INTRODUCTION



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BENGALURU, KARNATAKA.

PROFORMA FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

|1. |NAME AND ADDRESS OF THE CANDIDATE | |Ms. PRAVEENA P.S. |

| | | |I YEAR M.Sc. NURSING, |

| | | |DAYANANDA SAGAR COLLEGE OF NURSING, KUMARASWAMY LAYOUT, BENGALURU -560078. |

| | | | |

|2. |NAME AND ADDRESS OF THE COLLEGE | |DAYANANDA SAGAR COLLEGE OF NURSING, KUMARASWAMY LAYOUT, BENGALURU -560078. |

|3. |COURSE OF STUDY AND SUBJECT | |IST YEAR M.SC. NURSING, |

| | | |MENTAL HEALTH NURSING. |

|4 |DATE OF ADMISSION | |06/06/2011 |

|5 |TITLE OF THE STUDY |

| |“EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING ANOREXIA NERVOSA AND ITS MANAGEMENT AMONG ADOLESCENT |

| |GIRLS IN SELECTED PRE-UNIVERSITY COLLEGE, BENGALURU”. |

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“Alone I am in a cage of thorns and dead roses

A few of the needle are poisoned

And in the risk of encountering one going to stop you?

It is okay, I will understand

Besides I am hungry for nothing but starving for all”.

In contemporary society, females want to be thin. The elite classes and the so called jet-setting citizens on the world both propagate and give in to the madness to be thin. Consequently, society also develops an interest in being thin which has reached an unhealthy height. Women are more of a slave to aesthetic and pressure of society than men are. Fueled by the boom of television and mass media, 1960’s marked an introduction of the infamous Barbie doll by Mattel and waif-thin model twiggy. Thus ideals of women’s bodies have attained a new concept of being thin. Concurrently, the thin feminine body became a commodity in mainstream industry. 1

As the mass media have come to rule of world with both full of super slim models, young girls end up in idolizing them. Adolescence is a period stuffed with lots of psychological problems. Youth health survey’s shows that psychological problems are more common in girls compared to boys. Higher number of girls are affected with common psychological problems like anxiety, sleeping disorder, depression, tension and eating disorders. Studies shown that among them most common psychological disorder among adolescent is anorexia nervosa. Many girls who strive to lose weight state “I wish I were anorexic”. They fail to recognize the wretchedness of the disease called Anorexia nervosa. 2

The term is of Greek origin: an (negation) and orexis (appetite), thus meaning a lack of desire to eat. Anorexia nervosa is a disorder characterized by extreme concern with body weight, an intense fear of becoming fat, and maintenance of body weight below expected levels for height and age. Individuals with anorexia nervosa typically express an in tense fear of gaining weight, tend to be preoccupied with thoughts of food, and worry irrationally about fatness. There are mainly two types of anorexia nervosa. One is restricting type and other one is binge-eating/purging type. In restricting type, during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior .In binge-eating/purping type, during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purping behavior.3

The history of anorexia nervosa begins with descriptions of religious fasting dating from the Hellenistic era and continuing in to the medieval period. By the thirteenth Century, it was increasingly common for women to participate in religious life and to even be named as saints by the Catholic Church. However it was not until the late 19th century that anorexia nervosa was to be accepted by the medical profession as recognized condition. In 1873,sir William Gull, one of queen Victoria’s physician and French physician Ernest-Charles Lesegue described series of cases of young women with impressive weight loss and psychological disturbances. Awareness of this condition is largely limited to medical profession until the latter part of the 20th century, when the German American psychoanalyst Hilde Bruch published her popular work “the golden cage: the enigma of anorexia nervosa” in 1978.3

The disease is threatening, primarily due to two reasons. First of all it affects the young generation. The second one is a little more complex. It’s a mental, as opposed to a physical disorder where the young persons, and even the pre-teens, who feels ‘social pressure’ of needing to fit in to society. Teenagers explore and easily attract towards the changing trends of life- styles of the society.2

