11. Eating disorders

Eating disorders are manifested as severe disturbances in eating behaviors. The two most common eating disorders are anorexia nervosa and bulimia nervosa.

Anorexia Nervosa

DSM-IV CATEGORIES

307.1 Anorexia nervosa (specify type: restricting type; binge-eating/purging type)

Clients with anorexia nervosa either voluntarily restrict their food intake or engage in binge-eating and purging behaviors. They manifest an extreme fear of becoming fat and have a distorted body image. They're unable to perceive an accurate body size and shape. The client maintains a body weight that's less than 85% of the weight that's appropriate for the client's age and height. Weight loss most often occurs through decreasing food intake, which is known as the restricting type of anorexia nervosa. The other classification of anorexia is the binge-eating purging type, which accomplishes weight loss by engaging in se.'-induced vomiting or the misuse of diuretics and laxatives or by becoming immersed in excessive exercise regimens. Even while continuing to lose weight, these clients verbalize that they still feel fat.

One of the main diagnostic criteria is the refusal to sustain body weight at or above a marginally normal weight for age and height. The absence of three consecutive menstrual cycles is one of the first physiologic manifestations in postmenarcheal females. With continuous loss of weight, clients may experience hypothermia, hypotension, cardiac arrhythmias, edema, lanugo (fine. neonatal-like hair), and metabolic changes. Clients also tend to be perfectionistic, secretive, and highly self-absorbed and to have obsessions and compulsions not necessarily related to food. These clients tend to be strong academic achievers. They may also inaccurately comprehend environmental stimuli and believe that they are personally ineffective. Many clients are overwhelmed by a fear of losing control and are paralyzed by their intense feelings of helplessness. For some people, a crisis situation precipitates the onset of the disorder. Typically, 90% of people with anorexia nervosa are females, and onset occurs during adolescence or young adulthood.

Researchers in neuroendocrinology are seeking a physiologic cause but have found nothing definite. Abnormalities in the hypothalamic-pituitary-adrenal axis are similar to those found in people with severe depression. Also, high levels of serotonin occur in clients with anorexia. The increased serotonin raises the satiety level and decreases food intake.

COMMUNICATION STRATEGIES

• Focus on developing a therapeutic relationship because many clients communicate on a superficial level and have difficulty developing interpersonal relationships.
• Use an accepting, nonjudgmental approach, and demonstrate a matter-of-fact attitude and practical expectations.
• Encourage the client to reveal true feelings, such as depression. loneliness, and sadness.
• Communicate empathetic understanding of the client's attempts at self-expression of feelings.
• Discuss topics such as school, music, and movies that develop the client's interest beyond self-absorption.
• Teach the client effective communication techniques with a focus on assertiveness skills.

NURSING DIAGNOSIS: ALTERED NUTRITION, LESS THAN BODY REQUIREMENTS

Probable Causes	Defining Characteristics
Conflictual family relationships Perfectionism Rigid and controlling parents Difficulty coping with emerging period of adolescence	Refusal to eat, with weight loss resulting in emaciation Excessive exercise Bradycardia or other cardiac arrhythmias Fluid and electrolyte imbalances

Long-Term Goal The client will maintain an adequate nutritional intake and gain the weight necessary to reach a level appropriate for age, height, and gender.

Short-Term Goal #1: The client will discuss fears and feelings about gaining weight.

Interventions and Rationales

• Provide emotional support and empathy as the client discusses fears and concerns about gaining weight. Emotional support helps the client deal with the anxiety related to the need to control weight.
• Encourage the client to get feedback from the nurse and others about her own behavior and perceptions. Validating feelings and pointing out discrepancies in perceptions of reality allow the client to begin working on troublesome issues.
• Reinforce the need for a behavioral contract and explain how it facilitates a plan that allows the client to have control other body. A slow, steady weight gain gives the client some control of the situation and prevents the client from regressing to previous behaviors.
• Identify and discuss the client's concerns about being rejected if normal weight is maintained. Fear of refection promotes self-doubt, anxiety, and social isolation and must be addressed sy staff.
• Educate the client on the seriousness of the problem by focusing on topics other than food and the client's obsession with weight because refusal to eat is a symptom of other problems that the client is unable to control. The establishment of a therapeutic relationship facilitates the trust necessary for the client to discuss overwhelming problems and feelings of loneliness, anger inadequacy, and failure.

