Eating Disorders: Anorexia Nervosa

Eating Disorders Introduction

• Eating disorders are complex with perplexing etiology theories

Major Eating Disorders

• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorders

Anorexia Nervosa

• Individuals fear gaining weight
• Characterized by intense fear of gaining weight and distorted body image
• Strategies to control weight are primary defense mechanism
• Body weight becomes very low due to restriction of energy intake

Anorexia Nervosa Types

• Restricted diet: weight loss through dieting, fasting, or excessive exercise, without regular binge eating or purging
• Binge purging: binge eating followed by purging behaviors such as self-induced vomiting or misuse of laxatives, diuretics or enemas; restrictive or excessive exercise may also occur

Three Factors for Identifying Anorexia

• Energy intake: insufficient food consumption
  • Calories: inadequate calories for healthy weight based on individual factors
  • Teens/children: weighing less than expected for age and growth patterns
• Intense fear of gaining weight: overwhelming fear, even when underweight
  • Can involve a deep fear of gaining any weight or continuously engaging in activities to prevent weight gain like extreme dieting or exercise
• Disturbance in body image
  • Distorted view of body weight
  • Self-worth: placing too much emphasis on body weight
  • Not recognizing the heath risks associated with low weight

Bulimia Nervosa

• Individuals have inappropriate compensatory behaviors such as vomiting or using laxatives
• Minimum duration of 3 months
• Compensatory behaviors: attempt to prevent weight gain after eating a short period of time (binge)

Bulimia Nervosa Types

• Purging type: regularly using self-induced vomiting, laxatives, diuretics, or enemas
• Non-purging type: using other inappropriate compensatory behaviors such as fasting or excessive exercise, but not regularly engaging in purging behaviors

Bulimia Nervosa Levels of Severity

• Mild: 1-3 compensatory behaviors per week
• Moderate: 4-7 behaviors per week
• Severe: 8-13 behaviors per week
• Extreme: 14+ behaviors per week

Binge Eating Disorders

• Binge eating occurs for three months, once per week
• Individuals have binging episodes inducing guilt, depression, disgust, etc.

Overview of a Binge Episode

• Eating occurs in a short period of time of any two hours
• Consuming a larger amount of nutrition that most would eat in similar circumstance and timeframe
• Lack of control over eating during the episode

Binge Eating Disorder Associations

• Eating more rapidly than normal
• Eating until feeling uncomfortable
• Eating large amounts of food while not physically hungry
• Eating alone due to embarrassment about amount of food consumed
• Feeling disgusted, depressed, or guilty afterward

Predisposing and Triggers

• Marked distress: feeling very upset about binge eating
• Interpersonal stressors
• Low self-esteem
• Boredom

Binge Eating Disorder Levels of Severity

• Mild: 1-3 binge eating episodes per week
• Moderate: 4-7 episodes
• Severe: 8-13 episodes
• Extreme: more than 14 episodes

Predisposing Factors

• Genetics
• Neurobiological influences
  • Serotonin
  • Norepinephrine
  • Dopamine
• Neurological changes during starvation: depression and obsessive thinking

Anorexia and Bulimia Neurobiological Connection

• Bulimia and anorexia are associated with serotonin, norepinephrine, and dopamine

Psychodynamic Factors

• Stems from unfulfilled sense of separation-individuation
• Threatening events lead to lack of control over body and self
• Food and eating behaviors provide a feeling of control

Assessment Factors and Index Measures

• Lack of family influences
• Body Mass Index (BMI)
  • Anorexia: BMI of 17 or lower
  • Extreme anorexia: BMI less than 15
• Psychological factors: based on learned behavior

Clinical Presentations of Anorexia Nervosa

• Low weight, caused by caloric restriction and excessive exercise
• Amenorrhea, caused by low weight
• Yellow skin (hypercarotenemia), caused by high carotene levels in blood from diet, reduced fat intake, or altered metabolism
• Lanugo from starvation
• Cold extremities from starvation
• Peripheral edema from hypoalbuminemia and refeeding
• Muscle weakening from starvation and electrolyte imbalance
• Constipation and abnormal lab values from starvation
• Abnormal CT scans and EEG changes

Anorexia Nervosa Effects on the body

• Starvation
• Cardiovascular abnormalities: hypotension, bradycardia, heart failure
• Starvation, dehydration, electrolyte imbalance
• Impaired renal function: dehydration
• Hypokalemia (low potassium): starvation
• Anemic pancytopenia: starvation, deficiency in blood cells
• Decreased bone density: estrogen deficiency, low calcium intake

Characteristics of Anorexia

• Low self-esteem, perfectionism, isolates self
• Obsession with food preparation for others, concealing or hoarding food, and talking about food excessively

Cognitive Deficits in Anorexia

• Overgeneralization: "Other girls don't like me because I'm fat."
• All-or-nothing thinking: "If I eat any dessert, I'll gain 50 pounds."
• Catastrophizing perception: "My life is over if I gain weight."
• Personalization: "Everyone is looking at me when I walk through the school hallway."
• Emotional reasoning: "I know I look bad because I feel bloated."

