives at least once
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For people with bulimia nervosa, the
number of binges per week can range from
2 to 40
◦ Average: 10 per week
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Binges are often carried out in secret
◦ Binges involve eating massive amounts of food
rapidly with little chewing
◦ Binge-eaters commonly consume more than
1500 calories (often more than 3000 calories) per
binge episode
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Binges are usually preceded by feelings of
tension and/or powerlessness
Although the binge itself may be pleasurable,
it is usually followed by feelings of extreme
self-blame, guilt, depression, and fears of
weight gain and “discovery”
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After a binge, people with bulimia nervosa
try to compensate for and “undo” the caloric
effects
The most common compensatory
behaviors:
◦ Vomiting
 Affects ability to feel satiated  greater hunger and
bingeing
◦ Laxatives and diuretics
 Almost completely fail to reduce the number of calories
consumed
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Compensatory behaviors may temporarily
relieve the negative feelings attached to binge
eating
◦ Over time, however, a cycle develops in which
purging  bingeing  purging…
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The “typical” case:
◦ A normal to slightly overweight female has been on
an intense diet
◦ Research suggests that even among normal
subjects, bingeing often occurs after strict dieting
 For example, a study of binge-eating behavior in a
low-calorie weight loss program found that 62% of
patients reported binge-eating episodes during
treatment
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Similarities:
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Onset after a period of dieting
Fear of becoming obese
Drive to become thin
Preoccupation with food, weight, appearance
Elevated risk of self-harm or attempts at suicide
Feelings of anxiety, depression, perfectionism
Substance abuse
Disturbed attitudes toward eating
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Differences:
◦ People with bulimia are more worried about
pleasing others, being attractive to others, and
having intimate relationships
◦ People with bulimia tend to be more sexually
experienced
◦ People with bulimia display fewer of the
obsessive qualities that drive restricting-type
anorexia
◦ People with bulimia are more likely to have
histories of mood swings, low frustration
tolerance, and poor coping
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Differences:
◦ People with bulimia tend to be controlled by
emotion – may change friendships easily
◦ People with bulimia are more likely to display
characteristics of a personality disorder
◦ Different medical complications:
 Only half of women with bulimia experience amenorrhea
vs. almost all women with anorexia
 People with bulimia suffer damage caused by purging,
especially from vomiting and laxatives
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Most theorists subscribe to a
multidimensional risk perspective:
◦ Several key factors place individuals at risk
◦ More factors = greater risk
◦ Leading factors:
 Sociocultural conditions (societal and family pressures)
 Psychological problems (ego, cognitive, and mood
disturbances)
 Biological factors
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Many theorists argue that current Western
standards of female attractiveness have
contributed to the rise of eating disorders
◦ Standards have changed throughout history toward
a thinner ideal
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Certain groups are at greater risk from these
pressures:
◦ Models, actors, dancers, and certain athletes
 Of college athletes surveyed, 9% met full criteria for an
eating disorder while another 50% had symptoms
 20% of surveyed gymnasts met full criteria for an
eating disorder
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The socially-accepted prejudice against
overweight people may also add to the “fear”
and preoccupation about weight
◦ About 50% of elementary and 61% of middle school
girls are currently dieting
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Families may play a critical role in the
development of eating disorders
◦ As many as half of the families of those with eating
disorders have a long history of emphasizing
thinness, appearance, and dieting
◦ Mothers of those with eating disorders are more
likely to be dieters and perfectionistic themselves
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Abnormal family interactions and forms of
communication within a family may also set
the stage for an eating disorder
◦ Minuchin cites “enmeshed family patterns” as
causal factors of eating disorders
 These patterns include overinvolvement in, and
overconcern about, family member’s lives
 Such families can be affectionate and loyal but can also
foster clinginess and dependency
 Children are allowed little room for individuality and
independence
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Bruch : eating disorders are the result of
disturbed mother–child interactions which
lead to serious ego deficiencies in the child
and to severe cognitive disturbances
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Bruch : parents may respond to their
children either effectively or ineffectively
◦ Effective parents accurately attend to a child’s
biological and emotional needs
◦ Ineffective parents fail to attend to child’s
internal needs; they feed when the child is
anxious, comfort when the child is tired, etc.
