Managing Challenging Eating Disorder Behaviours in an Inpatient Setting

The fact sheet outlines how to manage challenging eating disorder behaviours in an inpatient setting.

People with eating disorders can engage in challenging and risky behaviours that are designed to protect the illness when they feel that their illness is under threat. Hospitalisation and treatment threatens the illness, making treatment exceptionally challenging for individuals with an eating disorder.

To manage challenging behaviours effectively, it is important to have a good understanding of the function of the eating disorder for that individual and the fear that drives these behaviours. Eating disorders provide individuals with a sense of control and safety. They can help the person to manage or avoid difficult emotions, provide a sense of identity and are often experienced by the individual as providing them with support like that of a friend.

When you have a good understanding of the individuals experience and understand the function of their illness, then you are more able to act from a place of empathy and work therapeutically with the individual.

The behavioural manifestations of the eating disorder can be difficult to manage and the approach of health practitioners is very important. Health practitioners need to be mindful to not take a paternalistic, punitive or judgmental approach, as this will only result in a break down in the therapeutic relationship and ongoing engagement in the behaviours.

The most important thing to understand is how difficult the person will find it to change their behaviour as the disorder compels them to behave in certain ways. As a result, asking the individual to promise not to engage in the behaviours or expecting that they will automatically ‘comply’ with program rules will set the person up for failure. Becoming exasperated or angry when they do fail contributes to the negative feelings the person may have about themselves, and enhances the isolation that they feel as a result of the eating disorder.

What are challenging behaviours?

Challenging behaviours include any behaviour that interferes with treatment. The following list, while not comprehensive, includes particular areas to be aware of.

• Food & eating: hoarding food, disposing of food (e.g. in pockets, in the toilet, in bed clothes, serviettes, pot plants), choosing low calorie or diet foods, chewing gum, picking at food, cutting food up into small pieces, eating at a very slow pace or very quickly, chewing & spitting food out, bingeing, regurgitating food & then re-swallowing.
• Fluid: excessive or inadequate fluid intake, consuming diet soft drinks, consuming significant quantities of artificial sugars in drinks as well as drinks that have a laxative/diuretic effect.
• Activity: excessive movement (shaking/jiggling legs), pacing around bedroom or ward, secretive exercise (in bathroom, sit ups in bed or leaving the ward to go for walks/runs).
• Nasogastric feeds: compromising nasogastric feeds by removing tube, emptying feed (in the toilet, sink, shower, in cups), diluting the feed, changing feed rate or turning the feed off, using sharps to puncture tube, or a syringe to draw back on tube.
• Vomiting: the eating disorder will force the person to look for opportunities to purge (e.g. in pockets, the bathroom, cups or bags, pot plants or vases).
• _Medications: _self-medication of laxatives, diuretics and diet pills.
• Weight: methods of weight falsification include fluid loading (increasing fluid intake the day prior to & the day of weighing), increasing salt intake prior to weigh days, hiding heavy objects on body (putting batteries in underpants/bra), gripping the scales.

Addressing challenging eating disorder behaviours

To effectively manage challenging behaviours, the team needs to be working cohesively and collaboratively, and have a set program protocol. A program protocol will help to establish and maintain consistency in managing the challenging behaviours. It is important that everyone involved is fully aware of the program protocols, including the person and their family. The consistent implementation of a program protocol is key, otherwise it implies to the individual that the program protocol isn’t really important, and that the eating disorder behaviours can continue.

People with an eating disorder will require additional support to reduce engagement in their behaviours and to commence treatment.

At the start of an individual’s admission it is important to assess for challenging behaviours and identify risk factors for engaging in behaviours. This will assist the team in looking out for behaviours, monitoring and preventing behaviours from occurring.

