NRNP 6635 Week 6 Eating, Sleeping, and Elimination Disorders

The process of assessment and diagnosis is complex. At the initial meeting, clients may want to vent about multiple areas in their lives, and they may not necessarily understand the assessment process or what kind of information the advanced practice nurse needs to elicit to diagnose. PMHNPs must strike a balance between keeping the assessment focused and structuring it in such a way that clients are encouraged to paint a complete picture of their chief complaint and history of present illness. If a client says that he or she is having a hard time dealing with family, difficulty in relationships, not eating regularly, or not sleeping, counselors must know how to listen and ask questions that can pull more information needed for an accurate diagnosis.

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You are now at the halfway point of the course and have explored the assessment and diagnosis of many categories of disorder from the DSM-5. This week, you put your knowledge of concepts related to psychopathology and diagnostic reasoning to the test by completing a midterm exam. Your Learning Resources this week focus on eating, sleeping, and elimination disorders. Although you will not complete a comprehensive client assessment on a patient with these disorders, be sure to review the resources on them because they are included on the midterm.

Learning Objective

Students will:

• Apply concepts related to psychopathology and diagnostic reasoning in advanced practice nursing care in psychiatric and mental health settings

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013h). Feeding and eating disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.dsm10

American Psychiatric Association. (2013). Elimination disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm11

American Psychiatric Association. (2013). Sleep-wake disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). https://doi-org.ezp.waldenulibrary.org/10.1176/appi.books.9780890425596.dsm12. NRNP 6635 Week 6 Eating, Sleeping, and Elimination Disorders

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

• Chapter 15 Feeding and Eating Disorders
• Chapter 16 Normal Sleep and Sleep-Wake Disorders
• Chapter 31.9 Feeding and Eating Disorders of Infancy or Early Childhood
• Chapter 31.10 Elimination Disorders

Required Media (click to expand/reduce)

Classroom Productions. (Producer). (2016). Eating disorders [Video]. Walden University.

TRANSCRIPT OF VIDEO FILE:

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BEGIN TRANSCRIPT:

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The information in this program is presented solely for educational purposes and should not be used for the assessment or treatment of any condition without the advice and supervision of licensed medical professionals. The situations presented in this program do not necessarily reflect actual situation you may encounter. Classroom Productions disclaims any liability and/or loss resulting from the information contained in this video. DSM-5® is a registered trademark of the American Psychiatric Association. The American Psychiatric Association has not participated in the preparation of this program. NRNP 6635 Week 6 Eating, Sleeping, and Elimination Disorders

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DIAGNOSING MENTAL DISORDERS

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DSM-5® AND ICD-10

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EATING DISORDERS

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SIOBHAN DOHERTY Food plays an important role in our society. It offers an opportunity to socialize with one’s community, brings pleasure through different smells and tastes, and most importantly provides nourishment. However, for individuals dealing with an eating disorder, the benefits of food can become overshadowed by fear, shame, or incapacitating malnourishment. Because both food and eating are such critical aspects of our culture and our survival, these disorders may lead to functional impairment in every facet of an individual’s life. In the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders or DSM-5, eating disorders are grouped due to their shared characteristics of disturbances in eating or behavior associated with eating, which causes significant physical or psychological distress. This disturbance can manifest itself in a number of disorders, but they have been organized in DSM-5 so that only one of the disorders maybe diagnosed at a given time. However, individuals may shift between different disorders. This program will first address the three most common eating disorders, anorexia nervosa, bulimia nervosa, and binge-eating disorder. Followed by three disorders that were categorized as childhood adolescent disorders in the previous version of DSM, DSM-4, namely Pica, avoidant-restrictive food intake disorder, and rumination disorder.

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DSM-5® AND ICD-10 CODING

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DSM-5®

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Eating Disorders

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SIOBHAN DOHERTY There are number of distinct eating disorders, each given its own diagnostic code.

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ICD

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World Health Organization’s

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International Classification of Diseases.

