Chapter 14: Eating Disorders

OK, let's let's unpack this because we have a lot of ground to cover.

Welcome back to the deep dive, everyone.

Today, we are doing something a little bit special, aren't we?

We're calling this a last minute lecture edition.

That's right.

We are pivoting just a little bit to help a very specific group of people tuning in, though, frankly.

I mean, this information is fascinating for anyone.

But today we are really speaking directly to nursing students.

Yeah, the stressed out, highly caffeinated nursing students who probably have a psych exam coming up in like, what, two days or two hours, honestly.

Exactly.

And the topic on the docket today is Chapter 14 from the Essentials of Psychiatric Mental Health Nursing, the fourth edition.

The chapter is simply titled Eating Disorders.

It's a heavy topic, very heavy and quite dense when you really get into the text.

Extremely dense.

There is a lot of pathophysiology woven into the psychology here.

So our mission today for you listening is pretty straightforward.

We are going to guide you through this chapter exactly as it is written in the book,

from the initial assessment all the way down to evaluation.

We're going to try and translate that dense clinical text into what I hope is a really clear conversational study guide.

Right.

We want to hit those light bulb moments.

We want to make sure you actually understand the underlying differences between anorexia, bulimia and binge eating disorder, not just rote memorization of the definitions, but really grasping the mechanics of them.

Because that's what shows up on the NCLEX.

Right.

And we need to talk about the nursing process, assessment, diagnosis, planning, all that good stuff.

We do.

But before we get into the nitty gritty of BMI ranges and specific medication names, I really think we need to start with the hook that the text provides early on, which I found to be quite profound.

Yeah, I saw this in the intro.

It contrasts the typical everyday human experience of eating with the experience of someone who is suffering from an eating disorder.

Right.

Just think about it for a second.

For most of us, eating is nourishment.

It's soul food.

It's community.

You know, you break bread to celebrate a birthday or to mourn at a funeral.

It's a connector.

It's biological, but it's also social glue.

Right.

It's how we socialize.

But for someone with an eating disorder, that entire script is flipped completely upside down.

Completely.

It becomes a source of intense anxiety, of terror and of massive disruption to their life.

And here's the sobering fact to kick us off.

These disorders have the highest mortality rate of any psychiatric disease.

That is, I mean, I read that in the source material and I literally had to pause

the highest, like higher than major depression, higher than schizophrenia, higher than depression, higher than schizophrenia.

It is a highly lethal condition.

And I think that sets the stakes for us right out of the gate.

We aren't just talking about, you know, a diet gone wrong.

We are talking about a life or death psychiatric illness.

OK, so give us the roadmap.

How are we tackling Chapter 14 today?

We're going to break it down very logically.

We'll start with the big picture.

So the concepts, the prevalence and the why, which is the etiology.

Then we are going to do a deep dive into anorexia nervosa, followed by bulimia nervosa and finally binge eating disorder.

And for each one of those, we'll look at the assessment, the clinical picture and the specific evidence based nursing interventions.

And I know there's some really specific case studies in the text like Tina, Stacey and the the we're going to walk through those two, right?

We absolutely will.

Those clinical vignettes are where the textbook theory meets reality.

We're going to spend some real time analyzing those because that's where you see the human being standing behind the diagnosis.

All right.

Let's dive right into Section one concept, prevalence and etiology.

So the text starts by defining nutrition itself.

It describes it as a continuum.

It ranges from optimal, which is where you're growing properly, repairing cells, preventing disease all the way to suboptimal.

And eating disorders or EDs represent a severe, severe disruption in that continuum.

Yes, it's a profound disruption in eating patterns accompanied by a disturbance in the perception of body shape and weight.

And we really need to look at the numbers here because they are staggering.

What jumped out at me immediately was the statistic regarding adolescence.

It is the third most common chronic illness among adolescents.

Third most common.

That is incredibly widespread.

I don't think people realize that they don't.

And when we break down the prevalence by specific disorder, we see some very distinct trends.

Let's start with anorexia nervosa, or a .n.

The lifetime prevalence is about point six percent.

And what are the gender differences there?

It is three times higher in females.

OK.

What about bulimia nervosa or B .N.?

That one is slightly more common.

The lifetime prevalence is one point zero percent.

And here the gender gap widens.

It's five times higher in females.

Wow.

And then the third one binge eating disorder or BED.

This is actually the most prevalent of all three.

The lifetime prevalence is two point eight percent.

And the gender gap narrows a bit here.

It's twice as many females as males, but that means a really significant number of men are affected, too, which is often overlooked.

And for the nursing students listening, if you get a multiple choice question about the typical age of onset,

what's the target they should look for?

Adolescents.

The peak onset is usually right between ages 13 and 17.

