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EATING DISORDERS
Reported by: N3C, Group 7 Lacerna, Mark Lapuz, Karen Aida M. Llanora, Katrina L. Magsanoc, Marissa M.

The regurgitation does not involve nausea, vomiting or any medical condition Children with rumination disorder repeatedly regurgitate and spit-out or rechew their food following eating. Usually develops in infants or young children. Must last at least 1 month before the diagnosis can be made. Do not show nausea, retching or disgust associated with their rumination behaviorf Do not have associated gastrointestinal problems that can account for the behavior. Symptoms usually begin between 3 and 12 months of age, and then often remit spontaneously (particularly in infants) after a period of time. Rumination disorder is uncommon, and seems to occur more often in males than in females.

Overview of Eating Disorders

In the late 1800s, doctors in England and France described young women who apparently used self-starvation to avoid obesity It was not until 1960s, however, that anorexia nervosa was established as mental disorder Bulimia nervosa was first described as a distinct syndrome in 1979

Pica
It is the ingestion of non-nutritive substances such as paint, hair, cloth, leaves, sand, clay and soil. It is commonly seen in children with mental retardation and it occasionally occurs in pregnant patient.

Predisposing Factors
Rumination cause is unknown. Adverse psychosocial environment An abnormal mother-infant relationship Onset and maintenance of rumination has also been associated with boredom, lack of occupation, chronic familial disharmony, and maternal psychopathology.

Rumination
Derived from the Latin word ruminare Means chew the cud

Repeated regurgitation and rechewing of food.

The child brings partially digested food up into the mouth and usually rechews and reswallows the food.

Learning-based theories

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Propose increase following positive reinforcement, such as pleasurable sensations produced by the rumination (e.g., self-stimulation) or increased attention from others after rumination. Maintained by negative reinforcement when an undesirable event (e.g., anxiety) is removed. Weight loss Halitosis Indigestion Chronically raw and chapped lips Regurgitation occurs almost every day following most meals. Regurgitation is generally described as effortless and is rarely associated with forceful abdominal contractions or retching.

Organic factors The role of medical/physical factors in rumination is unclear. Although an association between gastroesophageal reflux (GER) and the onset of rumination may exist, some researchers have proposed that various esophageal or gastric disorders may cause rumination. Dilatation of the lower end of the esophagus or of the stomach Overaction of the sphincter muscles in the upper portions of the alimentary canal Cardiospasm Pylorospasm Gastric hyperacidity Movements of the tongue Insufficient mastication Pathologic conditioned reflex Aerophagy (ie, air swallowing) Finger or hand sucking

Management
The main treatment is the

Comprehensive Behavioral Modification Plan (based on learning

principles) which is designed to promote normal eating behavior and to discourage ruminative behavior. Parents may be taught parenting techniques which aim to provide increased attention, interaction, and stimulation for affected children in support of these behavior modification goals. They may also be encouraged to consult with a nutritionist. Behavior modification plans designed to reduce and ultimately eliminate rumination disorder symptoms need to be applied consistently across all environments that children encounter in order for best results to occur. Children who are in serious life threatening danger due to their condition will, of course, need to be hospitalized until their condition stabilizes.

Heredity Although occurrences in families have been reported, no genetic association has been established.

Signs and Symptoms

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Anorexia Nervosa
It is a life-threatening eating disorder characterized by the clients refusal or inability to maintain a minimally normal body weight, intense fear of gaining weight or becoming fat, significantly disturbed perception of the shape or size of the body, and steadfast inability or refusal to acknowledge the seriousness of the problem or that one even exists. It is a condition that goes beyond out-ofcontrol dieting. A person with anorexia often initially begins dieting to lose weight. Over time, the weight loss becomes a sign of mastery and control. 90% of clients with eating disorders are female. Anorexia begins between the ages of 14 and 18.

Etiology The specific cause is unknown Biologic factors: Familial tendency Genetic vulnerability Dysfunction of the hypothalamus Family history of mood or anxiety disorders

Risk Factors Developmental factors

Issues of developing autonomy and having control over self and environment Developing a unique identity Dissatisfaction with body image

Clients with anorexia nervosa can be classified into subgroups:

Family factors Family lacks emotional support Parental maltreatment Cannot deal with conflict

Restrictive Subtype
Dieting, fasting or excessive exercising

Binge eating and purging subtype

Binge eating means consuming a large amount of food (far greater than most people eat at one time) in a discrete period of usually 2 hours or less. Purging means the compensatory behaviors designed to eliminate food by means of self-induced vomiting or misuse of laxatives, enemas, and diuretics.

Sociocultural factors Cultural idea of being thin Media focus on beauty, thinness, fitness Preoccupation with achieving the ideal body

Symptoms Fear of gaining weight or becoming fat even when severely underweight

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Body image disturbance Depressive symptoms Preoccupation with thoughts of food Feelings of ineffectiveness Inflexible thinking Strong need to control environment Limited spontaneity and overly restrained emotional expression Amenorrhea for at least 3 consecutive cycles Bodyweight that is 85% or less of that expected for their age and height For families who demonstrate enmeshment, unclear boundaries among members, and difficulty handling emotions and conflict

Individual therapy If family cannot participate in family therapy If the client is older or separated from nuclear family If client has individual issues requiring psychotherapy

Bulimia Nervosa
Often simply called bulimia is a serious eating disorder in which a person engages into recurrent binge eating followed by inappropriate compensatory behaviors to control ones weight. A person suffering from bulimia have episodes of binging and purging. The amount of food consumed during a binge episode is much larger than a person would normally eat. Clients with bulimia tend to hide their eating behavior to others. The weight of the clients with bulimia is usually normal, although some are overeight. Begins in late adolescence or early adulthood, average age is 18 or 19. Usually affects people over age 35 and is more frequent in men.