Short-Term Goal #2: The client will develop a pattern of normal eating behavior and gain 2 lb per week.

Interventions and Rationales

• Collaborate with the health care team to determine the caloric requirements necessary to preclude a life-threatening situation. A team approach is necessary to determine the severity of the nutritional situation and to initiate a plan for remediation.
• Establish a behavior contract to help the client participate in the goal of gradual, realistic weight gain. A simple behavior contract outlines expectations for change without creating a power struggle between staff and the client.
• Obtain the client's cooperation through a behavior contract to monitor weight three times a week using a consistent weighing procedure. Using the same scale, wearing clothing that has a consistent weight, and weighing at the same time promote consistency of the measurement.
• Assess for behavior that creates the illusion of weight gain. such as keeping heavy items in her pockets, drinking a large amount of water before being weighed, and not voiding until after being weighed. Monitoring the client's behavior prevents the client from manipulating the contract agreement.
• Provide nutritionally appropriate meals, incorporating foods that the client prefers, and allow a reasonable time for the client to eat. Giving the client some choice, along with setting limits. enables the client to participate in the care and promotes a sense of self-control.
• Sit with the client to provide structured support at mealtime. but do not encourage or coax the client to eat. The nurse's role is to monitor the eating behavior at this time and see how the client adheres to the behavior contract.
• Observe the client at mealtimes for hoarding, hiding, and improper disposal of food. Recognize and deal with attempts to manipulate the contract agreement.
• Record the client's intake and output, and restrict the amount of physical exercise after eating as indicated in the behavior contract. Monitoring the client demonstrates that staff is firm ana consistent in carrying out their end of the contract.
• Accompany the client if the client must use the bathroom within 90 minutes after a meal. The client may try to dispose of hidden food or induce vomiting as a last resort to prevent weight gain.
• If weight loss occurs, review with the health care team the possibility of using nutritional supplements, tube feedings, or hyperalimentation. These methods are used as a final resort if symptoms of starvation become evident.
• Monitor vital signs and laboratory values, especially electrolyte, acid-base balance, and liver enzyme levels. Physical health is a priority, especially if the client is demonstrating symptoms of malnutrition.

Short-Term Goal #3: The client will verbalize awareness of the sensation of hunger and other body stimuli.

Interventions and Rationales

• Help the client acknowledge and discuss feelings about self and body. The client needs to increase awareness about body sensations and other feelings.
• Help the client understand the relation between self-starvation and the strong need to control her own life. Control is a major area of concern for anorectics, and it is necessary for the client to begin seeing healthy ways to control her lifestyle.
• Identify and discuss the meaning of hunger and other body sensations. Discussion enables the client to become aware of anxiety associated with body sensations and adolescent growth and development.

NURSING DIAGNOSIS: INEFFECTIVE INDIVIDUAL COPING

Probable Causes	Defining Characteristics
Loss or major change in the family Dysfunctional family behaviors Sense of inadequacy and powerlessness Unrealistic perceptions of self	Denial of problem Verbalization of a distorted self-concept and feelings of shame Severe anxiety about handling adolescence High, unrealistic goals

Long-Term Goal The client will demonstrate methods of coping that allow taking charge of personal needs and facilitating a healthy lifestyle.

Short-Term Goal #1: The client will learn and demonstrate adaptive ways of coping with daily life stressors.

Interventions and Rationales

• Encourage the client to identify strengths and adaptive ways or functioning that were successful in the past. Validating the clients strengths empowers the client to build on prior healthy methods of coping.
• Encourage the client to develop realistic personal expectations. Learning how to develop personal expectations enables the client to see the purpose of working from a realistic and healthy set of goals.
• Teach the client relaxation exercises, guided imagery, and deep breathing techniques. Strategies to relieve stress promote comfort in dealing with anxiety and feelings of insecurity.
• Encourage the client to develop appropriate hobbies and ways to spend time. Many clients with anorexia nervosa devote their energies to overinvoivement in food preparation and gourmet cooking.

