Eating DisordersEating DisordersAnorexia Nervosa & Bulimia NervosaAnorexia Nervosa & Bulimia Nervosa

Power Point Presentation for Nursing Students Power Point Presentation for Nursing Students

By Katrina Tyne (2005)By Katrina Tyne (2005)

Presentation overviewPresentation overview

PrevalencePrevalence Influencing factors for developing Eating Influencing factors for developing Eating

DisordersDisorders Signs & Symptoms of Eating DisordersSigns & Symptoms of Eating Disorders Diagnostic Criteria and comorbidityDiagnostic Criteria and comorbidity Treatment of Eating DisordersTreatment of Eating Disorders

PrevalencePrevalence

Anorexia NervosaAnorexia Nervosa 0.5% of women 0.5% of women

between 15 and 40 between 15 and 40 yearsyears

3-5% mild sub clinical 3-5% mild sub clinical form of anorexiaform of anorexia

Bulimia NervosaBulimia Nervosa 2% of women 2% of women

between 15 and between 15 and 45years45years

5-10% have mild sub 5-10% have mild sub clinical form of bulimiaclinical form of bulimia

Up to 40% of 9-10 year old girls are worried about becoming fat.

Influencing FactorsInfluencing Factors

FamilialFamilial Sociocultural Sociocultural BiologicalBiological TraumaTrauma

FamilialFamilialKenny (1991) suggested that a person with anorexia:Kenny (1991) suggested that a person with anorexia: comes from a family, which discourages him or her from making outside contactcomes from a family, which discourages him or her from making outside contact Is expected to succeed and achieveIs expected to succeed and achieve Is oppressed by domineering parentsIs oppressed by domineering parents

Palazzoli (1974) has looked at familial factors in more detail and has found these Palazzoli (1974) has looked at familial factors in more detail and has found these factors to be involved:factors to be involved:

A rejection of communicated messagesA rejection of communicated messages Poor conflict resolutionPoor conflict resolution A covert alliance of family membersA covert alliance of family members

Munichin (1978) also found these factors:Munichin (1978) also found these factors: EnmeshmentEnmeshment over-protectivenessover-protectiveness RigidityRigidity Lack of conflict resolutionLack of conflict resolution

SocioculturalSociocultural

adolescents view adolescents view under-weight rock under-weight rock stars, models and stars, models and actresses as being actresses as being more happy, popular, more happy, popular, wealthy and wealthy and acceptable.acceptable.

Relationship between Relationship between cultural and religious cultural and religious values values

BiologicalBiological

Medical illnessMedical illness• Inflammatory bowel Inflammatory bowel

diseasedisease• Malignancies/cancerMalignancies/cancer• Thyroid diseaseThyroid disease• Diabetes mellitusDiabetes mellitus• Chronic infectionsChronic infections

Family historyFamily history Eating disorderEating disorder DietingDieting Mood disordersMood disorders Alcoholism in 1Alcoholism in 1stst

degree relativesdegree relatives

Physical Signs & Symptoms of an Physical Signs & Symptoms of an Eating DisorderEating Disorder

Anorexia NervosaAnorexia Nervosa Weight lossWeight loss Failure to gain weight in proportion Failure to gain weight in proportion

to heightto height primary or Secondary amenorrheaprimary or Secondary amenorrhea Low blood GlucoseLow blood Glucose Liver function changesLiver function changes BradycardiaBradycardia HypotensionHypotension HypothermiaHypothermia Peripheral cyanosisPeripheral cyanosis Hair loss, brittle hairHair loss, brittle hair Lanugo Lanugo HyperactivityHyperactivity Dry skinDry skin constipationconstipation

Bulimia NervosaBulimia Nervosa Swollen or tender parotid glandsSwollen or tender parotid glands Dental enamel erosionDental enamel erosion Large number of new cariesLarge number of new caries Calloused scarred area on back of Calloused scarred area on back of

handhand Perioral irritationPerioral irritation Mouth ulcersMouth ulcers Edema Edema diarrhoeadiarrhoea Yo-yo weight patternYo-yo weight pattern Metabolic AlkalosisMetabolic Alkalosis Electrolyte changesElectrolyte changes