Management For severely malnourished clients, their medical condition must be stabilized before psychiatric treatment can begin. Medical management will focus on weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte imbalances Psychopharmacology Amitriptyline (Elavil) & cyproheptadine (Periactin) promote weight gain Olanzapine (Zyprexa) antipsychotic effect and weight gain Fluoxetine (Prozac) prevent relapse in clients whose weight has been partially/completely restored

Family therapy For families of clients younger than 18 years

Two types of bulimia

Purging type

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In which the person regularly engages in self- induced vomiting. A person may also misuse laxatives, diuretics likewise enemas. Irregular menstrual periods Chipped, ragged teeth; loss of dental enamel Alterations in fluids and electrolytes

Non-purging type
The second type of bulimia wherein one tries to control weight with the use of fasting and excessive exercise without purging regularly. Management

Cognitive-Behavioral Therapy
Strategies designed to change the clients thinking and action about food focus on interrupting the cycle of dieting, binging, purging and altering dysfunctional thoughts and belief about food, weight, body image, and overall self-concept

Etiology Biologic Developmental Family Influence Sociocultural

Psychopharmacology

Predisposing Factors Early dieting and obesity Self-perception of being overweight or fat and being unattractive. Alterations in the neurotransmitters Familial influences Cultural considerations such as when they link beauty to thinness.

Antidepressants more effective than the placebos in reducing binge eating. It als improves mood and reduced preoccupation with shape and weight.

Assessment of Clients with Eating Disorders

Family members often describe clients with anorexia as perfectionists with above-average intelligence, ahievement oriented, dependable, eager to please, and seeking approval before their condition began. Parents describe clients as being good, causing us no trouble until the onset of anorexia Clients with bulimia are often focused on pleasing others avoiding conflict. They have a history of impulsive behaviour such as substance abuse

Clinical Manifestation Recurrent episodes of binge eating. Self-induced vomiting, misuse of laxative, diuretics and enemas Excessive exercise Depressive and anxiety symptoms

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and shoplifting as well as anxiety, depression, and personality disorders. Clients are initially pleasant and cheerful as though nothing is wrong.

General appearance and motor behaviour Anorexia Appear slow, lethargic, fatigued, emaciated, depending on the amount of weight loss May be slow to respond to questions and have difficulty deciding what to say Often reluctant to answer questions fully because they do not want to acknowledge any problem Often wear loose-fitting clothes in layers, regardless of the weather Eye contact may be limited

Thought process and content Spend most of the time thinking about dieting, food, and food-related behavior Preoccupied with attempts to avoid eating or eating bad or wrong foods Anorexia Body image disturbance May have paranoid ideas about their family and health care professionals, believing they are their enemies who are trying to make them fat by forcing them to eat Bulimia Eating, binging, or purging leads to anxiety, depression, and feeling out of control.

Bulimia May be underweight or overweight but are generally close to expected body weight for age and size Appear open and willing to talk

Sensorium and intellectual processes General appearance is not unusual Mood and affect Anorexia Labile mood Often seem sad, anxious, and worried Seldom smile, laugh or enjoy any attempts at humor; somber and serious most of the time Bulimia They generally are alert and oriented. Anorexic clients who are severely malnourished show signs of starvation such as mild confusion, slowed mental processes, and difficulty with concentration ad attention.

Judgment and insight Anorexia

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Very limited insight and poor judgment about health status Do not believe they have a problem Believe others are trying to interfere with their ability to lose weight Continue to restrict food intake despite negative effect on health Tend to lead secret lives. Time spent buying and eating food and then purging can interfere with role performance at home and at work.

Psychologic and self-care considerations Excessive exercise, almost to the point of exhaustion Sleep disturbances such as insomnia, reduced sleep time, and early-morning wakening Dental problems, such as loss of tooth enamel, chipped and ragged teeth, and dental caries

Bulimia Ashamed of their behaviors (binge eating and purging) Feel out of control and unable to change Self-concept

Low self-esteem See themselves only in terms of their ability to control food intake and weight. Overlook/ignore other personal characteristics or achievements

Possible Nursing Diagnosis

Imbalanced Nutrition: Less than/More than Body Requirements Ineffective Coping Disturbed Body Image

Roles and relationships Anorexia May begin to fail at school, which is in sharp contrast to previously successful academic performance. Withdraw from peers and pay little attention to friendships. Believe others will not understand or fear they will begin-out-of-control eating with others.

Interventions for Clients with Eating Disorders

Establishing Nutritional Eating Patterns Total parenteral nutrition or enteral when a clients health status is severely compromised. Diet of 1, 200 1, 500 cal/day, with gradual increases in calories. Monitor meals and snacks.

Bulimia Bulimic clients feel great shame about their behaviors

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Discourage client from performing food rituals, e.g. cutting food into tiny pieces Be alert for attempts to hide or to discard food. For bulimic patients are often treated on outpatient basis, encourage to them eat along with friends and families. Encourage client to always sit in a designated eating area. Remind client to avoid buying foods that are frequently consumed during binge eating. Encourage client to set realistic goals. For clients who purge, teaching should include information about harmful effects of purging by vomiting and laxative abuse. Teach techniques of distraction and delay. Explain to family and friends that they can be most helpful by providing emotional support, love, and attention.

Self-Monitoring Encourage a client to keep a diary of the foods consumed throughout the day including binge and moods. Teach client relaxation techniques to control emotions.

Body Image Issues Help clients view themselves in terms other than weight and size likewise satisfaction with body image Identify clients strengths and interest that is not related to size and weight. Maintain a positive attitude.

Client and Family Education Provide education to help clients take control of nutritional requirements independently. Extensive teaching about basic nutritional needs and the effects of restrictive eating, dieting, and the binge and purge cycle.