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SIOBHAN DOHERTY The diagnostic codes correspond to the codes used by the World Health Organization in the International Classification of Diseases or ICD. In DSM-5, each disorder is first linked to the coding system from ICD-9, with the codes for ICD-10 listed in parenthesis. Hence, all of the DSM codes cross walk to the ICD codes, including the newest generation, ICD-10. For example, Bulimia nervosa is a sign to the code 307.51 from ICD-9 and (F50.02) from ICD-10. This is because the ICD-9 system was still in use when DSM-5 was first released. ICD-10 was released in the fall of 2015 in the United States, although it was adopted previously in other countries. However, because ICD-10 is now the standard in the United States, this program will be listing the newer code from ICD-10 first followed by the (ICD-9 codes).

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Schizophrenia

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SIOBHAN DOHERTY Sometimes when relevant, we will also delineate the ICD-9 and 10 codes when we mentioned a disorder from a different grouping of mental disorders. For example, Schizophrenia mentioned later in this program is coded as F20.9 (295.90). Part of the F20 to F29 section of ICD-10 on Schizophrenia, Schizotypal, Delusional, and other non-mood psychotic disorders. Eating disorders are included in F50 to F59. ICD-10’s block on Behavioral Syndromes associated with physiological disturbances and physical factors, specifically, F50, or eating disorders. This section is organized quite differently from DSM-5 chapter on feeding and eating disorders. F50 does include anorexia nervosa and Bulimia Nervosa, as well as two broader headings. Other eating disorders and eating disorder unspecified. However, one of the main differences in ICD-10 is that is it does not include predominantly childhood-adolescent disorders in the section on eating disorders. For example Rumination Disorder is instead included in F90 to F98, part of the block on behavioral and emotional disorders with onset usually occurring in childhood adolescence. Similarly, while Pica in adults is included in the F50 section, Pica in children is included in F98, other behavioral and emotional disorders with onset usually occurring in childhood and adolescence. It is useful to notice the differences in organization because it points to the primarily adolescent nature of these disorders while the inclusion of these disorders in the feeding and eating disorders chapter of DSM-5 allows for the diagnoses of older patients who may suffer from disorders that typically affect children and adolescence. Binge-eating disorder now recognized as one of the most prevalent eating disorders, is not specifically recognized in ICD-10, but it’s rather included under the code for other eating disorders.

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ANOREXIA NERVOSA

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SIOBHAN DOHERTY One of the most widely recognized eating disorders, anorexia nervosa affects up to 1% of the population, predominantly women. Anorexia nervosa is characterized by a deep fear of gaining weight and additional fear that one is already overweight and consistent repeated behavior that leads to individuals being significantly underweight.

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ANOREXIA NERVOSA

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FUNDAMENTAL CHARACTERISTICS

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SIOBHAN DOHERTY For anorexia nervosa to be diagnosed, the patient’s body weight is purposefully and consistently below what is considered minimally normal. This is one of the main features that separates anorexia nervosa from other eating disorders. The individual also expresses a significant fear of weight gain or consistently acts and ways that inhibit weight gain, excessive dieting, exercise or misuse of laxatives or diuretics. This fear of being overweight may become increasing heighten even as an individuals weight diminishes to potentially fatal levels. Another fundamental characteristic of anorexia nervosa is that the patient incorrectly perceives the condition. This can mean feeling overweight when they are really not or down playing the seriousness of the disorder despite having an effect their everyday life.

