Chapter 10. Eating Disorders

Eating disorders are serious and potentially life-threatening when interventions are nonexistent, delayed, or unsuccessful. In the 1970s, eating disorders began to receive closer public and clinical attention as a result of the hospitalizations and deaths of high-profile celebrities whose eating problems were disclosed.

During that time a national trend toward adoration and emulation of unnaturally slender bodies gained momentum. Television, magazines, films, and clothing stores projected the thin image everywhere. Enmeshed in this trend were many people who seemed obsessed with being excessively thin. Normal-sized, healthy individuals were starving themselves or purging their food in an effort to fulfill the image. As a result, the number of eating disorders grew rapidly. Other causes for eating disorders are discussed next.

ETIOLOGY

Eating behaviors and related issues are multiple and complex. Research on psychologic and psychosocial etiology is more available than research on biologic causes, largely because many identifiable biologic changes in clients with eating disorders may result from the disorder rather than being the cause (Box 10-1). As with other disorders, the combination or convergence of biopsychosocial factors is probable. Another problem arises in attempting to describe causation for eating disorders because of coexisting disorders with similar symptoms.

BOX 10-1

Etiology of Eating Disorders ^*

BIOLOGIC

▪ Genetic (no marker implicated to date)

▪ Neuroendocrine dysfunction

▪ Neurotransmitter dysregulation

▪ Neuropathology (enlargement of ventricles and sulci in cortex)

▪ Gastrointestinal enzymes

PSYCHOLOGIC/DEVELOPMENTAL

▪ Psychoanalytic (interrupted autonomy/individuation/separation)

▪ Gender identity disturbance

▪ Emerging sexuality (fears related to roles, expectations)

▪ Comorbid disorders (depression)

▪ Perception of failure (resultant low self-esteem)

▪ Need for control

▪ Obsessive-compulsive disorder

SOCIAL

▪ Image comparison (TV, films, magazines, models)

▪ Body dissatisfaction

▪ Unrealistic body proportions as play things (dolls, figurines)

▪ Exercise/beauty myth

▪ Family dysfunction (rigid, enmeshed, overprotective; parents fear child’s development)

▪ Sexual abuse

*Etiology is attributed to a combination of biologic, psychologic, psychosocial, and environmental factors.

EPIDEMIOLOGY

Eating disorders usually begin in adolescence and affect females more than males by a ratio of 10:1. (N ote: Fewer samples of males have been researched.) Age of onset is usually 14 to 16 years for anorexia and 18 to 24 years for bulimia, but bulimia occurs in all age groups. Statistics are similar in the United States and in all other industrialized countries. Lifetime occurrence for anorexia nervosa in young women is 0.5% to 1%, and 1% to 3% have bulimia nervosa. White and Hispanic women have a higher prevalence than Asian American or African American women. Prevalence in first-degree relatives is high for both disorders.

Comorbidity

Other mental disorders may coexist with eating disorders. With anorexia nervosa, dysthymia, and major depression are prevalent, as well as anxiety disorders, particularly obsessive-compulsive disorder (OCD). OCD occurs in approximately one half or more of those with anorexia and exists before the eating disorder in most clients. The most common disorders with bulimia are depression, substance-related disorders, and OCD. Personality disorders are also often diagnosed in clients with eating disorders.

ASSESSMENT AND DIAGNOSTIC CRITERIA

Anorexia Nervosa

Defining characteristics of anorexia nervosa are (1) refusal to attain or maintain minimal normal body weight for age and height, (2) extreme fear of gaining weight, (3) perceptual disturbance (sees self as “fat,” even when grossly underweight), and (4) amenorrhea (after menarche, females miss at least three consecutive menstrual periods; before menarche, menstrual cycle is delayed).

Weight loss is caused primarily by food intake reduction as the diet becomes more and more restricted, eliminating high-caloric foods. The term anorexia is a misnomer because there is seldom a loss of appetite until the individual is extremely malnourished and near death. Death occurs in more than 10% of those individuals who require hospitalization and usually results from starvation, suicide, or electrolyte imbalance.

