Study Guide 12: Psychiatric Disorder: Eating Disorders

Topic Outline
1.1 Bulimia Nervosa
1.2 Anorexia Nervosa

Learning Objectives

NCM-117 (Care of Clients w/ Maladaptive Patterns of Behavior

After studying this module, you will be able to:
 Discuss various etiologic theories of eating disorders
 Compare and contrast the symptoms of anorexia nervosa and bulimia nervosa.

Introduction
Hello future Nurses!
Eating is part of everyday life. It is necessary for survival, but it is also a social activity and part of many happy
occasions. People go out for dinner, invite friends and family for meals in their homes, and celebrate special events
such as marriages, holidays, and birthdays with food. Yet for some people, eating is a source of worry and anxiety.
Are they eating too much? Do they look fat? Is some new weight loss promotion going to be the answer?
Obesity has been identified as a major health problem in the United States; some call it an epidemic. The
number of obesity-related illnesses among children has increased dramatically. At the same time, millions of people,
predominantly women, are either starving themselves or engaging in chaotic eating patterns that can lead to death.
This study guide focuses on anorexia nervosa and bulimia nervosa, the two most common eating disorders
found in the mental health setting. It discusses strategies for early identification and prevention of these disorders.

Discussion

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EATING DISORDERS

Causes:
1. Biological factors
 Personality types: obsessive-compulsive, sensitive-avoidant
 Persons with sister or mother with anorexia nervosa are 12 times more likely than others with no family
history. They are 4 times likely to develop bulimia.

2. Psychological factors – perfectionists, with unrealistic expectations of themselves and others, feels inadequate,
defective, and worthless

3. Family factors – belongs to overprotective family, with rigid rules, and are ineffective in solving conflicts. Because
of high expectations children learn to hide doubts, fears, anxiety, and imperfections

4. Social factors – into relationships that encourage eating disorders where the patient needs to be thin to be
continually accepted (e.g., sorority, theater group, dance companies, school cliques)

5. Cultural pressures – in Westernized countries, women are pressured to be thin causing a self esteem inversely
related to her weight

6. Media factors – happy and successful people are portrayed by actors and models that are young, toned, and thin

7. Lifestyle – lifestyle may also place intense demands for illness (e.g., jockeys, cheerleaders, socialites, dancers,
models, actresses)

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8. Physical and sexual abuse – try numbing painful feelings by binging or starving. Some symbolically cleanse
themselves with purging or vomiting. Some starve themselves because they believe they are “bad” and do not
deserve the comfort and nourishment they give.

BULIMIA NERVOSA

NCM-117 (Care of Clients w/ Maladaptive Patterns of Behavior

“The Diet-Binge-Purge Disorder”

 Disorder characterized by alternating dieting, binging, and purging through vomiting, enema, and laxatives
 Person engages in starvation and other methods of weight control, then engages in uncontrolled and rapid
eating then terminates the binge by inducing self to vomit
o Bulimia – insatiable appetite
o Binging – eating an unusually large amount of food over a short period of time
o Purging – self-induced vomiting or abuse of laxatives, diuretics, or enema as an attempt to
compensate for calories consumed
 A chronic disorder that usually manifests during adolescence and early adulthood (15 – 24 years old)
 Bulimic person belong to a family and society that place great value on appearance. The person strives to be
thin to be accepted.
 Usually of normal weight or obese, extrovert, reports self loathing, low self esteem, with symptoms of
depression, fear of losing control, and self destructive tendencies like suicide
 Friends describe them as competent and fun to be with but this usually is just a brave front for a person who
is often depressed, lonely, ashamed, and feel empty inside. They often feel guilty, unworthy and with deeply
buried anger.
 Impulse control may be a problem (e.g., shoplifting, sexual adventurousness, alcohol and drug abuse, other
kinds of risk taking behaviors)
 Person is aware that behavior is abnormal, but fears that she cannot stop the behavior voluntarily.