Although it is worth noting that binge eating disorder tends to appear a bit later, often in a person's mid 20s.

Now, in psychiatric nursing, we rarely see a patient walk through the door with just one single diagnosis.

Comorbidity seems to be the absolute rule here, not the exception.

Absolutely.

The text is very clear on this point.

More than 50 percent of patients with anorexia and almost 95 percent of patients with bulimia have a concurrent psychiatric disorder.

Ninety five percent.

That is practically every single patient.

It is.

You are almost always treating something else alongside the eating disorder.

Mood disorders, anxiety, OCD, substance use and trauma history, specifically sexual abuse and physical neglect are very, very common risk factors.

Now, there was a specific medical comorbidity mentioned in the chapter that I found really concerning type one diabetes.

Yes, this is a critical clinical pearl.

Adolescent girls with type one diabetes are twice as likely to develop disordered eating.

Why is that?

What's the link there?

It's a highly dangerous mechanism.

These patients figure out that if they omit their prescribed insulin, they lose weight rapidly.

Right, because without the insulin, the body literally can't store the blood sugar.

Exactly.

They spill all that excess glucose into their urine.

But they are essentially omitting a life saving hormone medication for the sole purpose of weight loss.

It puts them straight into DKA diabetic ketoacidosis, which can kill you quickly.

It's incredibly dangerous.

But the psychological drive for thinness completely overrides the biological fear of the medical crisis.

Wow.

OK, let's move to the why.

The etiology.

I feel like for a long time, the general public just thought this was all about vanity or wanting to look like a fashion model.

But the science is something completely different.

The science has evolved tremendously over the last few decades.

We now look at a neurobiological model.

This isn't just about wanting to be thin.

It's fundamentally about a faulty reward system in the brain.

So let's get into the weeds here.

Talk to me about dopamine.

How does dopamine function differently in these patients?

Well, typically for you or me, the act of eating triggers a dopamine release in the brain's reward centers.

It feels good.

It's a reward.

We eat a great burger.

Our brain says, yes, that was awesome.

Do that again.

But in anorexia, the text suggests that eating doesn't trigger pleasure.

It triggers anxiety.

Wait, so when they eat a meal, they don't get a yum signal.

They get a panic signal.

Exactly that.

There's a release of dopamine in a specific area called the dorsal striatum that actually triggers severe anxiety.

So restricting food isn't just a diet for them.

It's a biological way to avoid that massive anxiety spike.

That makes so much sense as to why it's so hard to treat.

You're asking them as a nurse to do something that chemically makes them feel terrible.

Correct.

Now, contrast that with bulimia.

In bulimia, the theory is that they have a weaker response to dopamine overall.

So they might binge eat massive amounts of food to try and chase that reward sensation that they just aren't getting from a normal sized meal.

Like the reward volume dial is turned way down.

So they have to scream at it with food just to hear it.

That's a really great analogy.

And structurally, we see physical changes in the brain, too.

The ordo frontal cortex, which is the part that tells you when to start eating.

And the insula, which reads internal body signals, are altered.

But there's a chicken and egg problem here, isn't there?

The text mentions this.

A huge problem.

Severe malnutrition literally changes the structure of the brain.

So when we scan these patients, we don't always know if the brain changes cause the eating disorder or if the prolonged starvation cause the brain changes.

OK, I want to stick on the biology for just a second, because the text mentions serotonin and tryptophan in a way that I think is really, really important for nursing students to understand, especially regarding medication later on.

Oh, this is a massive concept.

It perfectly explains why some meds just do not work early on in treatment.

Right.

So explain the tryptophan connection for us.

OK, so let's look at the basic chemistry.

Serotonin is the neurotransmitter that regulates mood, right?

It keeps us calm, happy,

emotionally regulated.

Right.

And we usually give SSRIs like Prozac to help boost that.

Exactly.

But here is the catch.

Your body cannot make serotonin out of thin air.

It needs a precursor.

It needs a raw material to build the serotonin molecules.

That raw material is an essential amino acid called tryptophan.

And where exactly do we get tryptophan?

Our diet.

It is only found in food.

Essential amino acids only come from what we consume.

I see exactly where this is going.

If a patient with anorexia is starving, they are not taking in any tryptophan.

If they have no tryptophan, their body physically cannot manufacture serotonin.

So their tank is completely empty.

The tank is dry.

Now think about how an SSRI actually works.

It stands for selective serotonin reuptake inhibitor.

It stops the brain from reabsorbing the serotonin that is already floating around, making it hang around longer in the synapse.

But if there's no serotonin there to begin with, then there's absolutely nothing to reuptake.

It's like trying to build a dam on a river that has completely dried up.

You can build the biggest dam in the world.

