Mental Health Nursing II

NURS 2310
Unit 9
Eating Disorders
 Bulimia Nervosa: Overview and Defining Features

 Binge Eating – Hallmark of Bulimia

– Binge – Eating excess amounts of food
– Eating is perceived as uncontrollable
 Compensatory Behaviors
– Purging – Self-induced vomiting, diuretics, laxatives
– Some exercise excessively, whereas others fast
 DSM-IV Subtypes of Bulimia
– Purging subtype – Most common subtype (e.g.,
vomiting, laxatives, enemas)
– Nonpurging subtype – About one-third of bulimics
(e.g., excess exercise, fasting)
 Bulimia Nervosa: Overview and Defining Features (cont.)

 Associated Features
– Most are over concerned with body shape,
fear gaining weight
– Most have comorbid psychological disorders
– Purging methods can result in severe medical
problems
– Most are within 10% of target body weight
 Anorexia Nervosa: Overview and Defining Features

 Successful Weight Loss – Hallmark of Anorexia

– Intense fear of obesity and losing control over eating
– Anorexics show a relentless pursuit of thinness, often
beginning with dieting
– Defined as 15% below expected weight
 DSM-IV Subtypes of Anorexia
– Restricting subtype – Limit caloric intake via diet and
fasting
– Binge-eating-purging subtype – About 50% of
anorexics
 Associated Features
– Most show marked disturbance in body image
 Binge-Eating Disorder: Overview and Defining Features

 Binge-Eating Disorder – Appendix of DSM-

IV
– Experimental diagnostic category
– Engage in food binges, but do not engage in
compensatory behaviors
 Associated Features
– Many persons with binge-eating disorder are
obese
– Share similar concerns as anorexics and
bulimics regarding shape and weight
 Bulimia and Anorexia: Facts and Statistics

 Bulimia
– Majority are female, with onset around 16 to 19 years of age
– Lifetime prevalence is about 1.1% for females, 0.1% for males
– 6-8% of college women suffer from bulimia
– Tends to be chronic if left untreated

 Anorexia
– Majority are female and white, from middle-to-upper middle
class families
– Usually develops around age 13 or early adolescence
– Tends to be more chronic and resistant to treatment than
bulimia
Anorexia Nervosa
 Definition
Prolonged loss of appetite; self-starvation
with a disruption in metabolism due to
inadequate calorie intake.

Incidence & Population Affected

 Increased in the past 30 years
 Affects approximately 1% of young women
– Occurs predominantly in females aged twelve
to thirty
– Less than 10 percent of cases are males
 Warning Signs of Anorexia

 Abnormal, rigid eating habits

 Eating very little food (300-600 kcal/day)
 Hiding and storing food
 Exercising compulsively
 Preparing meals for others, but not eating
 Withdrawing from friends and family
 Critical of self and others
 Sleep disturbances and depression
 Ammenorrhea
 Anorexia Health Problems
 “Skin-and-bone” appearance
 Lowered body temperature
 Lanugo and loss of hair
 Lower basal metabolism, decreased heart rate
 Iron deficiency anemia and other nutrient
deficiencies
 Rough, dry, scaly, cold skin
 Low white blood cell count, potassium
 Constipation, ammenorrhea
 < % body fat, shutdown of reproductive
hormones
 Etiology & Characteristics
 Morbid fear of obesity
 Gross distortion of body image; sees self as “fat”
when obviously underweight
 Preoccupation/obsession with food
– hoarding or concealing food
– preparing elaborate meals for others while severely
restricting self
 Refusal to eat; marked weight loss
 May include extensive exercising
 Physiological symptoms include amenorrhea,
hypothermia, bradycardia, hypotension, edema,
lanugo, and metabolic changes
 Diagnostic Criteria
 Refusal to maintain body weight at or
above a minimally normal weight for age
and height
 Intense fear of gaining weight or becoming
fat, even though underweight
 Disturbance in the way in which one’s body
weight or shape is experienced, undue
influence of body weight or shape on self-
evaluation, or denial of the seriousness of
the current low body weight
 Amenorrhea
 Nutrition Therapy

