Personality Disorders

Eating Disorders Anorexia Nervosa / Bulimia Nervosa • Often Enter Health Care System By Being Admitted To ICU And Electrolyte Imbalance • May Be Due To Fact That Restrictive Anorexic Subtype Receding In Incidence, Purging Subtype Becoming More Common • Most Common Cause Of Death With An Eating Disorder Is Heart Failure Due To Electrolyte Imbalance. Incidence • Age at onset usually early to late adolescence • Occurs mainly in females (1 out of every 100 females between the ages of 16 to 18 years old). More males are currently being diagnosed than before. • Often have other problems such as anxiety or depression (mood disorders) along with the eating disorder Causes: • Biological Factors o Genetics o Neuroendocrine abnormalities • Psychological o Elements of power and control – the only thing they can control is what they are eating, this may be a rebellion against the control of their parents o Comorbidity of depression, anxiety, social anxiety, OCD • Socialcutural o Societal ideal is to be very thin A large number of these clients have been sexually abused (20 to 60%) Anorexia • Characterized By A Morbid Fear Of Obesity Bulimia • An Episodic Uncontrolled, Compulsive Rapid Ingestion of Large Quantities of Food. Over A Very Short Period of Time. Called Binging • Binging Is Followed By Some Type Of Compensatory Behavior That Rids The Body Of Excess Calories. That Is Called Purging • Purging Can Be Anything From Self Induced Vomiting, To Excessive Exercise, Laxatives, Enemas, Or Diuretics Anorexia Nervosa • Low body weight – less than 85% of where they should be • Fear of becoming obese • Distorted view of their body size (delusional) • Excess physical activity • Denies feelings of hunger • Preoccupation with food preparation • Bizarre eating habits – may eat one pea at a time or break food up into tiny pieces • Vomiting, laxatives, diuretics – to rid the body of calories

• • • •

Amenorrhea – skip three menstrual periods Refusal To Maintain Body Weight May engage in excess exercise or physical activity Deny feelings of hunger

Diagnostic Criteria of Anorexia • Refusal To Maintain Body Weight • Fear Of Gaining Weight or becoming obese • Undue Influence Body Weight Or Shape On Self Evaluation • How They Feel About Themselves Is Based On How They Look • Amenorrhea • They Feel They Are Fat No Matter How Thin They Become • Perception Of Being Fat • Marked Wt Loss (Less Than 85% Of Expected Weight) • Hypothermia – Due To No Insulation • Bradycardia – Decrease Pulse • Edema – Too Little Protein • Lanugo – Downy Hair • Metabolic Changes • Constipation • Obsessed With Food – Talk About It A Lot, Prepare Foods But Do Not Eat, May Hide Food • Depression /Anxiety • Lab Finding o Decrease H/H, Decreased K, Decreased Na o Electrolyte Imbalance More Often Seen In Bulimia o Fatigue, Weakness o Sob, Arrhythmias Clinical Manifestations - Skin tenting (skin is very dry) - Dehydration - Abdominal pain - Amenorrhea – skip 3 menstrual cycles - Constipation - Lethargy - Dizziness - Fatigue - Hypothermia – they have no subcutaneous fat to keep them warm - Lanugo (fine downy body hair) - Yellowing of skin - Socially withdrawn, irritable, moody and depressed Medical complications • Cardiovascular (might have heart muscle damage) - Bradycardia - Arrhythmias (may be due to hypokalemia) - Hypotension • Hematological

•

•

•

- Anemia - Leukopenia (low white blood cell count) Metabolic - Dehydration – urine might be very concentrated - Hypokalemia, hypomagnesia, hypocalcemia (electrolyte imbalances) o Most people die of hypokalemia Endocrine - Amenorrhea – normal nutrition will restore menstrual cycle - Reduced levels of growth hormone – normal nutrition will restore growth hormone - May have growth retardation Skeletal - Osteopenia - Increased risk for fractures and may go into osteoporosis (not taking in any calcium)

Bulimia Nervosa • 2 Types: o Purging – Uses Vomiting, Laxatives, Enemas & Diuretics o Non-Purging – Would Exercise For Hours Trying To Get Rid Of The Calories Consumed. Bulimia Nervosa • Binge Eating – eat very large amounts of food in a very short amount of time – generally in less than 2 hours. The food that they eat is generally very high calorie; is of soft texture and is sweet. (Examples ice cream, candy, chocolate) • Self induces vomiting, laxatives, enemas, diuretics • Compensatory Behavior To Prevent Weight Gain • Occur 2 Times A Week For 3 Months (may occur more) • Self Evaluation is influenced By Body Shape, Weight • Does Not Occur Exclusively During Anorexia Nervosa Clinical Manifestations • Binge Eating With High Calorie Foods • Very Pleasurable While Eating • Sweet, Soft, Eaten Rapidly • Binge Eating Occurs In Secret • Purging Behavior • Bring Pleasure While Eating, Followed By Depression; The Depression Is What Causes Them To Engage In The Purging Behavior. • Persistent Over-Concern For Their Personal Appearance • Weight Fluctuations Are Common • Vomiting / Laxative Use and/or Excessive Exercise Leads To Dehydration, Electrolyte Imbalance Cause Cardiac Arrhythmias, Tears In Gastric Or Esophageal Mucosa Erosion Of Teeth Due To Gastric Acids. • Mood Disorders, Anxiety Disorders, Substance Abuse Problem (Depression) • Generally they are very anxious and engage in impulsive behaviors – they may even have impulsive stealing. Signs and Symptoms & Complications (Bulimia)