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ANOREXIA NERVOSA

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SPECIFIERS

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SIOBHAN DOHERTY Viewer should note that the codes for anorexia nervosa are now specified by subtype depending on the individual’s behavior over the three months prior to diagnosis. The patient is diagnosed as restricting type if the last three months included extremely low food consumption and or excessive exercise but zero instances of binging or purging. Knowing that close nature, just you want to share clothes and stuff like that and she is some, she’s smaller than I am, her shoulders are smaller, her hips are smaller. And I, and I, and I can’t like share stuff with her. And so, so I’ve been trying to like I used to do whatever I can and be the same size as my sister. The patient is marked as a binge-eating purging type, if they have repeatedly engaged in purging, self induced vomiting, laxatives etc, or binge-eating over the previous three months. The results of the option of specifying the current severity which is separated into categories by current body mass index. The ranges used in DSM-5 were delineated by the World Health Organization for adults before levels of severity are mild, moderate, severe, and extreme. The severity level can be increased to reflect decreased functionality. The clinician may also specify that the disease is in partial remission if he or she is maintaining or at least within the minimum normal weight, but still either expresses their concern of weight gain or experiences incorrect perception of their weight and or shape. The clinician may specify that anorexia nervosa is in full remission if they have not met the diagnoses for a significant amount of time.

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ANOREXIA NERVOSA

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DIFFERENTIAL DIAGNOSIS

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SIOBHAN DOHERTY While the binge-eating purging type of anorexia nervosa shares some features of both bulimia nervosa and binge-eating disorder. Patients with anorexia nervosa will be remarkably underweight and rarely express the feeling of being out of control when it comes to their weight. Other causes of low weight must be taken into consideration before diagnosing anorexia nervosa, such as medical conditions like hyperthyroidism, gastrointestinal diseases and AIDS, as well major depressive disorder, Schizophrenia, and substance-use disorders.

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ANOREXIA NERVOSA

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OTHER FEATHRES

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SIOBHAN DOHERTY Individuals with anorexia nervosa may present with additional laboratory abnormalities such as abnormal vital signs, sinus bradycardia, mild anemia, low serum estrogen levels, hypercholesterolemia, amenorrhea, leukopenia, and low bone mineral density. Lanugo which is light fine hair that covers the body may also develop. Individuals may report excess energy, sensitivity to cold, lethargy or constipation. The individual will seek help due to distress rather than the weight loss itself.

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BULIMIA NERVOSA

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SIOBHAN DOHERTY Bulimia nervosa affects 1 to 2% of adolescent and young adult women, making it even more common than anorexia nervosa. Bulimia nervosa is generally characterized by binge-eating during which the individual feels out of control, followed by activities designed to counteract weight gain, such as use of laxatives or drugs, extreme exercise or most commonly self induced vomiting. This happens on an average of at least once a week for three months. Bulimia nervosa differs from anorexia nervosa and that patients with bulimia nervosa have a more accurate self perception of their body shape and weight and are usually maintaining around the minimum normal weight.

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BULIMIA NERVOSA

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FUNDAMENTAL CHARACTERISTICS

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SIOBHAN DOHERTY Bulimia nervosa is characterized by repeated episodes of binge-eating. These episodes are characterized by both eating more than most people would within a certain amount of time under similar circumstances. For example, eating contests are not qualifying episodes. And the feeling that one does not have control over themselves to stop eating once the binging episode has started. Self induced vomiting, use of laxatives or fasting may be used to curve weight gain from episodes of binge-eating. Individuals may also exercise excessively to the point that it interferes with important activities or happens at inappropriate times or settings. On average, over the last three months, patients will have engaged in binge-eating and purging at least weekly. Patients expressed heighten concerned over their current physical shape or weight. Additionally anorexia nervosa and bulimia are mutually exclusive, so the patient will not be diagnosed with both at the same time.

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BULIMIA NERVOSA

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SPECIFIERS

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SIOBHAN DOHERTY The clinician may specify the severity of diagnoses constricted from the occurrence of purging. Mild, indicates an average of 1 to 3 episodes per week, moderate 4 to 7 episodes, severe 8 to 13 episodes, and extreme indicates an average of 14 or more episodes per week. Specifiers of in partial remission and in full remission are also available.

