Transcript Psychopharmacology and Other Biologic Treatments

Eating Disorders
Chapter 24
Clinical Course of Anorexia Nervosa
 Onset in early adolescence
 Chronic condition with relapses characterized by
significant weight loss
 Often continued to be pre-occupied with food
 10%-25% go on to develop bulimia nervosa
 Poor outcome related to initial lower minimum
weight, presence of purging, and later age of onset
Anorexia Nervosa
 Refusal to maintain body weight
 Intense fear of gaining weight
 Drive for thinness
 Disturbance in body image
 Undue influence of body weight or shape or
denial of current low weight
 Absence of three consecutive menstrual cycles
 Weight loss of 25 lbs
The thinner I got, the happier I felt. It becomes illogical.
You’re sixty pounds and you think you’re still fat.... I
hate being weighed. That is the worst part of my day. I
do the blind weights, where I turn backward, but I’m
getting to where I can hear the clicks, and I’m afraid to
hear that second click at a hundred.
—Erin, 24
Types of Anorexia
 Restricting -- restrict intake or excessive
exercise
 Binge eating/purging
Conceptual Issues
 Body image: the discrepancy between selfperception and others.
 Drive for thinness: an intense physical and
emotional process that overrides all
physiologic body cues, such as hunger and
weakness.
 Interoceptive awareness: sensory response to
emotional and visceral cues, such as hunger.
Epidemiology
 0.5%-1% lifetime prevalence
 Mostly in 14-16-year old
 Female to male ratio 10:1
 Culturally defined body weight expectations
 Familial predisposition
 Comorbid with depression, dysthymia and
obsessive-compulsive disorder and anxiety
Etiology: Biologic
 Dieting -- a risk factor and etiology
 Little evidence to substantiate
dysregulations in appetite-satiety systems
 No evidence of brain structure changes as a
cause
 Biopsychosocial model best explains
etiology (figure 22.2)
Psychological Theories
 Psychoanalytic theory
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At adolescence child turns to eating as a way of control
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Conflict regarding separation & individuation
 Feminist theories
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Role pressure, trying to please others
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Text box 22-3
 Other explanations
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Body-image and self-image
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Sexuality fears
Social Theories
 Social Expectations
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Societal norms and expectations
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Media, fashion industry, peer pressure
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See Research Box 22.4
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Body dissatisfaction related to low self-esteem,
depression, dieting, bingeing,and purging. Body
becomes overvalued.
 Family Responses
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Enmeshment
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Overprotectiveness
Risk Factors
 Biologic
 Dieting
 Overweight
 Increase in (BMR)
 Over-exercising
 Concurrent eating disorders
 Psychological
 Low self-esteem
 Body dissatisfaction
 Feeling of ineffectiveness
 Sexual abuse
 Social
 Media, fashion industry, and focus on ideal body type
 Peer pressure, peer attitudes
 Family attitudes
Interdisciplinary Treatment
 Goals
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Initiating nutritional rehabilitation
Resolving conflicts around body image disturbance
Increasing effective coping
Addressing underlying conflicts
Assist family with healthy functioning and communictation
 Treatment modalities
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Hospitalization usually necessary
Intensive therapies
 Pharmacologic management--SSRIs
Priority Care Issues
 Mortality
 Stigma
Nursing Management
Biologic Domain
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Assessment
Evaluation of systems
Careful history (patient
and family)
Determine weight with
BMI
Menses history
Sleep pattern
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Nursing diagnosis
Imbalanced nutrition
Sleep disturbance
Fatigue
Fluid volume deficit
Bowel elimination
altered
Biologic Assessment
Vomiting/Laxative Use
 Metabolic
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Hypokalemia
BUN
 Gastrointestinal
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Salivary gland and pancreas, inflammation
Esophageal erosion
Dysfunctional bowel
 Dental
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Erosion of enamel (frontal teeth)
 Neuropsychiatric
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Seizures
Nursing Interventions
Biologic
 Refeeding
 Strict monitoring and recording of intake
 Weight-increasing protocols (usually a
behavioral plan with reward)
 Sleep hygiene
 Exercise is usually not permitted. Exercise
needs to be monitored.