You can give them the highest dose of Prozac, but no water is going to pool up behind it.

That is a huge aha moment.

So for the nursing students listening,

you can't just throw pills at a starving brain and expect them to work.

Yeah.

You have to feed the brain first.

Precisely.

Nutrition is always the first line intervention, because without it, the psychopharmacology is completely useless.

OK, that clears up the biological side perfectly.

Let's look at the environment now.

Family dynamics.

The text makes a point to distinguish between the typical anorexia family and the typical bulimia family.

Oh, interesting.

What's the general profile of an anorexia family?

They often have severe boundary problems.

The clinical term used in the text is enmeshment.

Enmeshment.

That is such a classic psych nursing word.

Break that down for us in plain English.

Imagine a family where the bedroom doors are never closed.

Everyone knows everyone else's business.

The parents emotional state entirely dictates the child's emotional state.

There is no clear line between me and you.

So the child really struggles to separate and become their own person.

Exactly.

They struggle to individuate.

They can't find their own distinct identity, so they subconsciously decide to control the one single thing they actually can control their own body and what goes into it.

Whereas families of patients with bulimia are often described in the text as chaotic, less rigid control, more conflict, more overall instability in the home environment.

Got it.

And what about trauma?

A major, major risk factor.

Sexual abuse and physical neglect are strongly correlated with the development of all eating disorders.

One last thing on the etiology personality traits.

Are there specific traits that show up before the disorder actually starts?

Yes, there are.

Perfectionism, obsessive traits and a very high achievement orientation.

These often precede the illness by years.

It's that stereotypical, straight A, highly driven student profile we often see.

OK, let's shift gears.

We've got the solid background.

Now let's dive into the first specific disorder.

Enter exe enter vosa.

This is section two assessment.

Right.

So to officially diagnose a and we need to see three core criteria.

Number one, restriction of energy intake leading to a significantly low body weight.

Basically clinical starvation.

OK, that's the obvious one.

Number two, an intense, overwhelming fear of gaining weight or becoming fat.

And this fear persists even when they are dangerously underway.

And the third criterion, a disturbance in self -evaluation or body perception.

They literally do not see in the mirror what we see.

Now, the text mentioned subtypes of anorexia.

It's not just one monolithic thing.

Correct.

There is the restricting type.

This is what the general public typically imagines.

Strict dieting, fasting, excessive exercise, but crucially, no binging or purging behaviors.

And the other subtype.

The binge eating purging type.

These patients primarily restrict their intake, but they also have episodes of binging or purging, which means using vomiting, laxatives or diuretics.

Wait, how is that different from bulimia then?

If they are binging and purging weight, that is the absolute key differentiator for your exams.

If the patient is significantly underweight, the diagnosis is anorexia, even if they regularly purge bulimia, patients are typically normal weight.

Got it.

OK, for the students listening, there is a screening tool mentioned in the chapter that seems absolutely perfect for exam questions.

The S .C .O .F.

questionnaire.

Yes, the S .C .O .F.

tool, S .C .O .F.

It's a quick verbal screen.

If a patient answers yes to two or more of these five questions, it indicates a higher risk for an eating disorder.

Let's actually role play this a bit so it sticks in the listener's minds.

I'll ask you the question.

OK, yeah, hit me.

Let's do it.

S.

Do you make yourself sick because you feel uncomfortably full?

OK, S is for sick.

Got it.

C.

Do you worry you have lost control over how much you eat?

C for control.

OK.

Oh.

Have you recently lost more than one stone in a three month period?

Quick conversion for the Americans listening.

Right.

A stone is an old British measurement.

It equals exactly 14 pounds.

OK.

So O is one stone, meaning 14 pounds.

Do you believe you are fat even when others say you are too thin?

Fat.

That directly targets the body dysmorphia.

And the last F, does food dominate your life?

So that's sick,

control, one stone, fat, food.

S.

Q.

O.

F.

That's a really great mnemonic.

Memorize it.

I guarantee it will be on a psych test at some point.

Let's talk about the physical assessment now, because these patients are often physically crumbling when they finally come in.

What specific signs are we looking for?

Well, obviously, their weight.

The text uses BMI to grade the severity of the anorexia.

Mild is considered a BMI greater than 17.

Extreme is a BMI of less than 15.

Less than 15.

That is incredibly, incredibly fragile.

It is.

And the body reacts to the severe starvation in very specific, visible ways.

You'll see dermatological signs.

Lenugo is a really big one.

Lenugo.

I always think of newborn babies or preemies when I hear that word.

That's exactly what it is.

It's that fine downy fur you see on a premature infant.

Why in the world does a teenager or adult grow baby fur?

Think about the physics of starvation in a severely anorexic patient.