Short-Term Goal #2: The client will evaluate the current dependency role and develop steps to progress toward independent functioning.

Interventions and Rationales

• Help the client explore and acknowledge dependency on others. It's important to assess how the dependency role is influences by the client's level of anxiety.
• Discuss the client's view of self and personal strengths, and help the client recognize self-worth. It's essential to encourage the client to see herself as a capable and competent person.
• Teach the client responsibility for her own nutritional needs by helping her to select foods that are high in calories, protein, and complex carbohydrates. Teaching the client how to meet normc. nutritional needs promotes personal responsibility and a sense of independence necessary for satisfactory self-care.
• Encourage the client to identify and implement ways to become as independent as possible in other self-care activities. Accepting personal responsibility for her own needs enhances independence and self-care skills.
• Help the client determine ways to become comfortable with social and emotional needs without resorting to dysfunctional eating behaviors. It's important to promote client acceptance o/ herself and her personal strengths and limitations.
• Explore the client's role in the family and how it promotes discomfort or prevents the client from growing up and separating from the family system. The client must understand and initiate measures to decrease the family's overinvolvement in her life.

NURSING DIAGNOSIS: SELF-ESTEEM DISTURBANCE

Probable Causes	Defining Characteristics
Unrealistic parental expectations Anxiety or depression Fears related to coping with life stressors Dysfunctional family	Lack of meaning and pleasure in life Distorted perceptions of self Preoccupation with weight Perfectionistic beliefs

Long-Term Goal The client will develop a positive view of self by verbalizing an accurate perception of self

Short-Term Goal #1: The client will decrease negative verbalizations about self

Interventions and Rationales

• Work with the client to recognize distortions and misper-ceptions about self. Talking about and questioning the client's pe'-ceptions assists in creating doubt about the client's view of self.
• Help the client identify the discrepancy between the real self and the ideal self. The client strives to be perfect and always in control rather than accepting herself as a human being with both assets and limitations.
• Discuss the client's needs and perceptions about abilities to meet these needs. This discussion generates a realistic appraisal of needs and abilities.
• Discuss how negative behavior interferes with the ability to feel good about oneself and have consistent contact with others. It's important for the client to understand the effects that behavior has on herself and others.

Interventions and Rationales

• Assess for regressive behavior. Sometimes the client resorts to childlike behavior to escape from being independent and performing self-care; identifying such behavior enables prompt intervention.
• Encourage the client to do schoolwork or other appropriate tasks rather than withdraw from age-appropriate activities. Maintaining as normal a routine as possible promotes feelings of control and success in what the client accomplishes.
• As physical health permits, provide activities with peers. Peer activities decrease feelings of being isolated and alienated from others.

NURSING DIAGNOSIS: ALTERED FAMILY PROCESSES

Probable Causes	Defining Characteristics
Conflicts between family members Parent-child conflict Family power struggles Family resistance to being involved in the client's needs or care	Family members engage in superficial conversation Family treats the client as emotionally immature Family has poor insight into the situation Family has great difficulty allowing the client to separate from the family

Long-Term Goal The family will demonstrate effective coping strategies through supportive behaviors and positive verbalizations.

Short-Term Goal #1: The family will view the illness as having meaning for all family members and verbalize knowledge about how to deal with it.

Interventions and Rationales

• Help family members discuss stressful family situations and identify effective ways to respond to them. The family needs constructive guidance with family issues.
• Support family members as they struggle with conflict, change, or stress. The family needs assistance with handling conflict rather than avoiding it.
• Explore how family members are over involved with one another, and determine if boundaries exist for each generation. Over protectiveness and lack of clear boundaries inhibit movement toward healthy independence, a necessary element for adequate family functioning.
• Evaluate the ability of family members to appropriately express affection for another. A lack of affection and warmth is common in families that have members with eating disorders.
• Have the client discuss the attempts made to preserve the marital relationship of the parents at the expense other own autonomy. The client may be overinvolved as a caretaker for the adults and directing energy into preserving their marriage rather than meeting the tasks of adolescence.