Nursing Assesment
Psychological Domain
Assessment
 Body distortion
 Fear of weight gain
 Unrealistic expectations
and thinking
 Ritualistic behaviors
 Difficulty expressing
negative feelings
 Inability to experience
visceral cues and emotions
 Instruments text box 22.8
Nursing Diagnosis
 Anxiety
 Disturbed body image
 Ineffective coping
 Ineffective interpersonal
skills
Nursing Interventions
Psychological
 Nurse-patient relationship -- focus on trust
development
 Journals linking physical state to feelings and
surrounding events
 Identifying feelings
 Avoid trying to change distorted body image
 Cognitive Therapies, Self-Monitoring
 Education
Nursing Management
Social Domain
Assessment
Nursing diagnosis
 School attendance
 Social isolation
 Family interaction
 Ineffective family
coping
Social Nursing Interventions
 Facilitate transition to school
 Family therapy
 Family education
Continuum of Care
 Hospitalization (brief)
 Emergency care
 Long term treatment with family therapy
 Outpatient treatment
 Prevention
Bulimia Nervosa
 Recurrent episodes of binge eating
 Generally, not life-threatening
 Present as overwhelmed and overly committed individuals
who have difficulty setting limits and establishing
boundaries -- “social butterflies”
 Treatment is outpatient therapy
 Usually normal weight
 Restriction of total calories between binges
 Undue influence of body weight or shape or denial of
current low weight
 Types: purging and nonpurging
Purging
Clinical Course
 Few outward signs
 Binge and purge in secret
 Treatment can be delayed for years
 Initiate treatment when control of their eating
is lost
 Once treatment initiated, patients recover
completely
Concepts
 Binge eating.
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Rapid, episodic impulsive, and uncontrollable
ingest of large amount of food over a short
period of time (1-2 hours).
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Eating followed by guilt, remorse, and severe
dieting is instituted.
 Dietary restraint.
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Restricting intake is believed to explain the
relationship between dieting and binge
behavior.
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Restraining intake is predictive of overeating.
Epidemiology
 Lifetime prevalence, 3%-8% (more prevalent than
anorexia nervosa)
 Onset is between 18-24 years (older than anorexia
nervosa)
 Females to males 10:1
 Related to Western culture social values
 First degree relatives more likely to develop
 Comorbid conditions include substance abuse and
dependence, depression, and OCD
Etiology
Biologic
 Dieting
 Neuropathic changes reverse when
symptoms subside
 Genetic -- some indications that there
are genetic influences
 Biochemical -- lowered brain serotonin
Psychosocial Theories
 Separation -- individuation theories
 Cognitive theory explains distorted thinking
 Chaotic families with unclear boundaries
Interdisciplinary Treatment
 Goals
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Stabilizing and normalizing eating
Restructuring dysfunctional thoughts and attitudes
Teaching healthy boundary setting
Resolving conflicts about separation-individuation
 Multifaceted approach
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Intensive psychotherapy
Pharmacologic -- SSRIs
Nutrition counseling
 Priority care issues
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Comorbid depression and suicide
Risk for self-mutilation
Impulsive behavior -- shop lifting, overspending, etc.
Nursing Management
 Assessment
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Similar to anorexia nervosa
Bingeing/purging behavior
 Diagnosis
 Intervention
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Biologic
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Nutritional counseling/management
Pharmacologic -- SSRIs
Nursing Management (Cont.)
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Psychosocial
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CBT and IPT can be used
Behavioral interventions (cue elimination, self-monitoring)
Self-responsibility (Ns-Pt Rel)
Identifying disordered eating patterns
Interrupting binge-purge cycle
Education
Eating Disorders Related Links