DSM-IV Criteria forDSM-IV Criteria forAnorexia NervosaAnorexia Nervosa

BMI < 17.5 or less than 85% of expected BMI < 17.5 or less than 85% of expected weight weight

Intense fear of gaining weight or becoming Intense fear of gaining weight or becoming fatfat

AmenorrheaAmenorrhea Distorted body imageDistorted body image

Restricting or binge/purging typeRestricting or binge/purging type

DSM-IV Criteria for DSM-IV Criteria for Bulimia NervosaBulimia Nervosa

Recurrent episodes of binge eatingRecurrent episodes of binge eating Recurrent compensatory behaviour to Recurrent compensatory behaviour to

prevent weight gainprevent weight gain Self-evaluation unduly influenced by body Self-evaluation unduly influenced by body

shape and weightshape and weight

Purging or non-purging Purging or non-purging

DSM-IV Criteria for Eating DSM-IV Criteria for Eating Disorders (NOS)Disorders (NOS)

The Eating Disorder Not Otherwise Specified category is for disorders The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating of eating that do not meet the criteria for any specific Eating Disorder.Disorder.

Examples include:Examples include: For females, all of the criteria for Anorexia Nervosa are met except For females, all of the criteria for Anorexia Nervosa are met except

that the individual has regular menses.that the individual has regular menses. All of the criteria for Anorexia Nervosa are met except that, despite All of the criteria for Anorexia Nervosa are met except that, despite

significant weight loss, the individual’s current weight is in the significant weight loss, the individual’s current weight is in the normal range.normal range.

All of the criteria for Bulimia Nervosa are met except that the binge All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur less eating and inappropriate compensatory mechanisms occur less frequently.frequently.

The regular use of inappropriate compensatory behaviour by an The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after consuming two cookies).(e.g., self-induced vomiting after consuming two cookies).

Common Comorbid Psychiatric Common Comorbid Psychiatric DisordersDisorders

Mood Disorders – Mood Disorders – Major depression and Dysthymic disorderMajor depression and Dysthymic disorder

Anxiety Disorders – Anxiety Disorders – Obsessive-Compulsive Disorders, Obsessive-Compulsive Disorders,

Generalised Anxiety DisorderGeneralised Anxiety Disorder

Personality DisordersPersonality Disorders ––

AN = Obsessive-Compulsive, Avoidant AN = Obsessive-Compulsive, Avoidant

BN = Borderline, Narcissistic, HistrionicBN = Borderline, Narcissistic, Histrionic

Treatment GoalsTreatment Goals

To become free of eating disorder symptomsTo become free of eating disorder symptoms To become free of preoccupation with foodTo become free of preoccupation with food To have healthy weight for height, age, ethnicityTo have healthy weight for height, age, ethnicity To develop adequate self esteemTo develop adequate self esteem To develop appropriate social skillsTo develop appropriate social skills To develop good body imageTo develop good body image To develop the ability to deal with emotionsTo develop the ability to deal with emotions

Management of Adolescents with Management of Adolescents with Anorexia NervosaAnorexia Nervosa

Medical ManagementMedical Management PsychoeducationPsychoeducation Individual Therapy Individual Therapy Family Therapy Family Therapy

Outpatient Medical ManagementOutpatient Medical Management

Weekly weight monitoring Weekly weight monitoring (see tips for weighing, BMI)(see tips for weighing, BMI)

Blood Pressure and Pulse Blood Pressure and Pulse Body TemperatureBody Temperature HydrationHydration Blood Tests Blood Tests Cardiac Examination (ECG) Cardiac Examination (ECG) (see starvation process)(see starvation process)

Dental ExaminationDental Examination Abdominal ExaminationAbdominal Examination Advise limits on exerciseAdvise limits on exercise

Indications for hospitalisationIndications for hospitalisation Rapid weight loss (>7kg Rapid weight loss (>7kg

in 4 weeks)in 4 weeks) Potassium below Potassium below

2.5mmol/l and/or with 2.5mmol/l and/or with significant ECG changessignificant ECG changes