According to national institute of mental health (NIMH) 0.5%-3.7% women suffers with anorexia nervosa at some point of lives. A study conducted by the national association of anorexia nervosa and associated disorder reported that 5-10% of anorexics will die within 10 years after contracting the disease;18-20% of anorexics will be dead after 20 years and only 30-40% ever fully recover .The mortality rate associated with anorexia nervosa is 12 times higher than the death rate of all causes of death for females 15-24 years old.20% of people suffering from anorexia will prematurely die from complications related to anorexia nervosa including suicide and heart problems.4

Anorexia nervosa is disease selectively befalls the young. They are scared and trapped. There is no known way to prevent anorexia nervosa. Early treatment may be the best way to prevent the disorder from progressing. Fear of hunger is so universal that undergoing in voluntarily often arouses admiration, awe and curiosity in others and the publicity seekers have exploited this. So teenagers have to be aware of the deleterious effects of anorexia nervosa.

6.2 NEED FOR THE STUDY

“Today’s child is tomorrow’s future. The child is the heritage of the family and children’s health is India’s health. Just as it is essential for the young shoot of the plant to be healthy for foundation of a strong healthy tree, healthy children are also for healthy India.”

- Jawaharlal Nehru

Children are assets to the nation. Healthy children are needed for the upliftment of every nation. Particularly a developing country like India needs young healthy generation, so that the country can develop in all aspects. But our teenagers are being trapped by so called ‘Barbie doll syndrome’, where the teenagers are starving themselves daily to attain ideal figure. The danger behind this trend is that severe weight loss makes a person unable to think clearly or function in daily life.

Anorexia nervosa is an intriguing psychiatric disorder that is becoming a significant public health issue for adolescent girls around the world. In a recent survey, the teenagers in America were asked what they feared the most. The results were indeed quite shocking. Fear of gaining weight topped the list, beating other fears like cancer, the fear of losing parents or even death.5

Anorexia nervosa is a puzzling disease, full of contradiction and paradoxes. The youngsters willingly undergo the ordeal of starvation, even to the point of death. Anorexia nervosa has disastrous consequences for women of all age groups; it can play havoc with the health of an adolescent or pre-adolescent by retarding their growth. Anorexia is not about feeling thin, proud and beautiful; if you take the time to listen to an anorexic you will hear that they feel fat, unattractive and inadequate. Anorexics mind are not their own; they are possessed by thoughts of weight, body image, food and calories. 2

It comes as little surprise that if we are taking world wide cases of anorexia nervosa more than 90% of all cases of anorexia nervosa occur in women. Anorexia once known as “golden girl syndrome” because it struck primarily rich, white, well-educated western women. Over the past five years, the self-starvation syndrome has spread to women all socioeconomic and ethnic background. 1

In US and other countries with high economic status, it is estimated about one out of every 100 adolescent girls has this disorder. Statistics on anorexia show that mortality rate from anorexia nervosa are the highest of any psychological disorder.With out treatment up to 20% of people with serious anorexia nervosa die and with treatment up to 2-3 % of people with anorexia nervosa. According to National Institute of Mental Health an estimated one thousand women die each year of anorexia nervosa.6

BBC news, on 17 June 2003 reported that most people in India struggle to get enough to eat-one estimate is that 60% of India’s women are clinically malnourished. But the psychiatrists in urban areas are reporting cases of anorexia nervosa, the so called slimming disease that can cause sufferers to starve themselves to death. And India is still way behind western countries where eating disorders are more pronounced.7

Times of India, on 18 July 2007 reported the news titled as “anorexia rising at a alarming rate”. It focuses on the fact that ten years ago the cases of anorexia nervosa were negligent in India. Psychiatrists claim that in the past few decades, the figure has increased from anything between 5-10 times. What is more alarming is that increasingly girls of younger age are falling prey for anorexia nervosa. 8

Isabella Caro, a French model and an actress who became an international face of anorexia when she allowed her ravaged body to be photographed nude for an Italian advertising campaign to raise awareness about the disease. “no-anorexia” ran across the top of the photography. At that time Ms Caro told “I decided to do it to warn girls about the danger of diets and fashion commandments”.Ms Isabella Caro, 28 years died on November 17, 2010.9