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There is some empirical support for Bruch’s
theory from clinical sources
◦ People with bulimia eat in response to emotions;
many mistakenly think they are also hungry
◦ People with eating disorders rely excessively on the
opinions, wishes, and views of others
 They are more likely to worry about how they are
viewed, to seek approval, to be conforming, and to feel
a lack of life control
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Many people with eating disorders,
particularly those with bulimia nervosa,
experience symptoms of depression
◦ Theorists believe mood disorders may “set the
stage” for eating disorders
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There is some empirical support for the
claim that mood disorders set the stage for
eating disorders
◦ Many more people with an eating disorder qualify
for a clinical diagnosis of major depressive
disorder than do people in the general population
◦ Close relatives of those with eating disorders
seem to have higher rates of mood disorders
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Biological theorists suspect that some people
inherit a genetic tendency to develop an
eating disorder
◦ Consistent with this model:
 Relatives of people with eating disorders are 6 times
more likely to develop the disorder themselves
◦ These findings may be related to low serotonin
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Other theorists believe that eating disorders
may be related to dysfunction of the
hypothalamus
◦ Researchers have identified two separate areas that
control eating:
 Lateral hypothalamus (LH)
 Ventromedial hypothalamus (VMH)
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Some theorists believe that the LH and VMH
are responsible for weight set point – a
“weight thermostat” of sorts
◦ Set by genetic inheritance and early eating
practices, this mechanism is responsible for
keeping an individual at a particular weight level
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Eating disorder treatments have two main
goals:
◦ Correct abnormal eating patterns
◦ Address broader psychological and situational
factors that have led to and are maintaining the
eating problem
 This often requires the participation of family and
friends
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The initial aims of treatment for anorexia
nervosa are to:
◦ Restore proper weight
◦ Recover from malnourishment
◦ Restore proper eating
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In the past, treatment took place in a
hospital setting; it is now often offered in
an outpatient setting.
In life-threatening cases, clinicians may
force tube and intravenous feeding
Most common technique now is the use of
supportive nursing care and high calorie
diets
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Therapists use a mixture of therapy and
education to achieve this broader goal
◦ One focus of treatment is building autonomy and
self-awareness
 Therapists help patients recognize their
need for independence and control
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Another focus of treatment is correcting
disturbed cognitions, especially client
misperceptions and attitudes about eating
and weight
◦ Using cognitive approaches, therapists correct
disturbed cognitions and educate about body
distortions
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Another focus of treatment is changing family
interactions
◦ Family therapy is important for anorexia
◦ The main issues are often separation and
boundaries
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The use of combined treatment approaches
has greatly improved the outlook for people
with anorexia nervosa
◦ But even with combined treatment, recovery is
difficult
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The course and outcome of the disorder vary
from person to person
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Positives of treatment:
◦ Weight gain is often quickly restored
 83% of patients still showed
improvements after several years
◦ Menstruation often returns with return to normal
weight
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Negatives of treatment:
◦ Close to 20% of patients remain troubled for years
◦ Even when it occurs, recovery is not always
permanent
 Relapses are usually triggered by stress
 Many patients still express concerns about body shape
and weight
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Treatment programs are relatively new but
have risen in popularity
Treatment is frequently offered in specialized
eating disorder clinics
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The initial aims of treatment for bulimia
nervosa are to:
◦ Eliminate binge-purge patterns
◦ Establish good eating habits
◦ Eliminate the underlying cause of bulimic patterns
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Programs emphasize education as much as
therapy
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Several treatment strategies:
◦ Individual insight therapy
 The insight approach receiving the most attention is
cognitive therapy, which helps clients recognize and
change their maladaptive attitudes toward food, eating,
weight, and shape
 As many as 65% stop their binge-purge cycle
 If cognitive therapy isn’t effective, interpersonal therapy
(IPT), a treatment that seeks to improve interpersonal
functioning, may be tried
 A number of clinicians also suggest self-help groups or
self-care manuals
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Several treatment strategies:
◦ Behavioral therapy
 Behavioral techniques are often included in treatment
as a supplement to cognitive therapy
 Diaries are often a useful component of
treatment
 Exposure and response prevention (ERP) is used to
break the binge-purge cycle
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Several treatment strategies:
◦ Antidepressant medications
 During the past decade, antidepressant drugs have
been used in bulimia treatment
 Most common is fluoxetine (Prozac), an SSRI
 Drugs help 25 to 40% of patients
 Medications are best when used in combination with
other forms of therapy
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Several treatment strategies:
◦ Group therapy
 Provides an opportunity for patients to express their
thoughts, concerns, and experiences with one another
 Helpful in as many as 75% of cases, especially when
combined with individual insight therapy
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Left untreated, bulimia can last for years
Treatment provides immediate, significant
improvement in about 40% of cases
◦ An additional 40% show moderate improvement
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Follow-up studies suggest that 10 years after
treatment, about 90% of patients have fully or
partially recovered
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Relapse can be a significant problem, even
among those who respond successfully to
treatment
◦ Relapses are usually triggered by stress
◦ Relapses are more likely among persons who:
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Had a longer history of symptoms
Vomited frequently
Had histories of substance use
Have lingering interpersonal problems
Finally, treatment may also help improve
overall psychological and social functioning
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