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EATING DISORDER. By Ni Ketut Alit A Faculty Of Nursing Airlangga University. REFERENCES. Black , J.M. & Matassarin E, (1997). Medical Surgical Nursing: Clinical Management for continuity of care . J.B.

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Ni Ketut Alit A

Faculty Of Nursing Airlangga University


  • Black, J.M. & Matassarin E, (1997). Medical Surgical Nursing: Clinical Management for continuity of care. J.B.

  • Barbara C.L & Wilma J.P. (2006). Essentials of Medical Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

  • Smeltzer, S.C., & Bare, B. (2003). Brunner and Suddarth's Textbook of Medical-Surgical Nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins.

  • Ignativicius & Bayne. (2001). Medical and Surgical Nursing. Philadelphia: W.B. Saunders Company.

  • Luckman & Sorensen. (2000). Medical Surgical Nursing. Philadelphia: W.B. Saunders Company.

  • Journals and article related to..


  • Current Western beauty standards equate thinness with health and beauty

  • There has been a rise in eating disorders in the past three decades

    • The core issue is a morbid fear of weight gain

  • Two main diagnoses:

    • Anorexia nervosa

    • Bulimia nervosa


  • The main symptoms of anorexia nervosa are:

    • A refusal to maintain more than 85% of normal body weight

    • Intense fears of becoming overweight

    • A distorted view of body weight and shape

    • Amenorrhea

Anorexia Nervosa

  • There are two main subtypes:

    • Restricting type

      • Lose weight by restricting “bad” foods, eventually restricting nearly all food

      • Show almost no variability in diet

    • Binge-eating/purging type

      • Lose weight by vomiting after meals, abusing laxatives or diuretics, or engaging in excessive exercise

        • Like those with bulimia nervosa, people with this subtype may engage in eating binges

Anorexia Nervosa

  • About 90–95% of cases occur in females

  • The peak age of onset is between 14 and 18 years

  • Around 0.5% of females in Western countries develop the disorder

    • Many more display some symptoms

Anorexia Nervosa

  • The “typical” case:

    • A normal to slightly overweight female has been on a diet

    • Escalation to anorexia nervosa may follow a stressful event

      • Separation of parents

      • Move or life transition

      • Experience of personal failure

    • Most patients recover

      • However, about 2 to 6% become seriously ill and die as a result of medical complications or suicide

Anorexia Nervosa: The Clinical Picture

  • The key goal for people with anorexia nervosa is thinness

    • The driving motivation is FEAR:

      • Of becoming obese

      • Of losing control of body shape and weight

Anorexia Nervosa: The Clinical Picture

  • Despite their dietary restrictions, people with anorexia are extremely preoccupied with food

    • This includes thinking and reading about food and planning for meals

    • This relationship is not necessarily causal

      • It may be the result of food deprivation, as evidenced by the famous.

Anorexia Nervosa: The Clinical Picture

  • People with anorexia nervosa also demonstrate distorted thinking:

    • Often have a low opinion of their body shape

    • Tend to overestimate their actual proportions

      • Adjustable lens assessment technique – overestimate size by 20%

    • Hold maladaptive attitudes and beliefs

      • “I must be perfect in every way”

      • “I will be a better person if I deprive myself”

      • “I can avoid guilt by not eating”

Anorexia Nervosa: The Clinical Picture

  • People with anorexia may also display certain psychological problems:

    • Depression (usually mild)

    • Anxiety

    • Low self-esteem

    • Insomnia or other sleep disturbances

    • Substance abuse

    • Obsessive-compulsive patterns

    • Perfectionism

Caused by starvation:


Low body temperature

Low blood pressure

Body swelling

Reduced bone density

Slow heart rate

Metabolic and electrolyte imbalance

Dry skin, brittle nails

Poor circulation


Anorexia Nervosa: Problems


  • Bulimia nervosa, also known as “binge-purge syndrome,” is characterized by binges:

    • Bouts of uncontrolled overeating during a limited period of time

      • Often objectively more than most people would/could eat in a similar period

Bulimia Nervosa

  • The disorder is also characterized by compensatory behaviors, which mark the subtype of the condition:

    • Purging-type bulimia nervosa

      • Vomiting

      • Misusing laxatives, diuretics, or enemas

    • Nonpurging-type bulimia nervosa

      • Fasting

      • Exercising excessively

Bulimia Nervosa

  • Like anorexia nervosa, about 90–95% of bulimia nervosa cases occur in females

  • The peak age of onset is between 15 and 21 years

  • Symptoms may last for several years with periodic letup

Bulimia Nervosa

  • Patients are generally of normal weight

    • May be slightly overweight

    • Often experience weight fluctuations

  • “Binge-eating disorder” may be a related diagnosis

    • Symptoms include a pattern of binge eating with NO compensatory behaviors (such as vomiting)

    • This condition is not yet listed in the DSM

Bulimia Nervosa

  • Teens and young adults have frequently attempted binge-purge patterns as a means of weight loss, often after hearing accounts of bulimia from friends or the media

  • In one study:

    • 50% of college students reported periodic binges

    • 6% tried vomiting

    • 8% experimented with laxatives at least once

Bulimia Nervosa: Binges

  • For people with bulimia nervosa, the number of binges per week can range from 2 to 40

    • Average: 10 per week

  • Binges are often carried out in secret

    • Binges involve eating massive amounts of food rapidly with little chewing

    • Binge-eaters commonly consume more than 1500 calories (often more than 3000 calories) per binge episode

Bulimia Nervosa: Binges

  • Binges are usually preceded by feelings of tension and/or powerlessness

  • Although the binge itself may be pleasurable, it is usually followed by feelings of extreme self-blame, guilt, depression, and fears of weight gain and “discovery”

Bulimia Nervosa: Compensatory Behaviors

  • After a binge, people with bulimia nervosa try to compensate for and “undo” the caloric effects

  • The most common compensatory behaviors:

    • Vomiting

      • Affects ability to feel satiated  greater hunger and bingeing

    • Laxatives and diuretics

      • Almost completely fail to reduce the number of calories consumed

Bulimia Nervosa: Compensatory Behaviors

  • Compensatory behaviors may temporarily relieve the negative feelings attached to binge eating

    • Over time, however, a cycle develops in which purging  bingeing  purging…

Bulimia Nervosa

  • The “typical” case:

    • A normal to slightly overweight female has been on an intense diet

    • Research suggests that even among normal subjects, bingeing often occurs after strict dieting

      • For example, a study of binge-eating behavior in a low-calorie weight loss program found that 62% of patients reported binge-eating episodes during treatment

Bulimia Nervosa vs. Anorexia Nervosa

  • Similarities:

    • Onset after a period of dieting

    • Fear of becoming obese

    • Drive to become thin

    • Preoccupation with food, weight, appearance

    • Elevated risk of self-harm or attempts at suicide

    • Feelings of anxiety, depression, perfectionism

    • Substance abuse

    • Disturbed attitudes toward eating

Bulimia Nervosa vs. Anorexia Nervosa

  • Differences:

    • People with bulimia are more worried about pleasing others, being attractive to others, and having intimate relationships

    • People with bulimia tend to be more sexually experienced

    • People with bulimia display fewer of the obsessive qualities that drive restricting-type anorexia

    • People with bulimia are more likely to have histories of mood swings, low frustration tolerance, and poor coping

Bulimia Nervosa vs. Anorexia Nervosa

  • Differences:

    • People with bulimia tend to be controlled by emotion – may change friendships easily

    • People with bulimia are more likely to display characteristics of a personality disorder

    • Different medical complications:

      • Only half of women with bulimia experience amenorrhea vs. almost all women with anorexia

      • People with bulimia suffer damage caused by purging, especially from vomiting and laxatives

Causes Eating Disorders

  • Most theorists subscribe to a multidimensional risk perspective:

    • Several key factors place individuals at risk

    • More factors = greater risk

    • Leading factors:

      • Sociocultural conditions (societal and family pressures)

      • Psychological problems (ego, cognitive, and mood disturbances)

      • Biological factors

Causes Eating Disorders: Societal Pressures

  • Many theorists argue that current Western standards of female attractiveness have contributed to the rise of eating disorders

    • Standards have changed throughout history toward a thinner ideal

Causes Eating Disorders: Societal Pressures

  • Certain groups are at greater risk from these pressures:

    • Models, actors, dancers, and certain athletes

      • Of college athletes surveyed, 9% met full criteria for an eating disorder while another 50% had symptoms

      • 20% of surveyed gymnasts met full criteria for an eating disorder

Causes Eating Disorders:Societal Pressures

  • The socially-accepted prejudice against overweight people may also add to the “fear” and preoccupation about weight

    • About 50% of elementary and 61% of middle school girls are currently dieting

Causes Eating Disorders : Family Environment

  • Families may play a critical role in the development of eating disorders

    • As many as half of the families of those with eating disorders have a long history of emphasizing thinness, appearance, and dieting

    • Mothers of those with eating disorders are more likely to be dieters and perfectionistic themselves

Causes Eating Disorders : Family Environment

  • Abnormal family interactions and forms of communication within a family may also set the stage for an eating disorder

    • Minuchin cites “enmeshed family patterns” as causal factors of eating disorders

      • These patterns include overinvolvement in, and overconcern about, family member’s lives

      • Such families can be affectionate and loyal but can also foster clinginess and dependency

        • Children are allowed little room for individuality and independence

Causes Eating Disorders Ego Deficiencies and Cognitive Disturbances

  • Bruch : eating disorders are the result of disturbed mother–child interactions which lead to serious ego deficiencies in the child and to severe cognitive disturbances

Causes Eating Disorders :Ego Deficiencies and Cognitive Disturbances

  • Bruch : parents may respond to their children either effectively or ineffectively

    • Effective parents accurately attend to a child’s biological and emotional needs

    • Ineffective parents fail to attend to child’s internal needs; they feed when the child is anxious, comfort when the child is tired, etc.

      • Children who receive such parenting may grow up confused and unaware of their own internal needs; they are unable to identify their own emotions

Causes Eating Disorders: Ego Deficiencies and Cognitive Disturbances

  • There is some empirical support for Bruch’s theory from clinical sources

    • People with bulimia eat in response to emotions; many mistakenly think they are also hungry

    • People with eating disorders rely excessively on the opinions, wishes, and views of others

      • They are more likely to worry about how they are viewed, to seek approval, to be conforming, and to feel a lack of life control

Causes Eating Disorders : Mood Disorders

  • Many people with eating disorders, particularly those with bulimia nervosa, experience symptoms of depression

    • Theorists believe mood disorders may “set the stage” for eating disorders

Causes Eating Disorders Mood Disorders

  • There is some empirical support for the claim that mood disorders set the stage for eating disorders

    • Many more people with an eating disorder qualify for a clinical diagnosis of major depressive disorder than do people in the general population

    • Close relatives of those with eating disorders seem to have higher rates of mood disorders

    • People with eating disorders, especially those with bulimia nervosa, have low levels of serotonin

    • Symptoms of eating disorders are helped by antidepressant medications

Causes Eating Disorders : Biological Factors

  • Biological theorists suspect that some people inherit a genetic tendency to develop an eating disorder

    • Consistent with this model:

      • Relatives of people with eating disorders are 6 times more likely to develop the disorder themselves

    • These findings may be related to low serotonin

Causes Eating Disorders : Biological Factors

  • Other theorists believe that eating disorders may be related to dysfunction of the hypothalamus

    • Researchers have identified two separate areas that control eating:

      • Lateral hypothalamus (LH)

      • Ventromedial hypothalamus (VMH)

Causes Eating Disorders : Biological Factors

  • Some theorists believe that the LH and VMH are responsible for weight set point – a “weight thermostat” of sorts

    • Set by genetic inheritance and early eating practices, this mechanism is responsible for keeping an individual at a particular weight level

      • If weight falls below set point:  hunger,  metabolism  binges

      • If weight rises above set point:  hunger,  metabolism

    • Dieters end up in a fight against themselves to lose weight

Treatments for Eating Disorders

  • Eating disorder treatments have two main goals:

    • Correct abnormal eating patterns

    • Address broader psychological and situational factors that have led to and are maintaining the eating problem

      • This often requires the participation of family and friends

Treatments for Anorexia Nervosa

  • The initial aims of treatment for anorexia nervosa are to:

    • Restore proper weight

    • Recover from malnourishment

    • Restore proper eating

Treatments for Anorexia Nervosa

  • In the past, treatment took place in a hospital setting; it is now often offered in an outpatient setting

  • In life-threatening cases, clinicians may force tube and intravenous feeding

    • This may breed distrust in the patient and create a power struggle

  • Most common technique now is the use of supportive nursing care and high calorie diets

Treatments for Anorexia Nervosa

  • Therapists use a mixture of therapy and education to achieve this broader goal

    • One focus of treatment is building autonomy and self-awareness

      • Therapists help patients recognize their need for independence and control

      • Therapists help patients recognize and trust their internal feelings

Treatments for Anorexia Nervosa

  • Another focus of treatment is correcting disturbed cognitions, especially client misperceptions and attitudes about eating and weight

    • Using cognitive approaches, therapists correct disturbed cognitions and educate about body distortions

Treatments for Anorexia Nervosa

  • Another focus of treatment is changing family interactions

    • Family therapy is important for anorexia

    • The main issues are often separation and boundaries

Treatments for Anorexia Nervosa

  • The use of combined treatment approaches has greatly improved the outlook for people with anorexia nervosa

    • But even with combined treatment, recovery is difficult

  • The course and outcome of the disorder vary from person to person

Treatments for Anorexia Nervosa

  • Positives of treatment:

    • Weight gain is often quickly restored

      • 83% of patients still showed improvements after several years

    • Menstruation often returns with return to normal weight

Treatments for Anorexia Nervosa

  • Negatives of treatment:

    • Close to 20% of patients remain troubled for years

    • Even when it occurs, recovery is not always permanent

      • Relapses are usually triggered by stress

      • Many patients still express concerns about body shape and weight

Treatments for Bulimia Nervosa

  • Treatment programs are relatively new but have risen in popularity

  • Treatment is frequently offered in specialized eating disorder clinics

Treatments for Bulimia Nervosa

  • The initial aims of treatment for bulimia nervosa are to:

    • Eliminate binge-purge patterns

    • Establish good eating habits

    • Eliminate the underlying cause of bulimic patterns

  • Programs emphasize education as much as therapy

Treatments for Bulimia Nervosa

  • Several treatment strategies:

    • Individual insight therapy

      • The insight approach receiving the most attention is cognitive therapy, which helps clients recognize and change their maladaptive attitudes toward food, eating, weight, and shape

        • As many as 65% stop their binge-purge cycle

      • If cognitive therapy isn’t effective, interpersonal therapy (IPT), a treatment that seeks to improve interpersonal functioning, may be tried

      • A number of clinicians also suggest self-help groups or self-care manuals

Treatments for Bulimia Nervosa

  • Several treatment strategies:

    • Behavioral therapy

      • Behavioral techniques are often included in treatment as a supplement to cognitive therapy

        • Diaries are often a useful component of treatment

      • Exposure and response prevention (ERP) is used to break the binge-purge cycle

Treatments for Bulimia Nervosa

  • Several treatment strategies:

    • Antidepressant medications

      • During the past decade, antidepressant drugs have been used in bulimia treatment

        • Most common is fluoxetine (Prozac), an SSRI

        • Drugs help 25 to 40% of patients

      • Medications are best when used in combination with other forms of therapy

Treatments for Bulimia Nervosa

  • Several treatment strategies:

    • Group therapy

      • Provides an opportunity for patients to express their thoughts, concerns, and experiences with one another

      • Helpful in as many as 75% of cases, especially when combined with individual insight therapy

Treatments for Bulimia Nervosa

  • Left untreated, bulimia can last for years

  • Treatment provides immediate, significant improvement in about 40% of cases

    • An additional 40% show moderate improvement

  • Follow-up studies suggest that 10 years after treatment, about 90% of patients have fully or partially recovered

Treatments for Bulimia Nervosa

  • Relapse can be a significant problem, even among those who respond successfully to treatment

    • Relapses are usually triggered by stress

    • Relapses are more likely among persons who:

      • Had a longer history of symptoms

      • Vomited frequently

      • Had histories of substance use

      • Have lingering interpersonal problems

  • Finally, treatment may also help improve overall psychological and social functioning

The Best Wishes…

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