)
 After a binge episode patient becomes guilty and depressed that she cannot control herself and engages in
self criticism and purges herself as a form of cleansing and punishment

Common complications:
 Chronic inflammation of esophageal lining
 Rupture of esophagus and stomach
 Electrolyte imbalance
 Dehydration
 Irritable bowel syndrome
 Rectal prolapse or abscess
 Dental erosion
 Fungal infection of vagina and rectum

Nursing Intervention
 Create an atmosphere of trust. Accept person as a worthwhile individual. If patient realizes that no
punishment or rejection is forthcoming when she discloses her problem, she may be more open and honest.
 Encourage patient to discuss positive qualities to increase self esteem
o Help patient identify feelings and situations that triggers binge eating
o Assist to explore alternative ways of coping
o Encourage making a journal of incident and feeling before, during and after an episode
 Make a contract with the patient to approach the nurse when they feel an urge to binge so that feelings and
alternative ways of coping can be explored
 Encourage adhering to a meal and snack schedule. Encourage participating in group activities with people of
the same disorder to gain additional support

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  Encourage family therapy to correct dysfunctional family patterns
 Cognitive-behavior therapy to help bulimic understand the problem and explore appropriate behaviors

ANOREXIA NERVOSA
“The relentless pursuit of thinness”

NCM-117 (Care of Clients w/ Maladaptive Patterns of Behavior

Anorexia is a disorder often affecting adolescent girls
 Patient is usually a high achiever, with good grades, described by parents as “a perfect child”
 Unlike bulimics, anorexics use denial and do not accept that they have a problem, which makes them more
difficult to treat
 10 – 20% of anorexics die and half of these are due to suicide
 They are often not recognized because they eat normally in social situations but purge themselves
immediately after
 To prevent eating and maintain their strict dietary program, they avoid socializations and become isolated
 They start as chubby children or overweight adolescents and the disorders begins when someone notices
their being overweight
 Esteem is based on acceptance so they diet to lose weight and feel accepted again
 Personality traits: perfectionist, introverted, with low self esteem, and with relationship problems with peers.
They are conscientious, hard working, and ideal students. Typically people-pleasers who seek approval and
avoid conflict
 May have low tolerance to change and do not adjust well to new situations
 May fear growing up and assuming responsibilities including an adult lifestyle
 The great importance placed in the society on physical appearance is the motivating factor
 Individual may have felt worthless and helpless and tries to combat these feelings by taking over a part of her
life which she can control, that is, her weight and the food she consumes

)
Assessment
 Behaviors directed towards weight loss (dieting, exercise, purging), denial of hunger
 Withdrawn and socially isolated
 Distorted body image (sees self as fat despite being emaciated)
 Intense fear of becoming fat
 Becomes preoccupied with food to the point of thinking they are authority on food, dividing them into
“good/safe” and “bad/dangerous”
 Depressed – sleep disturbances, suicidal tendencies, crying spells
 Compulsive rituals
 In women – amenorrhea and lack of interest in sexual activities
 In men – level of sex hormones drop (10% of patients w/ eating disorders are male)
 Bradycardia, lanugo, hypothermia, dehydration, hypotension (due to decrease metabolic rate as body’s
compensatory mechanism to low food intake and changes in the heart muscles)
 Muscle loss and weakness
 Bone density reduction (osteoporosis), dry and brittle bones
 Fainting, fatigue, overall weakness, dry skin, brittle hair
 Induces vomiting, uses enema, diet pills, excessive exercise, use of diuretics and laxatives
 Becomes deceitful, stubborn, hostile, manipulative

Nursing Intervention
 Cognitive and behavior therapy by positive and negative reinforcement (focus on client’s responsibility to
gain weight)
o Privileges gained with weight gain
o Privileges lost with weight loss

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transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited. 3
  Acceptance and nonjudgmental approach, assist in finding other positive qualities about themselves
(increases self esteem; patient realizes that she doesn’t need to be thin to be accepted)
 Teach patient about her disorder (information will validate the problem and patient will be unable to deny it)
 Monitor weight 3x a week, with patient facing away from the scale to avoid focusing on the weight. Weigh in
hospital gown
 As soon as ideal weight is gained, allow patient to regulate her own progression and program