A long-term study matching 51 teenagers with anorexia nervosa with 51 teenagers with out anorexia nervosa has produced interesting result. It is the only study in the world that reflects the natural course of anorexia nervosa in the population. Result shows that with 1 % of all teenage girls suffers with anorexia nervosa.39% have at least one other psychiatric disorder, in addition to anorexia nervosa. Most common is obsessive-compulsive disorder.10

The above facts made the investigator to realize the importance of problem in current situation and created an intention to administer a structured teaching program to assess the knowledge of the adolescent girls regarding anorexia and its management, thereby enhancing the awareness on anorexia nervosa and ability to manage.

6.2 REVIEW OF LITERATURE

The review of literature for the present study is organized as follows;

1. Studies related to signs and symptoms.

2. Studies related to etiology.

3. Studies related to complications of anorexia nervosa.

4. Studies related to management of anorexia nervosa.

5. Studies related to knowledge regarding anorexia nervosa.

1. Studies related to etiology

A study was conducted to determine to what extent psychosocial factors are associated with selected eating disorders among 605 adolescents. A short 13-item polish version of TFEQ (three factor-eating questionnaires) instrument was applied representing three factors: cognitive restraint, uncontrolled eating and emotional eating. Results shown that negative behaviors such as: dietary restrictions, uncontrolled eating and emotional eating may have strong association with psychosocial factors in adolescence.11

A descriptive study was done among African Americans suggest that the pre-valence of anorexia nervosa among them is higher than previously thought and is rising. Survey leaders of a popular African American fashion magazine found levels of abnormal eating attitudes and body dissatisfaction that were at least as high as similar survey of Caucasian women, with a negative correlation between body dissatisfaction and a strong black identity. It has been hypothesized that thinness is gaining more value within the African American culture, just as it has in the Caucasian culture.12

A study was conducted on UK population to investigate whether season-of-birth has effect in anorexia nervosa. Researchers compared the distribution of births (n = 1293) from four independent UK cohorts to that of the general UK population (n = 21 914 037), using both the Walter & Elwood seasonality and chi-squared tests. They found an excess of anorexia births from March to June and a deficit from September to October. These results indicate that environmental risk factor(s) are operative during gestation or immediately after birth and their identification will be important for disease prevention strategies.13

2. Studies related to signs and symptoms

An Experimental study was conducted in 19 patients suffering from eating disorders, and age between 12 and 24 years old.15 of them suffered from the restrictive form of anorexia nervosa and 4 suffered from bulimia nervosa. The control group consisted of 30 girls in the same age interval. In this study authors used the beck depression inventory (BDI) and the Quebec quality of life questionnaire. Results shown that comparison of a number of points acquired in the survey using beck depression scale revealed statistic significance which indicate frequent occurrence of depression symptoms among persons with eating disorders comparing to control group. The authors observed a statistically significant increased frequency of suicidal thoughts in the study group compared to the control.14

Osteoporosis is one of the manifestations of anorexia nervosa (AN). Since bone is a tissue requiring large amounts of energy, investigators examined the disproportionate increase in resting energy expenditure (REE) that occurs with refeeding of Anorexia nervosa patients to determine if it was related to bone accretion. An experimental study was conducted in thirty-seven anorexia nervosa patients aged 23.4 ± 4.8 years underwent a behavioral weight-gain protocol lasting a median of 66 days; 27 remained amenorrheic, and 10 regained menses. Control group consists of 25.1 ± 4.7 years of age- and % IBW matched with patients. REE was measured using a respiratory chamber-indirect calorimeter .Amenorrheics had lower BMDs. These findings were absent in the regained menses group. The increase in REE seen in women with Anorexia nervosa during nutritional rehabilitation may be related to active bone formation, which is not as prominent when menses have returned.15

