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Ni Ketut Alit A
Faculty Of Nursing Airlangga
Slide 1

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..

Slide 2

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

Slide 3

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

Slide 4

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
Slide 5

Anorexia Nervosa
About 9095% of cases occur in females
The peak age of onset is between 14 and 18


Around 0.5% of females in Western countries

develop the disorder

Many more display some symptoms

Slide 6

Anorexia Nervosa
The typical case:
A normal to slightly overweight female has been on a diet
Escalation to anorexia nervosa may follow a stressful
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
Slide 7

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

Slide 8

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.

Slide 9

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

Slide 10

Anorexia Nervosa: The Clinical Picture

People with anorexia may also display certain

psychological problems:

Depression (usually mild)

Low self-esteem
Insomnia or other sleep disturbances
Substance abuse
Obsessive-compulsive patterns

Slide 11

Anorexia Nervosa: Problems

Caused by starvation:

Slow heart rate

Low body temperature

Metabolic and
electrolyte imbalance

Low blood pressure

Body swelling
Reduced bone density

Dry skin, brittle nails

Poor circulation

Slide 12

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

Slide 13

Bulimia Nervosa
The disorder is also characterized by

compensatory behaviors, which mark the

subtype of the condition:
Purging-type bulimia nervosa
Misusing laxatives, diuretics, or enemas

Nonpurging-type bulimia nervosa

Exercising excessively
Slide 14

Bulimia Nervosa
Like anorexia nervosa, about 9095% of

bulimia nervosa cases occur in females

The peak age of onset is between 15 and 21

Symptoms may last for several years with

periodic letup

Slide 15

Bulimia Nervosa
Patients are generally of normal weight
May be slightly overweight
Often experience weight fluctuations

Binge-eating disorder may be a related


Symptoms include a pattern of binge eating with

NO compensatory behaviors (such as vomiting)
This condition is not yet listed in the DSM
Slide 16

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
Slide 17

Bulimia Nervosa:
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

Slide 18

Bulimia Nervosa:
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

Slide 19

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:
Affects ability to feel satiated greater hunger and bingeing

Laxatives and diuretics

Almost completely fail to reduce the number of calories

Slide 20

Bulimia Nervosa:
Compensatory Behaviors
Compensatory behaviors may temporarily

relieve the negative feelings attached to binge

Over time, however, a cycle develops in which
purging bingeing purging

Slide 21

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

Slide 22

Bulimia Nervosa vs.

Anorexia Nervosa
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
Slide 23

Bulimia Nervosa vs.

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

Slide 24

Bulimia Nervosa vs.

Anorexia Nervosa
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

Slide 25

Causes Eating Disorders

Most theorists subscribe to a multidimensional risk

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

Slide 26

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

Slide 27

Causes Eating Disorders: Societal Pressures

Certain groups are at greater risk from these

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

Slide 28

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

Slide 29

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

Slide 30

Causes Eating Disorders : Family

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 members lives
Such families can be affectionate and loyal but can also foster
clinginess and dependency
Children are allowed little room for individuality and
Slide 31

Causes Eating Disorders

Ego Deficiencies and Cognitive Disturbances
Bruch : eating disorders are the result of

disturbed motherchild interactions which

lead to serious ego deficiencies in the child
and to severe cognitive disturbances

Slide 32

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 childs biological

and emotional needs
Ineffective parents fail to attend to childs 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

Slide 33

Causes Eating Disorders:

Ego Deficiencies and Cognitive Disturbances
There is some empirical support for Bruchs

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
Slide 34

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

Slide 35

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
Slide 36

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

Slide 37

Causes Eating Disorders : Biological Factors

Other theorists believe that eating disorders

may be related to dysfunction of the

Researchers have identified two separate areas
that control eating:
Lateral hypothalamus (LH)
Ventromedial hypothalamus (VMH)

Slide 38

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

Slide 39

Treatments for Eating Disorders

Eating disorder treatments have two main

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

Slide 40

Treatments for Anorexia Nervosa

The initial aims of treatment for anorexia

nervosa are to:

Restore proper weight
Recover from malnourishment
Restore proper eating

Slide 41

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

Most common technique now is the use of

supportive nursing care and high calorie diets

Slide 42

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
Therapists help patients recognize their need
for independence and control
Therapists help patients recognize and trust
their internal feelings
Slide 43

Treatments for Anorexia Nervosa

Another focus of treatment is correcting

disturbed cognitions, especially client

misperceptions and attitudes about eating and
Using cognitive approaches, therapists correct
disturbed cognitions and educate about body

Slide 44

Treatments for Anorexia Nervosa

Another focus of treatment is changing family

Family therapy is important for anorexia
The main issues are often separation and

Slide 45

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

The course and outcome of the disorder vary

from person to person

Slide 46

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

Slide 47

Treatments for Anorexia Nervosa

Negatives of treatment:
Close to 20% of patients remain troubled for
Even when it occurs, recovery is not always
Relapses are usually triggered by stress
Many patients still express concerns about body shape
and weight

Slide 48

Treatments for Bulimia Nervosa

Treatment programs are relatively new but

have risen in popularity

Treatment is frequently offered in specialized

eating disorder clinics

Slide 49

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


Slide 50

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 isnt effective, interpersonal therapy (IPT), a
treatment that seeks to improve interpersonal functioning, may be
A number of clinicians also suggest self-help groups or self-care

Slide 51

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

Slide 52

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

Slide 53

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

Slide 54

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
Slide 55

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

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