• • • • • • • •

Dental Caries – due to stomach acid affect on the enamel on the teeth Parotid glands will swell Dilate gastric area and rupture it Rupture of the esophagus Scar on hands where the teeth meet their fingers for self induced vomiting (Russel’s sign) Peripheral edema and muscle weakness Electrolyte Imbalances (Hypokalemia, hypomagnesia, hypocalcemia, hyponatremia) – due to vomiting, use of diuretics and laxatives EKG changes due to the electrolyte imbalances

With anorexia and bulimia, generally the client will be admitted to the ICU because of electrolyte imbalances. Initially will treat the physical symptoms because complications can lead to death. Once the client is physically stabilized, then they can move on to other types of treatment (psychological). Normal psychiatric facilities are not ideal for treating these disorders (most of the time treated as an out-patient) These are ways of thinking that Cognitive Therapy will try to change: o These clients will over generalize. Two examples would be – “He did not ask me out; it must be because I am fat” or “I was happy when I wore a size 6. I must get back to that size and weight.” o They may have all or nothing thinking – “if I have one popsicle; I must have five” or If I allow myself to gain weight; I will blow up like a balloon”. o They might catasrophize – “If I gain weight, my weekend will be ruined” or “When people say I look better; I know that they think I am fat.” o Personalization – “I know everybody is watching me eat” or “I think people will not like me unless I am thin” o Emotional reasoning – “I know that I am fat because I feel fat. When I am thin, I feel powerful.” Predisposing Factors • Family Influences • Elements Of Power And Control – The One Thing They Can Control • Increased Value On Being Perfect Nursing Diagnosis • Altered Nutrition: Less Than Body Requirements o Getting them to eat again is the hardest thing to do because if they have been anorexic for a while, then the body rejects the food. Re-feeding is a big issue. This is a very slow process. Need to feed this client very small amounts initially, possibly more often. They might even be put on tube feedings. o Have To Fix The Physical Needs First o Regularly scheduled weigh ins o Goal to meet every week – possibly to gain 2-3 pounds per week – may weigh with their backs to the scale so they cannot see what they have gained o Privileges And Restrictions Are Based On Compliance With Their Diet. If they do not gain weight, they lose privileges o Daily Weights And I&O

Assess Skin Turgor Assess Mucous Membranes Assess Hair After A Meal The Nurse Should Stay At Least 30 Minutes To 1 Hour To Make Sure They Don’t Engage In Any Purging Activities. o Limit The Amount They Are Sitting At The Table Eating o Be Consistent o Let Them Know If They Are Not Going To Eat Then Tube Feeding Will Be Put In Place o Matter-Of-Fact With Clients o Re-feeding is a big issue – small meals several times a day o Possible tube feeding o In an in-treatment facility, there will be very structured routines. They will have to adhere to a selected menu with possibly a few options. Staff will stay with this client during meals and 1 hour after meals. The facility may even lock the bathrooms after meals. o Have to have at least 90% of their body weight to menstruate again. Body Image Disturbance o Perfection Is Not Possible o Need To See Themselves Realistically o Learn To Accept Themselves o Work on how they feel about themselves as a person – their self esteem is very low. o Work in groups (look at magazines, cut out pictures that show how they look) o Feedback might help their image sink in Decreased Cardiac Output o Monitoring EKG, lab values Anxiety Low Self Esteem Knowledge Deficit Ineffective Individual Coping Powerlessness Hopelessness Risk for injury – electrolyte imbalances, esophageal rupture Ineffective Denial R/T Retarded Ego Development And Fear Of Losing The Only Aspect Of Life o Develop Trusting Relationship Get Them To Talk About Problems o Don’t Bargain With Them Or Make Deals o o o o

•

• • • • • •

Treatment for Anorexia and Bulimia • Goal: Restore Nutritional Status, Complications Of These Disorders Can Lead To Death. Once the physical condition is no longer life threatening, other treatment modalities can be used. • Must Be Constantly Assessed For: Electrolyte Imbalance, Dehydration • Must Restore The Body Back To Physical Health. Once Their Physical Health Is No Longer Life Threatening Then You Can Use Some Other Therapy. o Cognitive-Behavior Therapy o Behavior Modification  Have To Gain Weight Or Maintain Diet o Individual Therapy

Helpful For The Patients That Need To Resolve Issues Of Control, Power, Rebellion. o Family Therapy  To Help Resolve Guilt And Anger  They Don’t Know What To Do To Help  Very important for family to be involved in therapy because these are family issues. o Psychopharmacology • Periactin  Stimulate Appetite • Antidepressant  SSRI’s – Prozac (It improves the weight gain and reduces relapse) • Low Dose of Thorazine For Anxiety • Zyprexa (antipsychotic) – reduces anxiety and agitation and reduces resistance to treatment 