Prolonged QT intervalProlonged QT interval DysrhythmiasDysrhythmias Unstable vital signsUnstable vital signs Severe malnutrition Severe malnutrition

(BMI<13)(BMI<13) Severe dehydrationSevere dehydration Rapidly diminishing Rapidly diminishing

exercise toleranceexercise tolerance

Frequent exercise Frequent exercise induced chest paininduced chest pain

Fainting or black outsFainting or black outs Renal dysfunction or low Renal dysfunction or low

urine output (<400ml/day)urine output (<400ml/day) Low phosphate during Low phosphate during

initial refeedinginitial refeeding Any significant medical Any significant medical

condition that would condition that would require hospitalisation require hospitalisation with a non-anorexic with a non-anorexic patientpatient

Eating Disorders and the Mental Eating Disorders and the Mental Health Act (1992)Health Act (1992)

In New Zealand application can be sought for involuntary In New Zealand application can be sought for involuntary assessment under the Mental Health Act for a patient assessment under the Mental Health Act for a patient with a dieting disorder if it is believed that the patient has with a dieting disorder if it is believed that the patient has a mental disorder of such a degree that ita mental disorder of such a degree that it

Poses a serious danger to the health and safety of that Poses a serious danger to the health and safety of that person or of othersperson or of others

Seriously diminishes the capacity of that person to take Seriously diminishes the capacity of that person to take care of himself or herself.care of himself or herself.

““Mental disorderMental disorder” in this situation is defined as an ” in this situation is defined as an abnormal state of mind characterised by delusions, or abnormal state of mind characterised by delusions, or by disorder of mood, perception, volition or cognition.by disorder of mood, perception, volition or cognition.

Communication Communication

How should I talk to someone with an How should I talk to someone with an eating disorder?eating disorder?

What’s it like for a child with Anorexia What’s it like for a child with Anorexia Nervosa?Nervosa?

What’s it like for their family?What’s it like for their family? What’s it like for the health clinician?What’s it like for the health clinician?

Communication StyleCommunication Style Be direct but non-confrontationalBe direct but non-confrontational Be encouraging and supportiveBe encouraging and supportive Defuse feelings of shame, blame and guilt Defuse feelings of shame, blame and guilt (externalise the disorder)(externalise the disorder)

Understand eating disorder as a coping mechanism against internal Understand eating disorder as a coping mechanism against internal and/or external stressorsand/or external stressors

Collaborative therapeutic relationshipCollaborative therapeutic relationship Try to engage with “healthy side” of patient while acknowledging Try to engage with “healthy side” of patient while acknowledging

part of them wants/needs to continue with eating disorder part of them wants/needs to continue with eating disorder Use medical information to enhance motivation for change in client Use medical information to enhance motivation for change in client

in a non-critical but concerned mannerin a non-critical but concerned manner

Recommendations from Dr R Mysliwiec (Feb, 2002) Auckland Recommendations from Dr R Mysliwiec (Feb, 2002) Auckland Eating Disorders ServiceEating Disorders Service

A Child’s Perspective of ANA Child’s Perspective of AN ““It’s no coincidence that I obtained the starring role in my school It’s no coincidence that I obtained the starring role in my school

play in the midst of my weight loss. The more I suffered from AN the play in the midst of my weight loss. The more I suffered from AN the more determined I became to be the best.”more determined I became to be the best.”

““If I maintained my weight that was acceptable; if I lost weight I was If I maintained my weight that was acceptable; if I lost weight I was satisfied and relieved. But if I put on even a fraction of a kilo, I satisfied and relieved. But if I put on even a fraction of a kilo, I was miserable”was miserable”

““I feel as though I’m in a box with a lid shut as tightly as can be, I feel as though I’m in a box with a lid shut as tightly as can be, open and shut, open and shut, but the lid never opens for me”open and shut, open and shut, but the lid never opens for me”

““I was convinced that the thinner I was the more loveable I would be I was convinced that the thinner I was the more loveable I would be to the rest to the world”to the rest to the world”

““I made a silent vow to myself that I would become like her I made a silent vow to myself that I would become like her (celebrity)”(celebrity)”

