Eating Disorders
INTRODUCTION
Eating is part of everyday life. It is necessary for survival, but it is also a
social activity and part of many happy occasions. People go out for dinner,
invite friends and family for meals in their homes, and celebrate special
events such as marriages, holidays, and birthdays with food. Yet for some
people, eating is a source of worry and anxiety. Are they eating too much? Do
they look fat? Is some new weight loss promotion going to be the answer?
Obesity has been identified as a major health problem in the United States;
some call it an epidemic. The number of obesity-related illnesses among
children has increased dramatically. At the same time, millions of people,
predominantly women, are either starving themselves or engaging in chaotic
eating patterns that can lead to death.
This chapter focuses on anorexia nervosa and bulimia nervosa, the two
most common eating disorders found in the mental health setting. It discusses
strategies for early identification and prevention of these disorders.
OVERVIEW OF EATING DISORDERS
Although many believe that eating disorders are relatively new,
documentation from the Middle Ages indicates willful dieting leading to self-
starvation in female saints who fasted to achieve purity. In the late 1800s,
doctors in England and France described young women who used self-
starvation to avoid obesity. It was not until the 1960s, however, that anorexia
nervosa was established as a mental disorder. Bulimia nervosa was first
described as a distinct syndrome in 1979.
Eating disorders can be viewed on a continuum, with clients with anorexia
eating too little or starving themselves, clients with bulimia eating chaotically,
and clients with obesity eating too much. There is much overlap among the
eating disorders; 30% to 35% of normal-weight people with bulimia have a
history of anorexia nervosa and low body weight, and about 50% of people
with anorexia nervosa exhibit the compensatory behaviors seen in bulimic
behavior, such as purging and excessive exercise. The distinguishing features
of anorexia include an earlier age at onset and below-normal body weight; the
person fails to recognize the eating behavior as a problem. Clients with
bulimia have a later age at onset and near-normal body weight. They are
usually ashamed and embarrassed by the eating behavior (Call, Attia, &
Walsh, 2017).
More than 90% of cases of anorexia nervosa and bulimia occur in women. Although fewer men than women suffer from eating disorders, the number of
men with anorexia or bulimia may be much higher than previously believed,
many of whom are athletes. Men, however, are less likely to seek treatment.
The prevalence of both eating disorders is estimated to be 2% to 4% of the
general population in the United States. In addition, a majority of the general
population is dissatisfied with body image and preoccupied with weight and
dieting at some point in their lives (Call et al., 2017).
CATEGORIES OF EATING DISORDERS
Anorexia nervosa is a life-threatening eating disorder characterized by the
client’s restriction of nutritional intake necessary to maintain a minimally
normal body weight, intense fear of gaining weight or becoming fat,
significantly disturbed perception of the shape or size of the body, and
steadfast inability or refusal to acknowledge the seriousness of the problem or
even that one exists. Clients with anorexia have a body weight that is less than
the minimum expected weight considering age, height, and overall physical
health. In addition, clients have a preoccupation with food and food-related
activities and can have a variety of physical manifestations.
Physical Problems of Anorexia Nervosa
• Amenorrhea
• Constipation
• Overly sensitive to cold, lanugo hair on body
• Loss of body fat
• Muscle atrophy
• Hair loss
• Dry skin
• Dental caries
• Pedal edema
• Bradycardia, arrhythmias
• Orthostasis
• Enlarged parotid glands and hypothermia
• Electrolyte imbalance (i.e., hyponatremia, hypokalemia)
Clients with anorexia nervosa can be classified into two subgroups
depending on how they control their weight. Clients with the restricting subtype lose weight primarily through dieting, fasting, or excessive
exercising. Those with the binge eating and purging subtype engage regularly
in binge eating followed by purging. Binge eating means consuming a large
amount of food (far greater than most people eat at one time) in a discrete
period of usually 2 hours or less. Purging involves compensatory behaviors
designed to eliminate food by means of self-induced vomiting or misuse of
laxatives, enemas, and diuretics. Some clients with anorexia do not binge but
still engage in purging behaviors after ingesting small amounts of food.