A noncontrolled clinical study was performed in 24 consecutive patients with the restrictive and the bulimic types of Anorexia Nervosa in order to verify whether the cutaneous signs are different in the two types. The dermatological examination included the entire skin, oral cavity, hair and nails, with attention to skin pathologies prior to the development of Anorexia Nervosa. In all the patients, the most frequent skin manifestations were xerosis (58.3%), hair effluvium (50%), nail changes (45.8%), cheilitis (41.6%), acne (41.6%), gingivitis (33.3%), acrocyanosis (29%), diffuse hypertrichosis (25%), carotenoderma (20.8%), generalized pruritus (16.6%), hyper pigmentation (12.5%), striae distensae (12.5%), factitial dermatitis, seborrheic dermatitis (8.3%), poor wound healing, melasma and Russell's sign (4.1%).Results shown that Skin changes are prevalent among patients with Anorexia nervosa.16

A study was conducted to determine the percentage of anorexia nervosa patients who present worse cognitive functioning according to neuropsychological criteria of cognitive impairment.37 adolescents (11-18 years) with diagnosis of anorexia nervosa in an acute state of illness and with low body mass index were compared with 41 healthy subjects of the same sex.30% of patients showed impaired neuropsychological functioning with worse performance on audio visual taks. Thus study recommended on longitudinal follow up studies are necessary to assess the stability of this profile after long treatment periods.17

3. Studies related to complications of anorexia nervosa

A Comparitive study was conducted to evaluate personality disorder (PD) comorbidity and its clinical correlates in a sample of adolescents with anorexia nervosa (AN) and to compare them with similar studies on adults. The study was conducted in one hundred one female anorexia nervosa outpatients (16-18 yrs), 57 with anorexia nervosa restrictive type and 44 with anorexia nervosa binge-purging type-and 71 age matched, healthy female participants were assessed using the structured clinical interview for DSM-iv axis 11 disorder. Five selected clinical variables of anorexia nervosa severity were also assessed. Results shown than overall, 24.8% of anorexia nervosa outpatients have one or more personality disorder compared with 4.2% of control participants. Personality disorders mostly found in anorexia nervosa outpatients were avoidant, borderline, and obsessive-compulsive.18

A study was conducted to analyse the echocardiographic abnormalities in patients with anorexia nervosa at initial examination and after weight restoration. Population for the study consists of 173 adolescents (aged 12-17 years) who were diagnosed as anorexia nervosa. In addition, 40 healthy adolescents of the same age with normal weight were examined. In adolescents with anorexia nervosa, 34.7% had a pericardial effusion which is clinically silent .In contrast, none of the controls presented with pericardial effusion. Remission of pericardial effusion was observed in 88% of the patients after weight restoration. Results indicate that adolescents with anorexia nervosa show cardiac abnormalities in comparison to healthy young women.19

A study was conducted in hospitalized adolescents with recent onset (psychotherapynews.

11. Mazur J, Dzielska, Malkowska-Szkutnik A. Psychological determinants of selected eating behaviors in adolescents. Medycyna Wieku Rozwojowego.[serial online].2011 Jul-Sep 15(3) 240-249 [cited 2011 Nov28]; Available from URL:.

12. Merry N Miller. Eating disorders: Culture and eating disorders.[online] 2008 December 12 [cited 2011 Nov 7] Available from; URL:http//eating disorders/main/eating disorders-culture.

13. Disanto G, Handel A E, Ramagopalan S V. Season of birth and anorexia nervosa.[serial online].2010 Oct [cited on Nov 7] ;Available from URL:.

14. Debska E, Jan’s A, Banczyk W, Janas-Kozik M. Depression or depressiveness in patients diagnosed with anorexia nervosa and bulimia nervosa. Psychiatria Danubina. [serial online] 2011 September 23; (1) 587-590 [cited 2011 Nov 6]; Available from URL:.

15. Misra M, Kilbanski A. Bone health in anorexia nervosa. Current opinion in endocrinology,diabetis,obesity.[serial online] 2011 Dec 18(6) 376-382 [cited 2011 November 5 ]; Available from URL:

16. Strumia R, Varrotti E,Manzato E. Skin signs in anorexia nervosa. Adolesc Med.[homepage on internet].2011 Oct [cited Nov 10].