““I believe that love is the keyword in recovery from anorexia nervosa. I believe that love is the keyword in recovery from anorexia nervosa. Inside I loathed myself and not eating was a way of expressing my Inside I loathed myself and not eating was a way of expressing my unworthiness”unworthiness”

““For a long time I simply drew but said nothing. It took a while For a long time I simply drew but said nothing. It took a while before I trusted my therapist enough to speak. Sometimes I felt before I trusted my therapist enough to speak. Sometimes I felt frustrated by the long lapses of silence. I often wished that we frustrated by the long lapses of silence. I often wished that we could have a real conversation together not based on theory…”could have a real conversation together not based on theory…”

Parent’s Perspective of ANParent’s Perspective of AN ““It’s to ask yourself all day and half the night what went It’s to ask yourself all day and half the night what went

wrong?”wrong?” ““It’s to read everything you can find on AN and try to It’s to read everything you can find on AN and try to

understand and help your child – then read it’s your fault”understand and help your child – then read it’s your fault” ““It’s to have everything about you rejected by your child - It’s to have everything about you rejected by your child -

your food, your body, your personality, your achievements”your food, your body, your personality, your achievements” ““I felt wooden and empty and afraid to speak for fear I would I felt wooden and empty and afraid to speak for fear I would

cry”cry” ““I didn’t know what I was supposed to say or do”I didn’t know what I was supposed to say or do” ““Some explanation of therapeutic goals would be helpful”Some explanation of therapeutic goals would be helpful” Getting help is difficultGetting help is difficult “my doctor laughed me out of the “my doctor laughed me out of the

office and told me I was an anxious mother…when I mentioned office and told me I was an anxious mother…when I mentioned her periods, he said “what does she want periods for anyway?”her periods, he said “what does she want periods for anyway?”

““waiting for admission is a time of indescribable anxiety”waiting for admission is a time of indescribable anxiety”

Staff perspectives on AN Staff perspectives on AN • ““You can put frustrating, in capital letters. And…it can be You can put frustrating, in capital letters. And…it can be

pleasurable. When they reach the bottom of the barrel and start pleasurable. When they reach the bottom of the barrel and start coming up and you see them blossom.”coming up and you see them blossom.”

• ““we could not get through to them. They never trusted us enough to we could not get through to them. They never trusted us enough to confide in us…all of us were really, really tired of fighting with these confide in us…all of us were really, really tired of fighting with these girls…”girls…”

• ““You think you’ve done a good job in getting them up to a healthy You think you’ve done a good job in getting them up to a healthy weight and good at getting them to eat a healthy diet. And then… weight and good at getting them to eat a healthy diet. And then… within weeks, they’ll just lose the weight and just come back , and within weeks, they’ll just lose the weight and just come back , and keep coming back.keep coming back.

• “…“…a good learning experience for me. I’ve become more open in a good learning experience for me. I’ve become more open in my thoughts…and gained a lot of knowledge”my thoughts…and gained a lot of knowledge”

• ““Now I just look after them like any other patient, no special Now I just look after them like any other patient, no special treatment really…just stick to the rules and maintain the care…I’ve treatment really…just stick to the rules and maintain the care…I’ve just switched off”just switched off”

Treatment Outcomes for Adults Treatment Outcomes for Adults with Eating Disorderwith Eating Disorder

Anorexia NervosaAnorexia Nervosa After 5 years: 1/3 recovered, 1/3 improved, 1/3 not After 5 years: 1/3 recovered, 1/3 improved, 1/3 not

improvedimproved After 10-20 years: 50% recovered, 30% improved, 10% After 10-20 years: 50% recovered, 30% improved, 10%

chronic, 10% mortality.chronic, 10% mortality.

Bulimia NervosaBulimia Nervosa After 5 years: 50% recovered, 20-35% improved, 15% After 5 years: 50% recovered, 20-35% improved, 15%

not improvednot improved

Among 15 % not improved a high number of comorbid Among 15 % not improved a high number of comorbid psychiatric diagnoses (especially borderline personality psychiatric diagnoses (especially borderline personality disorder) exist.disorder) exist.

The EndThe End

Thank you for your timeThank you for your time