The body has lost all of its fat insulation.

It is literally freezing to death on a daily basis.

So the body reverts to a primitive biological defense mechanism.

It grows a fine fur coat to try and trap whatever body heat is left.

It's a tragic sign that the body is regressing just to survive.

That is so sad, but it makes it very easy to remember for a clinical assessment.

What else are we looking for?

Carotidinemia.

This presents as a yellowish pallor of the skin, often very noticeable in the palms of the hands.

Is that liver failure like jaundice?

No, and that's an incredibly important distinction for an assessment.

It's not liver failure.

It happens because their overall metabolism is so severely slowed down that they can't process carotene, which is vitamin A, from vegetables properly.

So it just deposits in the skin layers.

The key is that their eyes, the sclera, stay white.

In true jaundice, the eyes turn yellow, too.

That's a great tip.

And what about acrocyanosis?

Blue hands and feet.

The heart muscle is simply too weak from starvation to pump blood all the way out to the extreme periphery, the fingertips and toes.

So it keeps the blood shunted in the core to keep the vital organs alive.

Speaking of the heart, that brings us to the most dangerous medical complications of this disease.

Bradycardia, a dangerously slow resting heart rate,

hypotension or low blood pressure,

and a prolonged QT interval on their ECG.

What does a prolonged QT interval actually mean for the patient practically?

It means the electrical reset phase of the heart rhythm is delayed.

It puts them at an extremely high risk for sudden cardiac arrest.

They could just drop dead from a fatal arrhythmia at any moment.

OK, there's a vignette in the text about a patient named Tina.

I think this story really perfectly captures the profound cognitive distortion we're talking about.

I want to actually read her dialogue because it's chilling.

Yeah, set the scene for us first.

So Tina is 16 years old.

She is chachectic, severely muscle wasted.

She's currently at 60 percent of her ideal body weight.

She is actively in the ICU because her heart rhythm is unstable.

She is in an absolute physiological crisis.

She is dying.

Right.

And as the critical care nurse is putting in the IV to literally save her life, Tina starts crying.

And she looks at the nurse and says,

there's not going to be sugar in the IV, is there?

Just stop right there.

Let that sink in for a moment.

It's I mean, it's completely irrational.

It's tragic.

Her heart is failing.

She is on the absolute precipice of death and her primary terror isn't dying.

It's the caloric content of the life saving five fluid.

That illustrates the depth of the illness way better than any textbook definition could.

It's clearly not a lifestyle choice.

It's a profound delusion.

Exactly.

And the text makes a crucial distinction here about the concept of hunger itself.

Do these patients feel hunger?

I think most people assume they just don't feel it anymore.

That is the most common misconception.

Unlike the general medical symptom of anorexia, where a cancer patient, for example, truly loses their appetite and anorexia nervosa, psychiatric disorder, the patient does feel hunger.

They are starving.

They feel the hunger pangs.

They are just fighting a brutal war against their own biology every single minute to ignore it.

OK, let's move to section three, the nursing process for anorexia.

We've assessed Tina.

Now, what do we actually do?

First step, diagnosis.

The primary physiological nursing diagnosis is usually impaired nutritional status, but psychologically, we are looking at disturbed body image and, very importantly, risk for self -mutilation or suicide.

And outcomes.

What are the specific goals we are shooting for in the care plan?

They must be measurable goals.

We want them to consistently eat 75 percent of their provided meals.

We want them to slowly achieve 85 to 90 percent of their ideal body weight and obviously refrain from any self -harm behaviors.

Now, regarding hospitalization, not everyone with an eating disorder gets admitted to the medical floor or psych ward.

What are the strict criteria?

This feels like a major exam corner moment.

This is absolutely a must know box.

It's box 14 .3 in the text.

If you get a test question that lists a patient's vitals and asks, who do you admit immediately?

Look for these specific numbers with the numbers.

Rapid weight loss greater than 30 percent over six months.

OK, 30 percent in six months.

A resting heart rate of less than 40 beats per minute.

Less than 40.

That's incredibly slow.

It is.

If you see H .R.

less than 40, that is an automatic, non -negotiable admission, a systolic blood pressure less than 70 millimeters of mercury,

a core body temperature less than 36 degrees Celsius, which is 96 .8 Fahrenheit.

Yeah.

Or severe electrolyte imbalances like a potassium level less than three.

OK, so once they meet those criteria and they're in the hospital, obviously we have to feed them.

But the text warns about a critical,

potentially fatal danger here.

Refeeding syndrome.

The text defines it briefly.

But I feel like we really need to understand the mechanism.

Why can't we just give a starving person a turkey sandwich and a glass of milk?

We need to pause and focus on a refeeding syndrome because this is what accidentally kills patients in the first week of well -meaning treatment.