17. Andres Perpina S, Lozano Serra, Puig O, Castro Fornieles J. Clinical and biological correlates of adolescent anorexia nervosa with impaired cognitive profile. European child and adolescent psychiatry [serial online] 2011 Dec 20 (11-12) 541-549 [cited 2011 Nov 3]; Available from URL:.

18. Gaudio S, Di Ciommo V.Prevalance of personality disorders and their clinical correlated in outpatient adolescents with anorexia nervosa.Psychosom Med.[serial online].2011 Nov 73(9) 769-774 [cited 2011 Nov 7];Available from URL:.

19. Kastner S, Salbach Andreae,Renneberg,Schmitz L.Echocardiographic findings in adolescents with anorexia nervosa at beginning of treatment and after weight recovery.[serial online] November 16 [cited 2011 Dec 3];Available from URL:.

20. Karen N C, Averin E, Riskin A,Tov N,Kugelman A. Respiratory functions in adolescents hospitalized for anorexia nervosa: A prospective study. International Journal of eating disorders.[serial online] 2011 sep 7 [cited 2011November 2];Available from URL:.

21. Portilla M G.Bardycardia:An important physical finding in anorexia nervosa. J Ark Med Soc.[serial online] 2011 Mar 107(10) 206-208 [cited 2011 Nov 6];Available from URL:.

22. Rockwell R E,Boutella K,Trunko M E,Jacobs M J,Kaye W H. An innovative short-term, intensive, family based treatment for adolescent anorexia nervosa: case series. European eating disorders review: The journal of eating disorder association [serial online] 2011 July-August 19(4):362-367 [cited 2011 Nov 10].Available from; URL:.

23. Schebendach J E, Mayer L E,Attia E,Contento I R. Food choice and diet variety in weight restored patients with anorexia nervosa. The Journal of the American Dietetic Association [serial online] 2011 May 111(5) 732-736[cited 2011 Nov 10]; Available from; URL:.

24. Carter F A, Jordan J, McIntosh V V, Luty S E, Joyce P R. The long term efficacy of three psychotherapies of anorexia nervosa: a randomized, controlled trial. International Journal of eating disorder [serial online] 2011 November 44(7) 647-654 [cited 2011 Nov14]; Available from URL:.

25. Michala L. Anorexia nervosa: a psychiatric illness with gynecological manifestations. A survey of knowledge and practice among Greek gynecologists. European journal of obstetrics, gynecology and reproductive biology[serial online] 2010 Dec 153(2) 170-172 [cited 2011 Dec 5];Available from URL: .

26. Laura Currin, Glenn Waller, Primary care physician’s knowledge and attitude towards eating disorder. Wiley periodicals.[homepage on internet].[cited 2011 Nov 20].

|9. |SIGNATURE OF CANDIDATE | |

| | | |

|10. |REMARKS OF THE GUIDE |This study will be feasible to conduct and enlarge the nursing knowledge.|

|11.1 |NAME AND DESIGNATION OF GUIDE |MRS.NEELIMA MADISETTY |

| | |ASSIS. PROFESSOR and HOD |

| | |DEPARTMENT OF MENTAL HEALTH NURSING, DAYANANDA SAGAR COLLEGE OF NURSING, |

| | |BENGALURU -78 |

|11.2 |SIGNATURE | |

|11.3 |HEAD OF THE DEPARTMENT |MRS.NEELIMA MADISETTY |

| | |ASSIS. PROFESSOR and HOD |

| | |DEPARTMENT OF MENTAL HEALTH NURSING, DAYANANDA SAGAR COLLEGE OF NURSING, |

| | |BENGALURU -78 |

|11.4 |SIGNATURE | |

|12.1 |REMARKS OF THE PRINCIPAL |This study will be feasible to conduct and enlarge the nursing knowledge.|

|12.2 |SIGNATURE | |

| | | |

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