00:12:35
BULIMIA NERVOSA

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OTHER CHARACTERISTICS

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SIOBHAN DOHERTY Those with bulimia nervosa usually keep their binge-eating secret due to embarrassment. Episodes of binge-eating may be triggered by stress, newly restrictive diet, and boredom, among these feeling down is the most common. Repeated purging by vomiting may lead to loss of tooth enamel as well as callus formation on fingers. Bulimia nervosa and its related behaviors may also lead to amenorrhea, fluid and electrolyte imbalances, and rectal prolapse as well as the possibility of life threatening symptoms like cardiac arrhythmias, tears in the esophagus, and gastric rupture.

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BINGE-EATING

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DISORDER

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SIOBHAN DOHERTY Binge-eating is something many of us have engaged in at one time or another, particularly around food-centric holidays such as Thanks Giving and Halloween. However, when binging becomes habitual or when it is used as a means of coping with stressful or emotional events, and particularly when it feels out of control, it may indicate that someone is suffering from binge-eating disorder. Binge-eating disorder is more common than the two more well known eating disorders, anorexia nervosa and bulimia nervosa. Binge-eating disorder was introduced in the appendix of DSM-4, but it’s now included in the main text of DSM-5.

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BINGE-EATING DISORDER

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FUNDAMENTAL CHARACTERISTICS

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SIOBHAN DOHERTY The main marker of binge-eating disorder is appropriately repeated episodes of binge-eating with the feeling of lack of control. Food is consumed in isolation due to shame. Food is consumed too quickly to the point of discomfort in huge amounts even if the individual is not hungry, afterwards the individual may feel guilty or depressed. The individual will also show signs of distress concerning their behavior. In terms of frequency, in order to diagnose, episodes of binge-eating take place in average of once weekly over the course of three months with severity depending on how many binge-eating episodes occur within a week. It can go from mild-to-moderate, severe and even extreme when it happens more than 14 times weekly. Individuals do not engage in behaviors such as vomiting or the use of laxatives with the intent to counteract episodes of binge-eating. It is vital to point out that binge-eating disorder is different from obesity even though they are associated likely because of the extra calories ingested during episodes. Some individuals with obesity may suffer from binge-eating disorder, but one does not exclusively signified the other.

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PICA

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SIOBHAN DOHERTY The main feature of Pica is the eating of substances that are not considered food over a period of atleast one month. These may include paper, dirt, chalk, clay, or hair as well as many others that are not considered the norm in the culture. Some ingested substances may point to specific mineral or other deficiencies that the patient is experiencing, but often the ingested substance posses little benefit to the patient. This eating behavior is also inappropriate for the intellectual and developmental level of the patient. Onset is more commonly reported in children, however, in adult it is more likely to appear when an additional factor such as an intellectual disability or a medical condition is also present. Pregnancy is also known as a condition that may trigger the onset of Pica. However, the ingestion must be severe enough to necessitate clinical attention which may be because of the quantity consumed or the potentially fatal nature of the substance being consumed.

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AVOIDANT-RESTRICTIVE FOOD INTAKE DISORDER

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SIOBHAN DOHERTY Those with this disorder may undereat because dislike certain food characteristics because they have a fear of choking or vomiting while eating or even because they simply lack interest in food. Unlike with some of the other eating disorders covered in this program, patients with avoidant-restrictive food intake disorder are not undereating because of the fear of being overweight or the self perception that they are already overweight. With avoidant-restrictive food intake disorder, these reasons for undereating lead to losing pounds or in children and adolescents failure to grow at a normal rate. Under-eating may also lead to nutritional deficiencies that are heighted to the point of needing nutritional supplements or dependent on gastronomy to feeding. In infants, this disorder may lead to nasogastric tube feeding. Avoidant-restrictive food intake disorder is also indicated when the eating disturbance interferes with normal psychosocial behaviors. Clinicians must make sure that the individual is not currently engaged in a normal cultural practice that includes undereating, such as religious fasting or dieting. It is highly unlikely that an adult would be diagnosed with avoidant and restrictive food intake disorder but it is not on unheard of. Clinicians are advised to rule out unavailability of food as well as other medical conditions that may cause vomiting or loss of appetite which may lead to undereating.