Bulimia Nervosa Clinical Presentations

• Excessive caloric intake with purging or exercising
• Generally normal to a slightly low weight
• Dental caries, tooth erosion from vomiting
• Enlarged parotid glands from increased serum amylase levels
• Self-induced vomiting from Russel's Sign (calluses and scars on hands)
• Peripheral edema: Rebound fluid, especially when diuretics are used
• Electrolyte imbalance causes muscle weakening
• Electrolyte imbalance, hypokalemia, and hyponatremia are abnormal diagnostic values
• Electrolyte imbalance leads to cardiovascular issues
• Cardiac failure (cardiomyopathy) indicates ipecac intoxication (drug induced to stimulate vomiting)

Bulimia Nervosa Interventions

• Patients need to be placed on liquid diets with NG tubes if they are unable to maintain a healthy oral intake
• If oral consumption is attainable then it is beneficial to collaborate with dietitians to determine calorie intake and fluids to achieve realistic weight goals
• Appropriate caloric intake is required for a weight gain of 2-3 lbs per week

Bulimia Nervosa - Monitoring & Education

• Regularly monitor lab values for phosphate, potassium, calcium and magnesium
• Refeeding syndrome can impact the body causing intracellular effects

Bulimia Nervosa - Therapy and Treatment

• Privileges and restrictions should be explained based on direct weight gain
• Directing focus to control issues, but also minimizing unhealthy eating patterns

Binge Eating Disorders, Signs and Symptoms and Treatment Methods

• Create journal for eating habits
• Identify eating habits relating to satisfying physical and/or physiological hunger
• Diet consits of low fat intake
• Plan diet similar to eating structure prior to the disorder
• Diet targets healthy patterns, while minimizing negative behaviours
• Therapy involves positive influence via effective coping and decreased stress

Treating Weekly Weight Loss

• 1 to 2 pounds a week helps with consistant weight loss
• Reduce triggers that cause irritability and exhaustion to prevent relapse
• Increase exercise for appetite, energy and build muscle

Eating disorder Treatment Modalities

• Behaviour modification aids in treating unhealthy eating habits with anorexia and bulimia
• Focus on healthy control, the patient must participate in their recovery
• Patient must be comfortable when exercising and inducing vomitting
• Healthcare team needs to set goals and determine rewards
• Patient has a right to refuse treatment

Eating Disorder Psychotherapy treatments

• Cognitive behaviour therapy (CBT)
• Individual or family therapy is beneficial

The Maudsley Approach (Family Treatment)

• Actively involves family steps to improve adolescent health
• Consists of family members and outpatient support -Parents provide their adolescent with support and the opportunity to gain weight

What should patient slowly retake control of?

• Eating due to maintiaining weight
• Shifting focus with helathy self idenitity via CBT and ETC

Medication in relation to Eating Disorders

• To this day there is not definite medicine to assist with all symptoms of Anorexia
• SSRI (fluoxetine) core symptoms of bulimia and not effective for anorexia
• SSRI helps patients with depression and suicidal thoughts
• SSRI can temporary stop binge eating

Addiction

• Compulsive need to use a substance causing distress if not fulfilled
• Severity is based on how many criteria are met in a year
• Caffeine, nicotine, alcohol are all substances that are widely accepted

Substance-Induced Disorders

• Intoxication: disturbed state of mind and body from psychoactive drug
  • Symptoms: changes in behavior, consciousness, and judgment
• Withdrawal: physical and mental symptoms from stopping an addictive substance
  • Can cause physical discomfort

Substance Use Factors, Psychological and Developmentally

• Can be used to self-medicate -Alcohol aids users who suffer from panic attacks
  • Opiods help minimize pain and anger
  • Anti depressants help alleviate depression
• In order have self esteem and maintain a healthy lifestyle, the following must be present: the ability to relax, communicate effectively etc.

Defense Mechanisms

• In addiction, irrational thinking patterns are central problem.