Clients with anorexia become totally absorbed in their quest for weight loss
and thinness. The term “anorexia” is actually a misnomer; these clients do not
lose their appetites. They still experience hunger but ignore it and also ignore
the signs of physical weakness and fatigue; they often believe that if they eat
anything, they will not be able to stop eating and will become fat. Clients with
anorexia are often preoccupied with food-related activities, such as grocery
shopping, collecting recipes or cookbooks, counting calories, creating fat-free
meals, and cooking family meals. They may also engage in unusual or
ritualistic food behaviors such as refusing to eat around others, cutting food
into minute pieces, or not allowing the food they eat to touch their lips. These
behaviors increase their sense of control. Excessive exercise is common; it
may occupy several hours a day.
Bulimia nervosa, often simply called bulimia, is an eating disorder
characterized by recurrent episodes of binge eating followed by inappropriate
compensatory behaviors to avoid weight gain, such as purging, fasting, or
excessively exercising. The amount of food consumed during a binge episode
is much larger than a person would normally eat. The client often engages in
binge eating secretly. Between binges, the client may eat low-calorie foods or
fast. Binging or purging episodes are often precipitated by strong emotions
and followed by guilt, remorse, shame, or self-contempt.
The weight of clients with bulimia is usually in the normal range, though
some clients are overweight or underweight. Recurrent vomiting destroys
tooth enamel, and incidence of dental caries and ragged or chipped teeth
increases in these clients. Dentists are often the first health care professionals
to identify clients with bulimia.
Related Disorders
Binge eating disorder is characterized by recurrent episodes of binge eating;
no regular use of inappropriate compensatory behaviors, such as purging or
excessive exercise or abuse of laxatives; guilt, shame, and disgust about eating behaviors; and marked psychological distress. Binge eating disorder
frequently affects people over age 35, and it occurs more often in men than
does any other eating disorder. Individuals are more likely to be overweight or
obese, overweight as children, and teased about their weight at an early age
(Call et al., 2017).
Night eating syndrome is characterized by morning anorexia, evening
hyperphagia (consuming 50% of daily calories after the last evening meal),
and nighttime awakenings (at least once a night) to consume snacks. It is
associated with life stress, low self-esteem, anxiety, depression, and adverse
reactions to weight loss (Tu, Meg Tseng, & Chang, 2018). Most people with
night eating syndrome are obese. Treatment with selective serotonin reuptake
inhibitor (SSRI) antidepressants has shown limited, yet positive effects
(McCuen-Wurst, Ruggieri, & Allison, 2018).
Eating or feeding disorders in childhood include pica, which is persistent
ingestion of nonfood substances, and rumination, or repeated regurgitation of
food that is then rechewed, reswallowed, or spit out. Both of these disorders
are more common in persons with intellectual disability.
Orthorexia nervosa, sometimes called orthorexia, is an obsession with
proper or healthful eating. It is not formally recognized in the Diagnostic and
Statistical Manual of Mental Disorders, fifth edition, but some believe it is on
the rise and may constitute a separate diagnosis. Others believe it is a type of
anorexia or a form of obsessive–compulsive disorder. Behaviors include
compulsive checking of ingredients; cutting out increasing number of food
groups; inability to eat only “healthy” or “pure” foods; unusual interest in
what others eat; hours spent thinking about food, what will be served at an
event; and obsessive involvement in food blogs (Costa, Hardi-Khalil, &
Gibbs, 2017).
Comorbid psychiatric disorders are common in clients with anorexia
nervosa and bulimia nervosa. Mood disorders, anxiety disorders, and
substance abuse/dependence are frequently seen in clients with eating
disorders. Of those, depression and obsessive–compulsive disorder are most
common. Both anorexia and bulimia are characterized by perfectionism,
obsessive–compulsiveness, neuroticism, negative emotionality, harm
avoidance, low self-directedness, low cooperativeness, and traits associated
with avoidant personality disorder. In addition, clients with bulimia may also
exhibit high impulsivity, sensation seeking, novelty seeking, and traits
associated with borderline personality disorder. Eating disorders are often
linked to a history of sexual abuse, especially if the abuse occurred before
puberty. Such a history may be a factor contributing to problems with intimacy, body satisfaction, sexual attractiveness, and low interest in sexual
activity (Mitchison et al., 2018). Clients with eating disorders and a history of
sexual abuse also have higher levels of depression and anxiety, lower self-
esteem, more interpersonal problems, and more severe obsessive–compulsive
symptoms. Childhood neglect, both physical and emotional, is also associated
with eating disorders (Pignatelli, Wampers, Loriedo, Biondi, & Vanderlinden,
2017). Whether sexual abuse has a cause-and-effect relationship with the
development of eating disorders, however, remains unclear.