It's not just a stomachache from eating too fast.

It's complete cellular chaos.

Walk us through the exact mechanism.

I'm a student.

I need to know the path of physiology.

OK.

When you are starving for a long time, your body switches to breaking down its own fat and muscle for energy.

That's called a catabolic state.

You're running on absolute fumes because you aren't eating.

Your insulin levels drop to almost nonexistent because there's no sugar coming into process.

Right.

So the pancreas basically sleep.

Exactly.

Now, suddenly they are admitted and you introduce carbohydrates.

You give them that sandwich.

Boom.

The pancreas wakes up and insulin spikes massively to handle this sudden influx of sugar.

Now, remember, insulin is a storage hormone.

It acts like a key.

It tells all the cells in the body, open up, taking glucose, taking all the electrolytes.

So the cells just selfishly grab everything.

They greedily grab everything right out of the bloodstream.

They grab the glucose, they grab potassium, magnesium, and most critically for this syndrome, phosphorus.

They pull it all out of the blood serum and hoard it inside the cells to start rebuilding tissue.

So the levels in the blood just completely crash.

The serum levels crash instantly.

And you get severe, sudden hypophosphatemia.

And why is low blood phosphorus such a disaster?

Because phosphorus is the P in ATP adenosine triphosphate.

It's the fundamental energy currency of every cell in your body.

Without it, your diaphragm muscle fails, meaning you can't breathe.

Your heart muscle fails.

You literally run out of cellular battery power and die.

Wow.

That is terrifying.

So the nursing treatment is made extremely slow, refeeding.

You start the clerk and take very low and go very slow while checking blood labs constantly, sometimes every few hours to preemptively replace those electrolytes before they crash.

OK, let's talk about implementation on the floor.

The text has a table of nursing interventions.

And honestly, some of these seem kind of strict.

They have to be.

Let's talk about the weighing protocol as an example.

It is highly specific and rigid to prevent manipulation.

Manipulation.

Yeah.

Like lying about their weight.

These patients are desperate, absolutely desperate to hide their weight loss so they don't get forced to eat more or stay in the hospital longer.

They will drink liters and liters of water right before weighing in to look heavier.

They call it water loading.

They will even hide heavy objects or weights in their pockets or underwear.

So what's the strict protocol to prevent that?

You weigh the patient at the exact same time every single day, usually early morning before breakfast.

They must be weighed after voiding, so after they pee.

And they must be wearing only a bra and panties or a standard empty hospital gown.

And the text notes an interesting psychological tactic.

Some protocols even have the patient turn their back to the scale.

Right.

To reduce their severe anxiety.

They don't need to see the daily number fluctuate.

The medical team needs to see the number.

Staring at it just fuels the obsession.

What about mealtime?

That must be a battleground.

It's definitely not a solitary activity.

Strict supervision is required.

You observe them directly during eating to prevent them from hiding food.

You know, subtly spitting it into napkins, smearing it flat on the plate to look like they ate it or dropping it in their lap.

But importantly, you also observe them after eating.

Why after?

For one to three hours post meal to prevent purging.

If they go to the bathroom immediately after finishing a meal, they might induce vomiting.

So you either restrict bathroom access entirely during that window or a nurse must supervise them in the bathroom.

This brings us to the second case study in the chapter about a girl named Stacey.

This is a really detailed interaction between a student nurse and Stacey.

I want to analyze this conversation because it really shows how to properly talk to these patients.

Set Stacey up for us.

Stacey is 15.

She's a straight A student, highly involved in activities, but she weighs 90 pounds.

Right.

And she says this incredible line during the interview.

I feel like a piece of taffy being pushed and pulled and stretched by everyone else.

What a vivid image, taffy.

It implies she feels she has no spine, no solidity of her own.

She's just being molded and stretched by others.

The student nurse in the vignette smartly picks up on this theme of control.

Stacey talks about her family.

Her mom is a prominent doctor.

Her dad is a university professor.

She says, you can't stay in that family unless you're at the absolute top of your game.

The pressure sounds immense, immense pressure to be perfect.

So how does the nurse respond?

She doesn't just say, oh, that sounds really hard.

No, she uses a specific communication technique called indirect questions.

She asked Stacey, I wonder if a person can stay in the family, yet still feel and do things a little differently.

That's really good.

It's gentle, not confrontational.

Exactly.

It helps the patient begin to separate her own identity from her family's overwhelming expectations.

That's the core developmental work of normal adolescence individuation.

Stacey is using severe anorexia to exert control because she feels she has zero control anywhere else in her life.

The nurse is gently planting a seed.

Maybe you can be your own eponymous person and still be accepted in this family.

Let's talk meds for a second.