Short-Term Goal #2: The family will learn effective coping mechanisms.

Interventions and Rationales

• Help family members discuss their concerns about the client s condition and ways that they can demonstrate an appropriate level of caring. It's essential that family members reinforce the client in appropriate ways.
• Assist the family in examining interpersonal conflicts and tension-provoking situations. Family members need to explore their role and contributions to family problems as the first step toward change.
• Encourage the client to identify ways to stay uninvolved in parental conflicts. It's essential that the client learn to separate self from parental conflicts.

THERAPIES

Individual Therapy

• Establish a relationship in which the client can discuss feelings of loneliness and inadequacy, fear of failure, and anger.
• Work to decrease and eliminate cognitive distortions, such as all-or-nothing thinking ("If I eat one piece of candy, I must eat the entire box."), over-generalizing ("She didn't talk to me today. It must be because I'm fat."), and catastrophizing ("When my family says I look better, 1 know they think I'm fat.").
• Help the client identify personal needs and develop effective communication skills in order to ask for help.
• Help the client identify emotional situations that trigger the client's inability to manage nutritional needs.
• Discuss the seriousness of the physical damage caused by the eating disorder as well as the impact the family's problems have on the client.
• Help the client establish appropriate eating behavior and problem-solving strategies.
• Incorporate behavioral techniques into a plan for weight gain, identifying both the rewards and the consequences for the client's behavior.
• Use a written contract to delineate all goals, expectations, and outcomes.

Family Therapy

• Provide support, education, and insight for family members.
• Help the family deal on a daily basis with the anxiety of interacting with a person who has an eating disorder.
• Teach communication skills and conflict-resolution skills.
• Promote healthy ways to interact with one another.
• Because family members may feel responsible if the client has a relapse, encourage them to verbalize the stress they feel about saying or doing something wrong.

Group Therapy

• Help clients deal with unhealthy behaviors and the dynamics of the eating disorder.
• Facilitate peer support to decrease feelings of isolation and perceptions of being different.
• Use peer pressure to expedite behavioral change.
• Provide methods for group members to gauge if expectations are realistic and if some actions originate from unrealistic expectations.
• Teach clients how to problem solve, to use group members ^o' support, and to use the group for help in handling problems related to interpersonal, social, and occupational functioning.
• Discuss dating relationships, intimacy, human sexuality, feminist themes, and social myths about the ideal person.
• Help clients prepare a nutritionally adequate meal, eat in a restaurant, and eat foods that have been avoided.

MEDICATIONS

• Antianxiety medications are used to decrease anxiety.
• Fluoxetine (Prozac), an antidepressant selective serotonin uptake inhibitor, has been used to improve the rate of weight gain and decrease the incidence of relapse.
• Psychotropic drugs have been used for short periods to enhance weight gain. (See Appendix D for medication information.)

FAMILY CARE

• Teach the family about the disorder, the client's behaviors, the importance of supporting the client, and developing positive coping behaviors.
• Identify and work on resolving conflict within the family.
• Assess for marital conflict and whether the client is involved the conflict.
• Refer to a therapist for marital or family counseling.
• Teach the family appropriate ways to express anger and other feelings.
• Promote comfort in expressing affection for other family members.
• Examine family eating habits and patterns, and encourage optimal nutritional and social behaviors.
• Encourage family meetings, and teach the family how to hold meetings for the purpose of handling conflicts and problems

Bulimia Nervosa

DSM-IV CATEGORIES

307.51 Bulimia nervosa (specify type: purging type/ nonpurging type)

Bulimia nervosa is characterized by recurrent episodes of binge eating, followed by compensatory behavior to prevent weight gain. Clients consume much more food than most people would eat during a similar period under the same circumstances. Examples of compensatory behaviors include purging behaviors, such as fasting, vigorous exercise, self-induced vomiting, and using enemas, laxatives, or diuretics. Binging is terminated because of abdominal discomfort, arrival of another person, or sleep. Bulimic clients also have a preoccupation with weight gain and body shape, but most are within their normal weight range, with some being slightly underweight or overweight.