Managing Restrictive Eating

• Validate the individuals struggle and distress in being required to eat the quantity/types of foods that are necessary for health.
• Work collaboratively with the individual to explore how to best support them in getting through the required amount of food. Do not enter into negotiations around the type and quantity of the food, but rather explore whether more support, distraction or eating with others may be more helpful.
• Ensure that the individual is aware of the program protocol from the outset, that they are required to complete 100% of their meals/snacks, and that a supplement will be offered on failure to complete their meal or snack.
• If the individual is struggling to complete their meal/snack, offer them support and coaching to take another bite – “I can see how difficult this is for you, so I’m going to help you if that’s ok? Try to take another bite.
• If the individual continues to refuse meals and snacks, then the team need to have a discussion with the individual (outside of meal times) about the individual’s goals of treatment.

Managing Laxatives, Diuretics & Vomiting (Purging)

• Ensure that the process of stopping laxative and diuretics are conducted carefully and under the direction of a qualified medical practitioner.
• Validate the individuals struggle and distress around purging.
• Provide education to the individual around the medical implications of purging.
• Explain to the individual that purging is ineffective in aiding weight loss.
• Work collaboratively with the individual to explore how to best support them in ceasing purging. Some suggestions include:
  • Ceasing stimulant laxatives. Lactulose can be prescribed if there are concerns about faecal impaction.
  • Supervise bathroom use. No bathroom access 1 hour after meals and limit time off the ward after meal times.
  • Do not leave tissues, binges, buckets, syringes or jubs near the individual as they may be used to purge feeds orally or via their nasogastric tube.
  • With permission conduct regular searches of the individuals belongings to ensure that they do not have access to laxatives and diuretics.
• Encourage regular meals and snacks, adequate fibre and fluid intake.
• Monitor bowel movements, fluid balance, electrolytes and cardiac function.
• Encourage the individual to approach a staff member for assistance and support if feelings associated with purging arise.

Managing Bingeing

• Validate the individuals struggle and distress around binging.
• Work collaboratively to identify any potential triggers for bingeing and any high-risk times e.g. mid afternoon or evening.
• Explore with the individual what might be helpful in preventing binge episodes and how staff may assist e.g. supervised meal/snack, change in meal plan, engaging in a distracting activities, breathing exercises, being with a staff member.
• Explore with the individual what has been working to reduce binge episodes and document this in the medical records and management plan.
• Encourage the individual to approach a staff member for assistance and support if feelings associated with bingeing arise.
• Assist the individual in making their environment less prone to binging i.e. ensuring that the individual does not have access to additional food and that meal trays and snacks are removed after meal times.

Managing Physical Activity

• Physical activity may be helpful or harmful depending on the medical and physical condition of the individual. Physical activity recommendations should be given by the medical team.
• Identify the individual’s exercise behaviours (it may also be helpful to consult with the family)
• Address any false beliefs that the individual has around exercise.
• Work collaboratively with the individual to Identify triggers that lead to these behaviours (.e.g before or after meal times, when alone in the bathroom)
• Explore with the individual what could help to manage these triggers (.e.g distraction strategies, supervised bathroom access)
• Explore with the individual to explore how to best support them in reducing or ceasing their exercise in line with the teams recommendations. A graded approach is often required.

What to include in a Program Protocol that can assist in limiting challenging behaviours

• Provide high level of nursing support at the beginning of the admission.
• Provide supervision and support at all meal and snack times.
• Limit meal times to 30 mins for main meals and 15 minutes for snacks.
• Limit access to food outside of planned meal and snack times.
• Food should not be brought in by the individual, their family or friends, unless approved by the team and Dietitian.
• Meals and snacks should be approved by a Dietitian.
• Individuals should attempt to complete 100% of their meals and snacks. If unable to complete, they should be given a supplement drink.
• Food should not be kept in the individuals room, and food should be removed from the individuals room once meal and snack times are over.
• Meals and snacks should be monitored where possible.
• Supervised bathroom use, with no access to the bathroom 1 hour after meals and snacks.
• Limit the availability/access to bins, buckets, jugs as these can be used to hide or hoard food, and to hide purging behaviours.