Pharmacology for anorexia.

We already touched on this with the tryptophan dam analogy, but let's formalize the textbook recommendations.

Surprisingly, there are very limited options.

SSRIs, specifically fluoxetine or Prozac, are often used.

But as we discussed at length, they have very limited value during the acute starvation phase.

Right, because of the serotonin precursor issue.

No tryptophan, no serotonin.

Right.

They are much more helpful for maintenance later on to treat the underlying OCD traits or depression once the patient's weight is physically restored and the brain has the building blocks again.

What about antipsychotics?

I saw one listed.

Alanzapine is mentioned in the text.

It's a second generation antipsychotic.

It helps with weight gain, which is normally an unwanted side effect of the drug, but useful here.

And it also significantly helps reduce the obsessive thinking and severe agitation around meals.

And for chronic long term cases of anorexia.

The text mentions a harm reduction approach.

For some patients who have had this for decades, a complete cure isn't possible.

So the clinical goal shifts to quality of life and basic medical stability rather than aggressively forcing them to a normal weight.

It's about keeping them alive and out of the hospital, minimizing the physical damage.

All right.

My brain is completely full of electrolytes, dopamine and communication strategies.

I need a second breath.

It's a lot of material.

OK.

We've thoroughly covered the starvation side anorexia.

Now we have to flip the coin.

We need to talk about bulimia.

And honestly, I always get the physical assessment signs mixed up between the two disorders.

You and half the medical students, I know.

It's the most common exam trap on psych tests.

Let's untangle it clearly.

Let's do it.

Section four, bulimia nervosa.

OK.

So while anorexia is primarily defined by severe restriction and low weight, bulimia is defined by a distinct cycle.

The binge and the purge cycle.

Exactly.

A binge is consuming an unusually large amount of food in a discrete short period of time, usually defined as less than two hours accompanied by a profound feeling of loss of control.

They feel they cannot stop.

And then comes the compensatory behavior.

Right.

Purging via self -induced vomiting, abusing laxatives, diuretics, or even using excessive punishing exercise to burn off the binge.

To meet the clinical diagnosis, this cycle requires this to happen at least once a week for three months.

Now, here's the really tricky part for nursing assessment.

What do these patients actually look like when they walk in?

That's the deceptive thing.

They often look completely normal to the untrained eye.

They're usually at a normal weight or even slightly overweight.

You usually can't spot a patient with bulimia from across the waiting room as easily as you can spot severe anorexia.

So you have to look really closely for the physical signs of chronic purging.

The text lists three big ones.

Let's hit those.

First, parotid gland enlargement.

Is that what they call chipmunk cheeks?

Yes.

The parotid salivary glands are located right here in the cheeks, just in front of the ears.

They get chronically hyper stimulated from the constant vomiting in the stomach acid and they swell up permanently.

It makes the patient's face look unusually wide or swollen at the jawline.

Second sign, rustle sign.

That's found on the hands.

Yeah.

Describe that for the listeners.

What are we looking for?

It presents as calluses, abrasions or scars on the knuckles or the back of the hand.

It comes from the patient repeatedly sticking their own fingers down their throat to induce vomiting.

The upper front teeth repeatedly scrape against the knuckles over months or years, causing scarring.

Ouch.

That is a very, very specific sign.

If you see scarred knuckles on a young woman who isn't a boxer, think bulimia.

Exactly.

It's a dead giveaway.

And the third major sign is severe dental erosion.

Because of the stomach acid.

Stomach acid is incredibly corrosive.

It literally eats away the enamel of the teeth, especially on the lingual side, the back of the front upper teeth.

Severe cavities, chipping and erosion are massive red flags for dentists who are often the first to catch the disorder.

Medically, what are the internal risks?

We talked about heart failure with anorexia.

It's somewhat similar to anorexia regarding the dangerous electrolytes.

Hypokalemia, which is dangerously low potassium and hypokalemia, low chloride, primarily from losing massive amounts of stomach acid through vomiting.

But there are also specific violent physical risks like esophageal tears from the force of retching.

And the text mentioned gastric rupture.

Yes.

The stomach organ can literally burst open from the sheer volume of the binge.

It's rare, but it is catastrophic and usually fatal.

Let's look at the vignette here is titled The Athlete, a college volleyball player.

Her story really highlights the profound shame of the disorder.

She talks about social eating, you know, confidently ordering burgers and fries with her teammates to look perfectly normal and then secretly sneaking away to purge immediately after.

She specifically mentions noticing broken blood vessels in her eyes.

Patekki.

It happens from the immense physical pressure of force vomiting.

The pressure causes the tiny capillaries in the sclera of the eyes to burst.

The key psychological theme here seems to be secrecy.