 Increase food intake to raise basal

metabolism
 Prevent further weight loss
 Restore appropriate food habits
 Restrict excessive activity
 Ultimately achieve and maintain
weight gain to establish setpoint
Bulimia Nervosa
 Definition
Excessive, insatiable appetite; episodic,
uncontrolled, compulsive, rapid ingestion
of large quantities of food over a short
period of time, followed by inappropriate
compensatory behaviors to rid the body
of the excess calories.
 Incidence & Population Affected
 More prevalent than anorexia nervosa
 Affects approximately 4% of young women
– Onset occurs in late adolescence or early
adulthood
– Occurs mainly in populations with an abundant
availability of food, and in which the ideal of
beauty is thinness
 Etiology & Characteristics
 Persistent overconcern with personal
appearance
 Weight fluctuations common due to
alternating binges and fasts
 Excessive vomiting and laxative/diuretic
abuse may lead to problems with
dehydration and electrolyte imbalances
 Gastric acid in vomitus contributes to the
erosion of tooth enamel
 Individual may experience tears in the
gastric or esophageal mucosa
 Diagnostic Criteria
 Recurrent episodes of binge eating
 Recurrent inappropriate compensatory
behavior in order to prevent weight gain,
such as self-induced vomiting; misuse of
laxatives, diuretics, enemas, or other
medications; fasting; or excessive exercise
 The binge eating and inappropriate
compensatory behaviors both occur, on
average, at least twice a week for 3 months
 Self-evaluation is unduly influenced by body
shape and weight
 Bulimia Health Problems
 Vomiting causes most health problems
 Demineralization of teeth
 Drop in blood potassium
 Swelling of salivary glands
 Stomach ulcers and bleeding
 Constipation
 Ipecac syrup is toxic
 Treatment of Bulimia Nervosa
 Decrease episodes of bingeing & purging
 Psychotherapy to improve self-acceptance
 Change “all-or-none” attitude about food
 Correct misconceptions about food
 Establish good, normal eating habits
 Group therapy
 Antidepressants
 Long-term therapy
Obesity
 Definition
Chronic disease defined by having a Body Mass
Index (BMI) of more than 30.

Incidence & Population Affected

 61% of the U.S. population age 20 or older
are overweight; 27% are obese; 4.7% are
morbidly obese
 Affects black women more than white
women, and white men more than black men
 6 times more prevalent among lower
socioeconomic classes
 Etiology & Characteristics
 May have a genetic component
 Lifestyle factors; lack of physical activity
 Leads to problems with hyperlipidemia,
hyperglycemia, diabetes mellitus,
osteoarthritis due to trauma to weight-
bearing joints, angina and respiratory
insufficiency due to increased workload of
the heart and lungs
 Food is considered a social outlet
 Depression/low self-esteem
 May involve binge-eating disorder
 Diagnostic Criteria
(Binge-Eating Disorder)
 Recurrent episodes of binge eating in which one
does not feel in control of what/how much is
being consumed
 Binge-eating episodes are associated with
– eating much more rapidly than normal
– eating until feeling uncomfortably full
– eating alone because of being embarrassed by
how much one is eating
– feeling depressed or guilty after overeating
 Marked distress regarding binge eating
 The binge eating occurs, on average, at least 2
days a week for 6 months
Nutritional Deficits
 Electrolyte imbalances

 Nutrient deficits

 Malnutrition

 Poor glucose control

 Deficiency in vital fats

 Vitamin deficiencies
Treatment Modalities
 Milieu Therapy
*Focuses on behavior modification
 Changing maladaptive eating behaviors
 Empowering client to take control of treatment
 Contract for privileges based on weight gain or
weight maintenance
 Goals of therapy agreed upon by client and staff
 System of rewards and privileges can be earned
by client, who is given ultimate control
– Client chooses whether or not to abide by the
contract
– Client is made accountable for choices and
behaviors
 Medical and Psychological Treatment of Bulimia Nervosa

 Drug Treatments
– Antidepressants can help reduce binging and
purging behavior
– Antidepressants are not efficacious in the
long-term
 Psychosocial Treatments
– Cognitive-behavior therapy (CBT) is the
treatment of choice
– Interpersonal psychotherapy results in long-
term gains similar to CBT
 Medical and Psychological Treatment of Anorexia Nervosa

 Medical Treatment
– Some prefer surgery
 Psychological Treatment
– Weight restoration – First and easiest goal to
achieve
– Treatment involves education, behavioral, and
cognitive interventions
– Treatment often involves the family
– Long-term prognosis for anorexia is poorer
than for bulimia
 Other Eating Disorders