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RUMINATION DISORDER

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SIOBHAN DOHERTY Rumination disorder involves at minimum a month long period of recurring episodes of regurgitated good. The regurgitated food is re-chewed and then often re-swallowed. The behavior does not occur only during episodes of another eating disorder and it’s not more clearly tied to another medical condition. The instances of regurgitation must be disruptive enough to demand further clinical attention if another mental disorder or medical condition is present. In infants, rumination disorder will most likely present with straining and arching the back and holding back the head while the mouth make sucking movements. At such a young age, rumination disorder can be difficult to detect and is potentially fatal due to malnutrition if most of the regurgitated food is spit out.

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OTHER EATING DISORDER

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SIOBHAN DOHERTY This category of disorders prefers to those that inhibit the social or professional lives of patients to a significant degree, but due so without meeting all of the specifications for one of the previously described disorders. This diagnosis is used if the clinician wants to specify why the disorder does not meet the requirements for one of the other eating disorders. Identifying the patient’s disorder is the first step in the treatment process to help the patient recognize and perhaps improve their relationship with eating and food, because of this understanding the distinctions between the different eating disorders is vital in beginning the course of treatment, helping patients to lead healthier more balanced lives.

00:20:05
Produced by

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Classroom Productions, INC.

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Technical Advisors

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Dr. Tracie Collins, MD, MPH

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Dr. Matthew Macaluso, DO

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Mary Llenell Paz, MS

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Directed by

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Sean Harrigan

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Written by

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Sean Harrigan

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Siobhan Doherty

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Script Editor

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Pandora Suderman

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Production Coordinator

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Siobhan Doherty

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Field Production

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Amanda Buffington

00:20:05
Hannah Huff

00:20:05
Merlin Huff

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Featured Cast

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Anatasha Blakely

00:20:05
Ross Crain

00:20:05
Siobhan Doherty

00:20:05
Brett Duggan

00:20:05
Abbey Grace

00:20:05
Zach Hallett

00:20:05
Jim Harrigan

00:20:05
Sean Harrigan

00:20:05
Kristen Henley

00:20:05
Hannah Huff

00:20:05
Marlin Huff

00:20:05
Dennis Hurley

00:20:05
Jason Ko

00:20:05
Matt Koening

00:20:05
Amy Landon

00:20:05
Maribel Martinez

00:20:05
Marissa Moosekian

00:20:05
Bree Murphy

00:20:05
Alan Ramos

00:20:05
Diana Sanchez-Vega

00:20:05
David Santana

00:20:05
Jennifer Shaevitz

00:20:05
Bette Smith

00:20:05
Eddie Smith

00:20:05
Lindsay Smith

00:20:05
Miller Tai

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Narration

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Siobhan Doherty

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Post-Production

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Sean Harrigan

00:20:05
Robert Suderman

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Property of

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Classroom Productions, Inc.

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Copyright 2016

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All Rights Reserved

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END TRANSCRIPT

NRNP 6635 Week 6 Eating, Sleeping, and Elimination Disorders Classroom Productions. (Producer). (2013). The new DSM-5 diagnosis: Understanding & treating binge eating disorder [Video]. Walden University.

Classroom Productions. (Producer). (2016). Elimination disorders [Video]. Walden University.

Classroom Productions. (Producer). (2016). Sleep disorders [Video]. Walden University.

MedEasy. (2017b). Eating disorders (anorexia, bulimia, and binge-eating disorder) | USMLE & COMLEX [Video]. YouTube. https://www.youtube.com/watch?v=bD8KCcipGaY

Midterm Exam

Prior to starting the exam, you should review all of your materials. There is a 2.5-hour time limit to complete this 100-question exam. You may only attempt this exam once.

This exam is a test of your knowledge in preparation for your certification exam. No outside resources—including books, notes, websites, or any other type of resource—are to be used to complete this exam. You are expected to comply with Walden University’s Code of Conduct.

By Day 7 of Week 6

Complete your exam.

Submission and Grading Information

Grading Criteria

To access your Exam:

Week 6 Midterm Exam

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