ETIOLOGY
A specific cause for eating disorders is unknown. Initially, dieting may be the
stimulus that leads to their development. Biologic vulnerability,
developmental problems, and family and social influences can turn dieting
into an eating disorder (Table 20.1). Psychological and physiological
reinforcement of maladaptive eating behaviors sustains the cycle.
Biologic Factors
Studies of anorexia nervosa and bulimia nervosa have shown that these disorders tend to run in families. Genetic vulnerability might also result from
a particular personality type or a general susceptibility to psychiatric disorders
(Bulik, Kleiman, & Yilmaz, 2016). Or, it may directly involve a dysfunction
of the hypothalamus. A family history of mood or anxiety disorders (e.g.,
obsessive–compulsive disorder) places a person at risk for an eating disorder.
Disruptions of the nuclei of the hypothalamus may produce many of the
symptoms of eating disorders. Two sets of nuclei are particularly important in
many aspects of hunger and satiety (satisfaction of appetite)—the lateral
hypothalamus and the ventromedial hypothalamus (Keel et al., 2018). Deficits
in the lateral hypothalamus result in decreased eating and decreased responses
to sensory stimuli that are important to eating. Disruption of the ventromedial
hypothalamus leads to excessive eating, weight gain, and decreased
responsiveness to the satiety effects of glucose, which are behaviors seen in
bulimia.
Many neurochemical changes accompany eating disorders, but it is difficult
to tell whether they cause or result from eating disorders and the characteristic
symptoms of starvation, binging, and purging. For example, norepinephrine
levels rise normally in response to eating, allowing the body to metabolize
and use nutrients. Norepinephrine levels do not rise during starvation,
however, because few nutrients are available to metabolize. Therefore, low
norepinephrine levels are seen in clients during periods of restricted food
intake. Also, low epinephrine levels are related to the decreased heart rate and
blood pressure seen in clients with anorexia.
Increased levels of the neurotransmitter serotonin and its precursor
tryptophan have been linked with increased satiety. Low levels of serotonin as
well as low platelet levels of monoamine oxidase have been found in clients
with bulimia and the binge and purge subtype of anorexia nervosa (Call et al.,
2017); this may explain binging behavior. The positive response of some
clients with bulimia to the treatment with SSRI antidepressants supports the
idea that serotonin levels at the synapse may be low in these clients.
Developmental Factors
Two essential tasks of adolescence are the struggle to develop autonomy and
the establishment of a unique identity. Autonomy, or exerting control over
oneself and the environment, may be difficult in families that are
overprotective or in which enmeshment (lack of clear role boundaries) exists.
These family environments may have an orientation toward control, system
maintenance, or conflict (Darrow, Accurso, Nauman, Goldschmidt, & Le Grange, 2017). Such families do not support members’ efforts to gain
independence, and teenagers may feel as though they have little or no control
over their lives. These teens begin to control their eating through severe
dieting and thus gain control over their weight. Losing weight becomes
reinforcing; by continuing to lose, these clients exert control over one aspect
of their lives.
It is important to identify potential risk factors for developing eating
disorders so that prevention programs can target those at highest risk.
Adolescent girls who express body dissatisfaction are most likely to
experience adverse outcomes, such as emotional eating, binge eating,
abnormal attitudes about eating and weight, low self-esteem, stress, and
depression. Characteristics of those who developed an eating disorder
included disturbed eating habits; disturbed attitudes toward food; eating in
secret; preoccupation with food, eating, shape, or weight; fear of losing
control over eating; and wanting to have a completely empty stomach
(Mitchison et al., 2017).
The need to develop a unique identity, or a sense of who one is as a person,
is another essential task of adolescence. It coincides with the onset of puberty,
which initiates many emotional and physiological changes. Self-doubt and
confusion can result if the adolescent does not measure up to the person she or
he wants to be.