Other methods the individual uses to lose weight are purging (excessive use of diuretics or laxatives and self-induced vomiting) and increased and excessive exercise. Often the voluntary food restriction cannot be maintained, and eating binges occur, followed by the purging. Usually, food is thought about constantly, and unusual behaviors may develop, such as passionately collecting recipes and cookbooks, preparing voluminous meals for other people but not eating them, or secretly hiding food throughout the house.

With the intense fear of weight gain comes a distorted self-image, and a very thin body is still perceived as fat. If the individual perceives herself as thin, the perception of “fat parts” (buttocks, thighs, abdomen) remains where none exists. Denial of any accompanying medical disturbances is strong among individuals with anorexia nervosa.

Amenorrhea occurs in postmenarchal females. Also, menarche may be delayed in anorexia nervosa because of failure of the pituitary to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH) that in turn stimulate estrogen production.

Associated disturbances most frequently found with anorexia nervosa are (1) symptoms of depression (major depression may be diagnosed, but determinants are necessary regarding depression as a secondary result of physiologic starvation); (2) obsessive-compulsive characteristics both in relation to food and unrelated to food and eating; (3) somatic complaints; and (4) other characteristics such as compulsive stealing, excessive need to control the environment, limited sociability, and feelings of ineffectiveness.

Bulimia Nervosa

The defining characteristic of bulimia nervosa is binge eating that is coupled with methods to prevent weight gain. Diagnosis is made when bingeing and associated weight loss methods occur at least twice a week for 3 months.

A binge refers to consumption of an amount of food that is much larger than most individuals can eat, with the eating done in usually less than 2 hours. Typically the type of food is soft, easy to swallow, sweet, and high in calories (ice cream, pastries, cakes), but many individuals eat foods other than sweets. Often the eating is done inconspicuously or secretively, and the individual feels a lack of control over the behavior. Snacking throughout the day, even though a large volume of food is consumed, is not considered binge eating.

Compensatory techniques are used by individuals with bulimia to prevent weight gain after binges. The most common method is self-induced vomiting, which is done by 80% to 90% of binge eaters. Most often a person sticks fingers down the throat to stimulate a gag reflex, but implements may be used, or, rarely, individuals use syrup of ipecac to induce vomiting. Another method of purging the system is through laxatives and diuretics; rarely, a person uses enemas for catharsis. Usually the person reaches a point of being able to vomit at will. Vomiting decreases weight gain but also decreases bloating and feelings of being full so that eating can continue. Many individuals describe a sense of relief or release of tension and anxiety after vomiting, but depression follows the episode as the person deals with postbinge remorse or despair.

As with anorexia nervosa, individuals with bulimia may employ excessive exercise methods to control weight, but this method is not usually used as vigorously as in anorexia nervosa. Fasting also may be used to control weight.

DSM-IV-TR

American Psychiatric Association
Eating Disorders

Anorexia nervosa

▪ Restricting type

▪ Binge-eating/purging type

NOS, Not otherwise specified.

Control is a major issue in bulimia nervosa, and a sense of lack of control predominates. A state of frenzy may exist during the eating binge, or the individual may describe feelings of dissociation during the episode. In either case, affected individuals say they lose an internal locus of control over the situation.

DSM-IV-TR Categories

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) categories for eating disorders provide subtypes for anorexia and bulimia (see DSM-IV-TR box and Appendix L).

Subtypes assigned to the diagnosis of anorexia nervosa are as follows:

▪ Restricting type: Weight loss primarily results from dieting, fasting, or excessive exercise.

▪ Binge-eating/purging type: Weight loss results from regular binge eating and purging during the current episode.

Subtypes of bulimia nervosa are the following:

▪ Purging type: Person regularly uses self-induced vomiting and misuses laxatives, diuretics, and enemas during the episode.

▪ Nonpurging type: Person uses methods other than purging, such as fasting and excessive exercise.

INTERVENTIONS

Primary prevention is key in eating disorders. Advocates for eating disorder awareness can do much to educate parents, teachers, and students about the pitfalls and dangers related to dysfunctional eating. Each group can learn to assess behaviors and potential problems and intervene to help the client before the problem is beyond control.