Anorexia is often worn by the patient almost as a badge of honor or a display of ultimate control.

Bulimia seems completely different emotionally.

It is.

Bulimia is overwhelmingly ego dystonic.

That's a psych term, meaning the patient's behavior conflicts with their ideal self image.

They hate what they're doing.

They feel immense shame.

They feel completely out of control and they desperately want to stop.

But the compulsion is too strong.

That brings us to section five, the nursing process for bulimia.

Does that internal shame make it easier or harder to treat them?

In terms of building a basic therapeutic alliance, it can actually be slightly easier.

The patient usually recognizes there is a problem and wants help.

They aren't fiercely clinging to the disorder as their entire identity in the exact same way a chronically anorexic patient might.

So the diagnosis focuses on decreased cardiac output due to the electrolytes, disturbed body image and powerlessness.

What are we doing for implementation?

Again, priority one is the physical interruption of the cycle.

Observation during and strictly after meals is critical on the unit.

You have to physically break the habit of purging before you can do the deep psych work.

And speaking of the psych work, the text has a fantastic box on cognitive distortions.

Box 14 .4.

These are the mental thought traps these patients fall into.

Yes, cognitive behavioral therapy focuses heavily on these.

Let's run through a few of the big ones.

First one, all or nothing thinking.

That is the absolute classic bulimia trait.

The thought process is I ate one single cookie.

I completely broke my strict diet.

I am a failure, so I might as well eat the entire box of cookies and then throw up to reset.

There is zero middle ground.

It's perfection or complete failure.

Next one, catastrophizing.

If I gain even two pounds, my entire life is over.

No one will ever love me or hire me.

Blowing things entirely out of proportion and emotional reasoning.

I feel fat and disgusting today.

Therefore, I literally am fat and disgusting.

They mistake a temporary emotion for objective reality.

Helping them identify these specific distortions in real time is a huge part of the psychiatric nurse's role.

You have to catch them in the act of thinking this way and challenge the logic.

What about medications for bulimia?

Is the approach different from anorexia?

Yes, it is.

Phylloxetine Prozac is actually formally FDA approved specifically for the treatment of bulimia.

Oh, really?

I didn't realize it had that specific indication.

Yes, and typically is prescribed at much higher doses than you would use for standard depression.

It has been shown to chemically decrease the frequency of the binge and purge episodes.

And the other one mentioned to pyramid.

That's primarily a mood stabilizer and anticonvulsant.

But off label, it helps significantly suppress the intense neurological urge to binge.

OK, moving on to the third and final big category, Section six, binge eating disorder or BED.

So BED is characterized by recurrent binging, just exactly like in bulimia.

But crucially, without the compensatory behavior,

no vomiting, no laxatives, no excessive exercise.

So logically, if you take in all those calories and don't purge, this disorder often leads directly to obesity.

It does.

But the text makes a very, very important distinction that nurses need to understand.

Most obese people in the general population do not have binge eating disorder.

That's really important to highlight.

BED is a specific diagnosable psychiatric condition characterized by severe mental distress, guilt and shame regarding the eating episodes.

It's not just a habit of overeating.

It's a true neurological compulsion used to soothe emotional pain.

How do we treat it clinically?

Psychotherapy is the absolute gold standard, CBT or cognitive behavioral therapy.

But there are pharmacological options.

Lisdexamphetamine, which goes by the brand name Vyvanse.

Wait, isn't Vyvanse an ADHD drug?

It is.

It's a central nervous system stimulant.

But it is actually FBA approved for moderate to severe BED.

Why a stimulant?

What's the mechanism there?

Remember our talk about dopamine.

It helps control the impulsive behavior.

It stimulates the dopamine reward pathways in the brain that we talked about earlier, providing that chemical satisfaction so the patient doesn't feel the overwhelming need to use massive amounts of food to get that same dopamine signal.

And there was a newer drug mentioned in the chapter, Dessotrolene.

Yes, it's a dopamine and norepinephrine reuptake inhibitor.

It shows a lot of promise in clinical trials for suppressing the binge urges.

Now, because BED often results in severe obesity, these patients very frequently seek out bariatric surgery, stomach stapling, gastric bypass.

The text has an evidence -based practice scenario about this exact situation that I found really intense and eye -opening.

This is a crucial lesson for med -surg nurses, not just psych nurses.

The scenario is a 47 -year -old man immediately post -op from a bariatric surgery.

The nurse brings him his scheduled meal, which is 15 middle eels of clear liquid.

Which is standard post -op protocol.

15 -milliliter eels is basically a sip.

You literally cannot fit more than that in the surgically altered stomach without bursting the staples.

Standard protocol.

And the patient completely flips out.

He becomes highly aggressive.