NCM-117 (Care of Clients w/ Maladaptive Patterns of Behavior

High protein and high carbohydrate diet, small frequent feedings, NGT if client refuses to eat
 Matter of fact attitude, casual and friendly if withdrawn
 Setting limits to avoid manipulative behavior
o Restrict bathroom use for 2 hours after eating
o Accompany to bathroom to ensure she will not induce vomiting
o Stay with client during meals
o Do not accept excuse to leave the eating area
 Help patient identify and express feelings,
 Help identify other bodily concerns like hairstyle and clothing (most have little bodily awareness except for
distorted perception of their size)
 Identify other non-weight related interest (for other creative outlet for energy, to raise self esteem, diverts
attention from weight and eating)
 Avoid being confrontational and engaging in long talks about food and body
 Ignore manipulative behaviors like vomiting, exercising, and purging (too much attention will give secondary
gains and reinforce behavior)
 Antidepressants
 Individual and family therapy
 Refer to support groups

ANOREXIA WITHOUT BINGING OR PURGING BULIMIA NERVOSA

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Rare vomiting or diuretic/laxative abuse Frequent vomiting or diuretic/laxative use
More severe weight loss Less weight loss
Slightly younger Slightly order
More introverted More extroverted
Hunger denied Hunger experienced
Eating behavior may be considered normal and a source Eating behavior considered foreign and source of distress
of esteem
Sexually inactive More sexually active
Obsessional and perfectionist features predominate Avoidant, dependent, or border line features as well as
obsessional features
Death from starvation (or suicide, in chronically ill) Death from hypokalemia or suicide
Amenorrhea Menses irregular or absent
Fewer behavioral problems (these increase with level of Drug and alcohol abuse, self-mutilation. And other
severity)

LESS KNOWN EATING DISORDERS AND RELATED PROBLEMS

PICA
 Persistent eating of nonnutritive food substances (e.g., clay, paint, plaster, ice, starch) or compulsive eating of
a specific food only
 This rare disorder is possibly caused by mental retardation, neglect, poor supervision, or mineral deficiency
 Behavior must occur for at least one month to be diagnosed as pica
ANOREXIA ATHLETICA (COMPULSIVE EXERCISING)
 Not a formal diagnosis
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  Usually a part of anorexia nervosa, bulimia, or obsessive-compulsive disorder
 Person is excessively obsessed with exercise and engages in it beyond the requirements of good health
 May be a fanatic about weight and diet
 Steals time from work, school, and relationships to exercise
 Self worth and respect is dependent on athletic achievements but is never satisfied with accomplishments
 After reaching an athletic goal, moves on to the next challenge

NCM-117 (Care of Clients w/ Maladaptive Patterns of Behavior

MUSCLE DYSMORPHIA (BIGOREXIA)
 The opposite of anorexia nervosa
 Worries excessively that they are too small, under developed and frail even if there is, in reality, good muscle
mass
ORTHOREXIA NERVOSA
 Not an official eating disorder diagnosis
 A pathological obsession on eating “proper, pure, or superior” food
 Feels superior to others who eat non-organic or junk food
 Obsessed with what to eat, how much to eat, how to prepare food “properly”, and where to obtain “pure
and proper” food
 Perhaps related to, or a type of obsessive-compulsive disorder
NIGHT-EATING SYNDROME
 Characterized by lack of appetite for breakfast because of preoccupation on the amount of food eaten the
night before
 Eating occurs late in the day or night
NOCTURNAL SLEEP-RELATED EATING DISORDER
 Classified as a sleeping disorder
 Characterized by a person who eats while asleep
 In the morning, person has no recollection that he has eaten during the night
RUMINATION SYNDROME

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 A bizarre eating pattern wherein the person eats, swallows, and regurgitates food back into the mouth where
it is chewed and swallowed again
 This practice may be repeated fro several times or several hours per episode
 Rumination may be voluntary or involuntary
 Reports that regurgitated food material does not taste bitter and returns to the mouth from the stomach not
by gagging but by burping
GOURMAND SYNDROME
 A rare disorder characterized by obsession with fine food, including its purchase, presentation, and
consumption
PRADER-WILLI SYNDROME
 A congenital problem usually associated with mental retardation and behavior problems that includes
incessant eating
CHEWING AND SPITTING
 A disorder commonly seen in anorexia, sometimes in bulimia
 Characterized by putting food in the mouth, tasting, chewing then spitting it
 It is a calories control behavior which allows the person to enjoy the taste of the food but avoids the calories
by not swallowing it

Reference
Videbeck, S., & Miller, C. (2020). Psychiatric-mental health nursing (8th ed., pp. 24-48). Wolters Kluwer.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or
transmitting in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited. 5