The first line of treatment for clients with acute eating disorders is safety and health. This may include suicide intervention (usually in the case of existing comorbid diagnoses) and interruption of self-destructive behaviors directed at starvation or purging of food. When it is determined that the client is free from self-harm, the focus shifts to reestablishing nutritional balance and, by learning new techniques, substituting healthy behaviors for existing harmful ones.

Therapies

Therapeutic Nurse-Client Relationship

The nurse-client relationship can be an effective vehicle for behavior change in clients who have eating disorders (see Chapter 1). The client with anorexia nervosa will probably defy the alliance because of habitual avoidance behaviors, anger, and mistrust that have developed as others, in the client’s perception, have “forced” the client to eat. The nurse performs a thorough autodiagnosis to avoid judging or becoming angry at the client or, in the worst case, to take the client’s rejection personally and abandon interactions. These clients pose a challenge to the nurse who is not prepared for opposition and rejection of help.

Clients with bulimia require the nurse’s careful attention to modeling mature interactions, tolerating the client’s superficial approach to treatment, and being patient while the client learns and practices alternatives to binge-purging behaviors. The care plans assist with specific nursing interventions and rationale.

General interventions involve relational, cognitive, behavioral, and medical techniques and include the following:

▪ Monitor meals, weight, and exercise.

▪ Stay with client for 1 hour after eating to prevent purging.

▪ Maintain adequate calories as determined for the client.

▪ Avoid manipulation and power struggles over type and amount of food.

▪ Educate about real versus idealized body weight/size and importance of fat in diet.

▪ Encourage activities and interactions that increase self-esteem.

▪ Encourage discussion of perceptions, thoughts, and feelings.

▪ Refute irrational ideas respectfully, and teach substitution of rational, positive thinking. (Cognitive therapy has proved to be more effective than relational therapies for some clients.)

▪ Encourage the client to engage in mature peer interactions.

▪ Teach assertiveness, and assist the client to practice with role-play.

▪ Support and praise all efforts to succeed in becoming healthy.

▪ Support the client and family working together to achieve wellness.

Safety

Clients may enter the hospital with suicidal ideation, threats, gestures, or attempts and must be protected from self-harm. The nurse follows guidelines as outlined in the care plans (see Chapter 3).

Cognitive-Behavioral Therapies

Behavior modification programs and cognitive-behavioral therapies, both in individual and group settings, have shown promise. Behavioral interventions focus on interruption of the dysfunctional eating patterns. Psychologic approaches strive to (1) increase insight into the complex dynamics of the disorder and (2) improve communication and coping skills (see Appendix G).

Family Therapy

Dynamics are frequently dysfunctional in families in which a member has an eating disorder. Education regarding the disorder and establishing healthy interactions is essential.

Medications

First-line medications used to treat eating disorders with concomitant depression are the atypical antidepressants or selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac) and paroxetine (Paxil). Fluoxetine and paroxetine inhibit neuronal reuptake of serotonin in the central nervous system (CNS) but not reuptake of norepinephrine. They provide relief from depression and have less intense side effects than the typical antidepressants. They may also relieve OCD behaviors such as rituals of binge-purge episodes. The SSRIs may be augmented with low-dose atypical antipsychotic medications to treat mild psychosis, obsessive thoughts, or ruminations. Benzodiazepines are not recommended because of their addicting qualities; therefore fluoxetine and paroxetine are also used to treat mild anxiety, induce relaxation, and promote a restful sleep (see Appendix H).

PROGNOSIS AND DISCHARGE CRITERIA

The prognosis for bulimia is better than for anorexia nervosa. For both disorders, early intervention increases probability of successful outcomes. Approximately 80% of clients who receive treatment for bulimia within the first few years recover, whereas only 69% to 70% recover if longer periods elapse before treatment occurs (Reas, 2002). Outcomes for anorexia nervosa are more guarded because of multiple interacting factors. When treated early, and when the client’s weight is not too low, outcome is more favorable.

Other important factors include (1) presence or absence of existing comorbid diagnoses, (2) degree of involvement and healthy support from family and significant others, (3) degree to which distorted thinking has been eliminated or modified, and (4) time of discharge. The last factor refers to clients being discharged before all their desired weight is regained and before they have practiced healthy techniques for a sufficient time. When intensive follow-up treatment is provided, clients with anorexia usually have a more favorable prognosis.