Sociocultural Factors

• Social learning and conditioning contribute to a person's likelihood of developing a substance use disorder
• Cultural and ethnic influences play a role in substance use

Dopamine, a central component

• Intensifying motivation increases dopamine and the reward system
• Ventral-tegmental area (VTA) initiates the reward pathway, which involves the amygdala, hippocampus, and prefrontal cortex
• Addiction impairs the prefrontal cortex making a person vulnerable to seeking for drugs for drug
• Drugs can hijack reward pathways, releasing more dopamine than natural rewards

Impacts on the human brain

• Prioritizing intense pleasure in brain's dopamine pathways
• Production of less dopamine reduces enjoyment

Alcohol Effects

• Relaxation and well-being
• Decreased social anxiety
• Calmness

Four Phases of Alcohol Use

• Pre-alcoholic: use to relieve stress and tension; learned acceptance from the environment
• Early alcoholic: blackouts occur, alcohol is needed rather than just enjoyed
• Crucial: loss of control, physiological addiction
• Chronic: emotional and physical disintegration

Alchohol effects

• Drinking in excess leads to individual feeling angry and ill
• Focus is on maintaining the addiction
• Willing to lose everything to maintain addiction

Negative affects of long usage

• Characterized by disintegration of emotion
• Intoxication from frequent usage and severe Depression

Alcohol's impact on long term users

• Abrupt usage results in fatality
• Peripheral neuropathy
• Wernicke's encephalopathy (thiamine deficiency) and Korsakoff's psychosis
• Cardiomyopathy, esophagitis, and gastric irritation

Assessing Alcohol Level

• Low concentration leads to mood change
• High concentration leads to motor control, confusion, memory reduction
• Extreme concentrate leads to fatality

Alcohol Withdrawal Symptoms

• Early symptoms (within 6 hours): headaches, tremors, GI disturbances, anxiety, insomnia
• 12-24 hours: auditory and visual hallucinations
• 24-48 hours: severe symptoms, shaking, sweating
• 48-72 hours: delirium tremens (DTs), high heart rate, elevated body temperature, and seizures

Treatment of Alcohol Withdrawal

• Benzodiazepines: Diazepam, lorazepam, chlordiazepoxide, and oxazepam reduces seizures
• Alcohol Abstinence includes taking Disulfiram daily and avoid using drug triggers.

-Disulfiram and alcohol can trigger respiratory depression with cardiovascular implications

• Naltrexone helps with liver function

Screenings with alcohol use

• Review all screenings and testings.
• Screening helps with intervening and give treatment

Hallucinogen and Stimulant use

• Stimulant users experience the following: grand mal seizures, delirium, and coma
• Hallucinogens and related depressants cause respiratory issues, slurred speech, and loss of judgement

Nursing Practices for Substance Use

• Encourage positive environments and care that is non judgmental
• Acknowledge their lab values when dealing with them directly.
• Acount for substance intake

Interventions for Specific Symptoms?

• Provide a safer living environment by following these approaches: assigning appropriate staff, quiet environment, suicide preventions, routine testing, and communication
• For patients in denial: objectively express the substance use disorder

Factors That Affect Blood Alcohol Level

• Body weight
• Gender
• Concentration of alcohol in drinks
• Number of drinks
• Gastric absorption rate
• Individual's tolerance level

Preclinical Alzheimer's Disease (Asymptomatic)

• Occurs years before symptoms appear
• Changes in the brain, no noticeable symptoms

Mild Cognitive Impairment (MCI)

• Individuals have memory lapses such as familiar words or locations
• Non-severe symptoms that do not involve with cognition or ADLS

Mild Alzheimer's Disease (Early stage)

• Memory loss that affect daily routines like dates
• Problems working and completing routine activities leading people to become confused.
• May start to reduce work and social activities

Moderate Alzheimer's Disease (middle stage)

• Increase memory loss and confusion
• Individuals may have trouble identifying family and friends and conversations.
• Behavioral changes will cause systematic problems

Severe Alzheimer's Disease (Late stage)

• Individuals cannot communicate
• Patient may struggle to sallow or control movement

Medication and Treatments

• Cholinesterase and NMDA inhibitor focus on increasing memory
• Amyloid treatment helps remove proteins in the brain slowing the progression of Alzheimer's disease.

Nursing Actions

• Creating a routine to increase assistance.
• The focus is oriented on safety.
• Maintain a low level simulation

Personality Disorders

• Defined the way a person thinks, feels, and behaves that is from others.
• Traits include the quality for people to act in a certain way.
• Causes challenges for functioning and emotional stress
• People become more focused on rigid behaviors

Types of Personality Disorders

• The different clusters of personailty consist of :
  1. Paranoid
  2. Schizoid
  3. Schizotypal
  4. Antisocial
  5. Histrionic
  6. Naricissistic
  7. Borderline
  8. Avoidant
  9. Obsessive
  10. Compulsive persinaloity disorder
  11. Dependent

Paranoid Personality Disorder

• Patterns and suspicions of others
• They may hold grudges and avoid personal relationships

Schizotypal Personality Disorder

• Perceived pattern of isolation and lack of emotional expressions
• Limited expression and little desire

With drawn personal disorder

• May use little expression and withdrawn from people via anxiety
• May undergo a bland affect while being intellectually superior