He demands real food.

He yells, get me some food right now.

What's going on in his head there?

Is he just physically starving?

No.

He was a severe binge eater before the surgery.

The surgery successfully fixed his stomach size.

It fixed the physical plumbing, but it did absolutely nothing to fix his brain.

He clearly didn't have the proper psychiatric preparation before going under the knife.

He is experiencing extreme agonizing emotional distress because his primary coping mechanism for life stress binging is suddenly physically impossible for him to do.

That is such a powerful reminder that surgery isn't just a magical quick fix for what is ultimately a psychiatric condition.

Exactly.

Treatment must be interdisciplinary.

You need the psych support firmly in place alongside the surgical intervention.

Otherwise you end up with what we call addiction transfer, where they might turn to alcohol instead, or just severe unmanageable psych distress on the surgical floor.

We are coming into the homestretch here.

Section seven, self -care for nurses.

I love that this chapter actually dedicates real space to the psychiatric nurse's own mental state and burnout.

It absolutely has to.

Treating eating disorders day in and day out is profoundly exhausting work.

Okay, I have to play devil's advocate here for a second.

I know we talked extensively about the biology, the dopamine, the genetics, but let's be real for a second.

Go ahead.

If I'm a tired nurse on a busy psych floor and I have a patient actively pulling out their seating tube or maliciously hiding pads of butter under their mattress so they don't have to eat them, doesn't it feel like a choice at some point?

Isn't there a very human part of us that just wants to shake them and say, just eat the damn sandwich?

Of course there is.

That is a completely natural human reaction to have.

It feels like stubbornness.

It feels like pure vanity.

You look at them and think, why are you actively doing this to yourself?

Exactly.

It's incredibly frustrating to watch someone destroy themselves.

But this is exactly where you have to take a breath and go back to the concept of anasognosia, the severe delusion.

When that anorexic patient looks at the turkey sandwich on the tray, they do not see food.

They genuinely see a lethal threat.

When they pull out the NG tube, they aren't just trying to annoy you.

They are desperately trying to silence a screaming biological alarm in their head that is telling them they are in mortal danger.

So if we treat it simply as a bad lifestyle choice, we lose the patient.

We lose immediately.

We become the enemy holding the weapon.

And that leads to a dangerous nursing trap called authoritarianism.

Being the food police.

Right.

Dictating to them, you have to eat this right now or else it becomes a massive power struggle.

And let me tell you from experience, you will lose that struggle every single time.

You absolutely cannot force control their internal desire to eat.

You can only control the external safety of the environment.

And dealing with the frustration of constant relapse.

Anorexia is a chronic relapsing disease.

Relapse is the rule, not the exception.

Nurses need clinical supervision, peer debriefing, and to constantly remind themselves of the neurobiology we discussed.

This is a severe brain illness, not a behavioral tantrum.

So let's officially wrap this up, the outro.

Let's summarize the key takeaways.

Let's recap the big three from Chapter 14 one last time for the notes.

Number one, anorexia nervosa.

Characterized by severe restrictions, significantly low body weight, and an intense fear of weight gain.

The primary acute medical danger is cardiac failure.

Always watch for a heart rate less than 40.

Number two, bulimia nervosa.

Defined by the binge and purge cycle.

The patient is usually at a normal weight.

The primary medical danger is severe electrolyte imbalance and esophageal damage.

Look for Russell's sign on the knuckles and dental erosion.

And number three, binge eating disorder.

Binging without any purging.

Accompanied by severe emotional distress and shame.

The primary long -term danger is obesity related medical complications.

And summarizing the psychiatric nurse's role in all of this.

The text beautifully describes the nurse as a companion in recovery.

It's not just about counting the calories on the tray.

It's about patiently helping a terrified person rebuild an entire sense of self that isn't solely attached to a fluctuating number on a bathroom scale.

I want to leave the listeners with a final provocative thought.

Something the text subtly loops to at the end.

We live in a society that universally praises and rewards thinness.

It's a paradox.

It raises a really difficult question.

How do these patients truly heal when the outside world constantly reinforces their psychiatric symptoms?

Right.

When a patient initially loses 20 pounds through starvation, society usually says, wow, you look great.

What's your secret?

But the psych nurse knows that their secret is a highly lethal psychiatric illness.

It's an incredibly complex cultural environment for a patient to try and navigate recovery in.

It really is.

Well, all the nursing students out there currently cramming chapter 14 for this psych exam.

Take a deep breath.

You've got this.

Remember the SQFF mnemonic.

Memorize those specific admissions safety criteria.

And above all, remember the clinical empathy required for these patients.

Good luck on your exams, everyone.

Thanks for listening to this last minute lecture on the deep dive.

We'll see you next time.