During binge episodes, clients can't control their eating. Sweet, high-calorie food is secretly and rapidly consumed. Fluid and electrolyte problems as well as dehydration may accompany the disorder. Bulimic clients can experience hypokalemia (decreased potassium levels), hyponatremia (decreased sodium levels), and hypochloremia (decreased chloride levels). Often, metabolic acidosis occurs as a result of the diarrhea caused by enemas and excessive laxative use. In contrast, metabolic alkalosis may occur as a result of frequent vomiting. Dental problems such as the formation of cavities and loss of tooth enamel, may also result from frequent vomiting. Amenorrhea or dysmenorrhea (irregular menstrual periods) is usually present in women with bulimia nervosa.

It is common for binge-eating behaviors to alternate with periods of normal eating. Typically coexisting with bulimia are anxiety disorders, mood disorders, personality disorders, and substance abuse, for example, abuse of sedatives, amphetamines cocaine, or alcohol. Onset usually occurs during adolescence or young adulthood, with many more females being affected than males.

Clients with bulimia nervosa have a decreased level of an intestinal hormone called cholecystokinin. Scientists have also found abnormalities in the hypothalamic-pituitary-adrenal pathway of clients with bulimia nervosa. This pathway influences the body organs affected by the hormones. Work continues to focus on identifying a specific relationship between neurochemical imbalances and abnormal eating behaviors. In clients with bulimia, low serotonin and low satiety levels coexist.

COMMUNICATION STRATEGIES

• Determine if the client is focused on self-defeating internal messages.
• Focus the client on reality rather than on the old pattern of using all-or-nothing thinking as a way to problem solve.
• Communicate empathetically about the client's fear of losing control.
• Talk about how negative feelings, guilt, and loneliness trigger binging episodes.
• Discuss how to promote a positive sense of self
• Communicate hope for developing a functional lifestyle.

NURSING DIAGNOSIS: ALTERED NUTRITION, LESS THAN BODY REQUIREMENTS

Probable Causes	Defining Characteristics
History of eating as a response to internal feelings rather than to hunger Distorted body image Lack of self-control Depression or other mental disorder	Binge-purge behaviors Use of laxatives or enemas, resulting in bloody diarrhea Self-induced vomiting after binges Knuckle abrasions and erosion of dental enamel from frequent, self-induced vomiting

Long-Term Goal The client will establish and maintain an appropriate weight by developing normal eating patterns and habits.

Short-Term Goal #1: The client will decrease the incidence of binge-purge behaviors.

Interventions and Rationales

• Establish a contract with the client for changing ineffective eating behavior. A contract is an effective strategy for involving tne client in the treatment plan because it reinforces the behaviors that the client needs to perform to sustain norma! weight.
• Work with the client and consult with a dietitians to determine a realistic caloric intake. A team approach assists the client in planning an adequate caloric intake to maintain an acceptable weight.
• Monitor eating behavior and stay with the client 90 minutes after each meal. This action deters hoarding food to binge on later; it also decreases the opportunity to be alone, when the client could induce vomiting.
• Have the client keep a diary about hunger, eating behaviors, feelings, and how the client acted on those feelings. Keeping a diary helps the client see how eating behaviors are related to feelings and issues of control.
• Encourage the client to eat with others. The client needs to have social interactions and be exposed to normal eating behaviors.
• Discuss ways to alter situations that generate hinging. The client can gain control over the triggers that precipitate binge behavior.
• Help the client develop distracting behaviors that can be used whenever the urge to binge or purge occurs. Distracting behaviors help the client reduce anxiety or manage it without resorting to dysfunctional eating behaviors.

Short-Term Goal #2: The client will learn how to plan and eat nutritionally adequate meals.

Interventions and Rationales

• Discuss with the client misperceptions about eating. Its important for the client to examine myths and false information about nutrition.
• Help the client establish meal plans and use a nutritional consultant when available. Maintaining an active role in meal planning empowers the client to take control of nutritional needs.
• Discuss the difference between eating to nourish the body and eating to satisfy emotional needs. The client needs to develop an awareness of issues that influence eating behavior.
• Plan for the client to attend a therapy group that focuses on eating disorders and discusses nutritional issues. A group can provide support and feedback about nutritional behaviors and what is happening in the client's life.