 Rumination Disorder
– Chronic regurgitation and reswallowing of partially
digested food
– Most prevalent among infants and persons with
mental retardation
 Pica
– Repetitive eating of inedible substances
– Seen in infants and persons with severe
developmental/intellectual disabilities
– Treatment involves operant procedures
 Feeding Disorder
– Failure to eat adequately, resulting in insufficient
weight gain
– Disorder of infancy and early childhood
SLEEP AND REST
 Definitions
 Rest: is a condition in which the body is in
a decreased state of activity without
emotional stress and freedom from
anxiety.
 Sleep: is a state of rest accompanied of
altered level of consciousness and relative
inactivity, and perception to environment
are decreased.
 Adequate rest and sleep are
important in:
 Promoting general health.
 Ensuring recovery from illness.
 Aid healing process.
 Increase ability to learn and concentration
and recalling know lodge.
 Help person to be socially adaptable.
Sleep and rest disturbance will be imply:

 Irritable, anxiety and stress.

 Fatigue.
 Reduce work optimally
 Seek assistance from physician.
 Poor concentration.
 Difficulty making decisions.
 Normal sleep patterns and
requirements:
 Newborn: 16-18 hours /day
 Infants: some 22 hours, and others from 12-14
 Toddlers: 10-12 hours
 Preschool: 11-12 hours
 School-Age: 8- 12 hours
 Adolescents: 8-10 hours
 Adult: 6-8 hours
 Elders: 6 hours
 Factors Affecting Sleep
 Developmental considerations
 Psychological stress
 Motivation
 Culture
 Lifestyle and habits
 Physical activity and exercise
 Dietary habits
 Environmental factors
 Illness
 Medications
 Sleep Disorders: An Overview

 Two Major Types of DSM-IV Sleep Disorders

– Dyssomnias – Difficulties in getting enough sleep,
problems in the timing of sleep, and complaints about
the quality of sleep
– Parasomnias – Abnormal behavioral and physiological
events during sleep
 Assessment of Disordered Sleep:
Polysomnographic (PSG) Evaluation
– Electroencephalograph (EEG) – Leg movements and
brain wave activity
– Electrooculograph (EOG) – Eye movements
– Electromyography (EMG) – Muscle movements
– Includes detailed history, assessment of sleep
hygiene and sleep efficiency
 The Dyssomnias: Overview and Defining Features of Insomnia

 Insomnia and Primary Insomnia

– One of the most common sleep disorders
– Difficulties initiating sleep, maintaining sleep, and/or
nonrestorative sleep
– Primary insomnia – Means insomnia unrelated to any other
condition (rare!)
 Facts and Statistics
– Insomnia is often associated with medical and/or
psychological conditions
– Females reported insomnia twice as often as males
 Associated Features
– Many have unrealistic expectations about sleep
– Many believe lack of sleep will be more disruptive than it is
 The Dyssomnias: Overview and Defining Features of Hypersomnia

 Hypersomnia and Primary Hypersomnia

– Problems related to sleeping too much or excessive sleep
– Person experiences excessive sleepiness as a problem
– Primary hypersomnia – Means hypersomnia unrelated to any
other condition (rare!)

 Facts and Statistics

– About 39% have a family history of hypersomnia
– Hypersomnia is often associated with medical and/or
psychological conditions

 Associated Features
– Complain of sleepiness throughout the day, but do sleep through
the night
 The Dyssomnias: Overview and Defining Features of Narcolepsy

 Narcolepsy
– Daytime sleepiness and cataplexy
– Cataplexic attacks – REM sleep, precipitated by strong emotion

 Facts and Statistics

– Narcolepsy is rare – Affects about .03% to .16% of the
population
– Equally distributed between males and females
– Onset during adolescence, and typically improves over time

 Associated Features
– Cataplexy, sleep paralysis, and hypnagogic hallucinations
improve over time
– Daytime sleepiness does not remit without treatment
 The Dyssomnias: Overview of Breathing-Related Sleep Disorders

 Breathing-Related Sleep Disorders

– Sleepiness during the day and/or disrupted sleep at
night
– Sleep apnea – Restricted air flow and/or brief
cessations of breathing
 Subtypes of Sleep Apnea
– Obstructive sleep apnea (OSA) – Airflow stops, but
respiratory system works
– Central sleep apnea (CSA) – Respiratory systems
stops for brief periods
– Mixed sleep apnea – Combination of OSA and CSA
 The Dyssomnias: Overview of Breathing-Related Sleep Disorders
(cont.)