It is very important for a bulimic client to recognize their triggers for binging. If something happens and they get to feeling a certain way and then they go binge. They need to identify what is it that is happening that makes me want to binge. They can work on maybe modifying this situation, this might stop some of their binging. If Client Complains Of Being Weak And Fatigue What Is The First Thing You Do. • H/H • May Be Sob

Legal/Ethical Issues -

Admission To Psychiatric Hospital o Voluntary – Dr Ordered o Involuntary – Court Committed, Legally Found To Need Psychiatric Help  Affidavit For Commitment Is Filed (with chancery clerk of county where client lives) • Accurate factual descriptions of the client’s behavior • Where it occurred, the time it occurred and if there are any witnesses to the behavior • This statement should support the need for treatment. It should support the fact that the person is a danger to himself and/or to others because of the mental illness.  Person Taken Into Custody by the Sheriff of that county (hospital or jail if there is no room in the hospital)  Examination By Physician And Psychologist • Physical And Mental Exam • When examining the client – he is told that they are examining him to see if he needs to go to the State Hospital for treatment of his mental illness. • The client has a Right To Not Answer Questions & the right to have an attorney present. If he does not have an attorney, they can appoint him one.

Procedure After Exam • There is a Master in charge of the Hearings • Appointment Of Attorney And Notice Of Hearing o Hearing Must Be Held Within 7 Days o Client Can Question Witnesses o They try not to have the patient under the influence of drugs, but if the client must be drugged, this must be a known fact and entered as evidence • Hearing-Discharge Or Admission o Try To Put Them In The Least Restrictive Facility To Meet The Needs Of That Person o Most Of The Time Is In-Patient Treatment o Stay In Jail If No Bed Is Open o 20 or 90 Days Observation, Diagnosis, And Treatment  Hearing On Need For Further Treatment At This Point • Reviewed Every 6 Months • Can Be Discharged o Must Take All Meds And Keep Every Appointment Or The Sheriff Will Pick Them Up Again o Given 2 Week Discharge Pass – If Do Not Maintain Treatment Can Be Brought Back Within 2 Weeks Without Going Through Commitment Process o Writ of Habeas Corpus – a special hearing where the client can question the validity of his/her commitment What Right Is Lost When A Client Is Committed? o The Right To Leave The Hospital What Rights Remain In Tact? (Handout) Important Decision o Wills – Must Know Extent Of Property, Know Who His Family Is And The Meaning Of Those Relationships before the client can make a valid will o Contracts – Must Understand The Nature Of The Contract (consequences, circumstances involved and they know what their responsibility will be in the contract) o Marriage – Must Understand The Nature Of The Contract o Divorce – Cannot Divorce On Grounds Of Mental Illness Unless They Have Been Mentally Ill For 5 Years And Have Very Little Chance Of Recuperation o Competency – Hearing Must Be Held To Approve Competency, Legal Guardian Will Be Set o McNaghten Rules – Used By The Defense To Get The Verdict Not Guilty By Reason Of Insanity (2 parts) 1. Individual Did Not Know Nature And Quality Of The Act At The Time Of The Act (saw his mother as the devil, thought he was stabbing the devil, but really stabbed his mother) 2. If He Did Know What He Was Doing, But He Didn’t Know It Was Wrong (Right from Wrong Test) – (the voice of the Lord told him to kill his mother, it is hard to not obey the Lord). 

-

Other Legal Issues

-

-

-

-

Right To Treatment – every client has a written treatment plan (green papers), treatment must meet the following criteria o The environment must be humane o The staff must be qualified and sufficient to provide adequate treatment o The plan of care must be indiviualized Right To Refuse Treatment o Most Persons That Is Danger To Self Or Other Person Can Be Given Medication Against Their Will o If not hurting other people or causing any problems, this client may refuse to take meds. Rights To Informed Consent o Must Be Informed on the nature of their condition, of Treatment, Risks, And Benefits. They need to be told about the side effects of their medications. Rights Regarding Restraint And Seclusion o Least restrictive things first. You hope you have the client realize that they need to go for “quiet time”, then we progress to “time out”, then we progress to seclusion or special treatment, and then restraints. (There may be some variations, like sometimes you might not see a person in seclusion but they might have some restraints at the waist. This would be a specialized case.) o Only put in seclusion when in danger to self or others o Can do without order if danger o Every 2 hours must be offered to go to bathroom or food/drink o Cannot overuse antipsychotic medication where a person is just a zombie o When a person gets better, they get out of seclusion or time out. o Never use seclusion for staff convenience (example short staffed) – just when the behavior warrants Supervisory Liability o Nursing duties must be delegated correctly and appropriately Short-Staffing Issues o If staffing isn’t appropriate, a written appeal would need to given. o Never work outside of the scope of your license. o Always put the clients rights first o Go by hospital policy manual o Follow chain of command if employee is being inappropriate with clients o Know and follow established practice standards o Keep accurate, concise and timely nursing records o A good relationship with the client – may prevent being sued, this will help the most