NURSING DIAGNOSIS: POWERLESSNESS

Probable Causes	Defining Characteristics
Coping style that reflects helplessness Self-defeating behavior pattern Unmet dependency needs History of family dependency	Verbalizations about failure and loss of control Difficulty making decisions Nonassertive behaviors Lack of peer relationships

Long-Term Goal The client will develop a plan to effectively handle stressful life situations and engage in adaptive coping behaviors.

Short-Term Goal #1: The client will verbalize the desire to increase control over stressful life situations.

Interventions and Rationales

• Help the client identify personal beliefs, values, and coping strategies used to handle stressful circumstances. Having the client talk about current life situations reveals the client's perceptions and provides assessment data for use in future interventions.
• Discuss current coping methods and their consequences, and introduce other options. It's important for the client to know how one's coping style and use of defense mechanisms can generate bulimic behavior.
• Ask the client to identify situations in which feelings of powerlessness occur and bulimic behaviors ensue. The client is empowered to control bulimic behavior by understanding which situations provoke the feeling of powerlessness.
• Explore with the client how the family affects the development of realistic life goals. Over involvement of the family in the clients life gives the message that the client is unable to take control of current life situations.

Short-Term Goal #2: The client will learn and practice problem-solving skills.

Interventions and Rationales

• Teach problem-solving skills. The ability to solve problems gives the client a sense of control over life situations.
• Help the client identify some community resources, such as group therapy and support groups, for the future. Knowing about community resources and other support systems can aid the client before and during times of crisis.
• Work with the client to establish realistic goals. Unrealistic goa.s set the client up for failure and sabotage the development of problem solving skills.
• Encourage the client to expand the use of problem-solving skills to deal with the triggers for bulimic behaviors. The client must develop alternative behaviors to prevent being discouraged when challenging situations arise.

THERAPIES

Milieu, individual, group, and family therapies have been useful modalities for clients with bulimia.

Milieu Therapy

• Establish an external support system.
• Create a formal mechanism to prevent binge-purge behaviors.
• Have the client participate in a structured program.
• Help the client gain control of eating behavior.
• Present reality through the use of staff and peer support.

Individual Therapy

• Involve the client in a behavior contract to help regain control over eating.
• Discuss binge-purge cycle behaviors, and help the client identify points at which the cycle can be interrupted.
• Teach behavioral techniques to stop the binge behaviors.
• Establish achievable goals to maintain treatment motivation.
• Explore negative thinking and distortion of reality.
• Intervene to minimize anxiety and depression.
• Teach assertiveness skills.
• Encourage the use of leisure time for age-appropriate activities.
• Focus on emotional issues, such as guilt and dependency, and the need for acceptance and approval.
• Teach the client how to develop satisfying relationships.

Group Therapy

• Provide support and opportunities to test reality.
• Provide nutritional education, peer reinforcement, and monitoring of appropriate behavior.
• Teach and encourage the practice of assertiveness skills.
• Explore ways to express feelings, fears, and concerns.
• Educate about sexuality and sexually appropriate behavior.

Family Therapy

• Work with the family on autonomy and separation.
• Teach the family strategies to handle issues related to the client's developmental stage.
• Teach conflict-resolution skills.
• Help the family learn how to overcome power struggles.
• Encourage the family to establish clear boundaries between the generations by reinforcing that adults act as adults and children act as children.

MEDICATIONS

• Antianxiety agents may decrease anxiety and panic attacks.
• Antidepressants such as the selective serotonin uptake inhibitors fluoxetine (Prozac) and paroxetine (Paxil) are useful. (See Appendix D for medication information.)

FAMILY CARE

• Help the family learn effective communication skills.
• Work with the family to resolve conflicts.
• Talk to family members about appropriate expressions of affection and love for one another. Have members verbalize their feelings and practice ways to express affection such as hugging someone.
• Dismantle the pressures and myth of the perfect family.