 Facts and Statistics

– More common in males, occurs in 1-2% of
population
 Associated Features
– Persons are usually minimally aware of apnea
problem
– Often snore, sweat during sleep, wake
frequently, and have morning headaches
– May experience episodes of falling asleep
during the day
 Circadian Rhythm Sleep Disorders

 Circadian Rhythm Disorders

– Disturbed sleep (i.e., either insomnia or excessive sleepiness
during the day)
– Problem is due to brain’s inability to synchronize day and
night

 Nature of Circadian Rhythms and Body’s Biological

Clock
– Circadian Rhythms – Do not follow a 24 hour clock
– Suprachiasmatic nucleus – The brain’s biological clock,
stimulates melatonin
 Types of Circadian Rhythm Disorders
– Jet lag type – Sleep problems related to crossing time zones
– Shift work type – Sleep problems related to changing work
 Medical Treatments

 Insomnia
– Benzodiazepines and over-the-counter sleep
medications
– Prolonged use can cause rebound insomnia,
dependence
– Best as short-term solution
 Hypersomnia and Narcolepsy
– Stimulants (i.e., Ritalin)
– Cataplexy is usually treated with
antidepressants
 Medical Treatments

 Breathing-Related Sleep Disorders

– May include medications, weight loss, or
mechanical devices
 Circadian Rhythm Sleep Disorders
– Phase delays – Moving bedtime later (best
approach)
– Phase advances – Moving bedtime earlier
(more difficult)
– Use of very bright light – Trick the brain’s
biological clock
 Psychological Treatments

 Relaxation and Stress Reduction

– Reduces stress and assists with sleep
– Modify unrealistic expectations about sleep
 Stimulus Control Procedures
– Improved sleep hygiene – Bedroom is a place for
sleep and sex only
– For children – Setting a regular bedtime routine
 Combined Treatments
– Insomnia – Short-term medication plus psychotherapy
is best
– Lack evidence for the efficacy of combined treatments
with other dyssomnias
 The Parasomnias: Nature and General Overview

 Nature of Parasomnias
– The problem is not with sleep itself
– Problem is abnormal events during sleep, or shortly
after waking
 Two Classes of Parasomnias
– Those that occur during REM (i.e., dream) sleep
 nightmare disorder

– Those that occur during non-REM (i.e., non-dream)

sleep
 sleep terror
 sleep-walking
 The Parasomnias: Overview of Nightmare Disorder

 Nightmare Disorder
– Occurs during REM sleep
– Involves distressful and disturbing dreams
– Such dreams interfere with daily life
functioning and interrupt sleep
 Facts and Associated Features
– Dreams often awaken the sleeper
– Problem is more common in children than
adults
 The Parasomnias: Overview of Nightmare Disorder (cont.)

 Sleep Terror Disorder

– Involves recurrent episodes of panic-like symptoms
– Occurs during non-REM sleep
 Facts and Associated Features
– Problem is more common in children than adults
– Often noted by a piercing scream
– Child cannot be easily awakened during the episode and has
little memory of it
 Treatment
– Often involves a wait-and-see posture
– Antidepressants (i.e., imipramine) or benzodiazepines for
severe cases
 The Parasomnias: Overview of Sleep Walking Disorder

 Sleep Walking Disorder – Somnambulism

– Occurs during non-REM sleep
– Usually during first few hours of deep sleep
– Person must leave the bed
 Facts and Associated Features
– Difficult, but not dangerous, to wake someone during
the episode
– Problem is more common in children than adults
– Problem usually resolves on its own without
treatment
– Seems to run in families
 Related Conditions
 Treatment for dyssomnias
 Pharmologic therapy
– Sedatives and hypnotics
 Nonpharmacologic therapy
– Stimulus control
– Sleep restriction
– Sleep hygiene
– Cognitive therapy
– Multicomponent therapy
– Relaxation therapy
Nursing Interventions to Promote Sleep
 Prepare a restful environment
 Promote bedtime rituals
 Offer appropriate bedtime snacks and beverages
 Promote relaxation and comfort
 Use night light
 Provide privacy
 Schedule nursing care to avoid disturbances
 Use medications to produce sleep
 Encourage patient to void before sleep
 Remove any irritants against patients skin such as
moist or wrinkled sheets