Advertisements, magazines, television, and movies that feature thin models
reinforce the cultural belief that slimness is attractive. Excessive dieting and
weight loss may be the way an adolescent chooses to achieve this ideal. Body
image is how a person perceives his or her body, that is, a mental self-image.
For most people, body image is consistent with how others view them. For
people with anorexia nervosa, however, body image differs greatly from the
perception of others. They perceive themselves as fat, unattractive, and
undesirable even when they are severely underweight and malnourished.
Body image disturbance occurs when there is an extreme discrepancy
between one’s body image and the perceptions of others and extreme
dissatisfaction with one’s body image (Mitchison et al., 2017).
Body image disturbance.
Self-perceptions of the body can influence the development of identity in
adolescence greatly and often persist into adulthood. Self-perceptions that
include being overweight lead to the belief that dieting is necessary before one
can be happy or satisfied. Clients with bulimia nervosa report dissatisfaction
with their bodies as well as the belief that they are fat, unattractive, and
undesirable. The binging and purging cycle of bulimia can begin at any time
—after dieting has been unsuccessful, before the severe dieting begins, or at
the same time as part of a “weight loss plan.”
Family Influences
Girls growing up amid family problems and abuse are at higher risk for both
anorexia and bulimia. Disordered eating is a common response to family
discord. Girls growing up in families without emotional support may try to
escape their negative emotions. They may place an intense focus outward on
something concrete—physical appearance. Disordered eating becomes a
distraction from emotions.
Childhood adversity has been identified as a significant risk factor in the
development of problems with eating or weight in adolescence or early
adulthood. Adversity is defined as physical neglect, sexual abuse, or parental
maltreatment that includes little care, affection, and empathy as well as
excessive paternal control, unfriendliness, or overprotectiveness.
Sociocultural Factors
In the United States and other Western countries, the media fuels the image of
the “ideal woman” as thin. This culture equates beauty, desirability, and,
ultimately, happiness with being thin, toned, and physically fit. Adolescents
often idealize actresses and models as having the perfect “look” or body, even
though many of these celebrities are underweight or use ways to appear
thinner than they are. Books, magazines, dietary supplements, exercise
equipment, plastic surgery advertisements, and weight loss programs abound;
the dieting industry is a billion-dollar business. Western culture considers
being overweight a sign of laziness, lack of self-control, or indifference; it
equates pursuit of the “perfect” body with beauty, desirability, success, and
willpower. Thus, many women speak of being “good” when they stick to a
diet and “bad” when they eat desserts or snacks (Churruca, Ussher, & Perz,
2017).
Pressure from others may also contribute to eating disorders. Pressure from
coaches, parents, and peers and the emphasis placed on body form in sports
such as gymnastics, ballet, and wrestling can promote eating disorders in
athletes (Giel & Hermann-Werner, 2016). Parental concern over a girl’s
weight and teasing from parents or peers reinforces a girl’s body
dissatisfaction and her need to diet or control eating in some way. Studies
indicate that bullying and peer harassment are also related to an increase in
disordered eating habits for both bullies and victims.
CULTURAL CONSIDERATIONS
Both anorexia nervosa and bulimia nervosa are far more prevalent in
industrialized societies, where food is abundant and beauty is linked with
thinness. In the United States, anorexia nervosa is less frequent among
African Americans. On the island of Fiji, when there was little television,
eating disorders were almost nonexistent and being “plump” was considered
the ideal shape for girls and women. In the 5 years following the widespread
introduction of television, the number of eating disorders in Fiji increased
significantly (Call et al., 2017).
Eating disorders are most common in the United States, Canada, Europe,
Australia, Japan, New Zealand, South Africa, and other developed
industrialized countries. As a society becomes more prosperous with
increased availability of foods high in fat and carbohydrates and increased
emphasis on the thinness equals beauty concept, the incidence of eating
disorders increases. In addition, immigrants from cultures in which eating
disorders are rare may develop eating disorders as they assimilate the thin-
body ideal (Anorexia Nervosa & Related Eating Disorders, 2019).
Schulte (2016) found that both male and female youths in the United Arab
Emirates experienced binge eating. Obesity was a prevalent problem, as was
emotional eating and body-related guilt. Eating disorders appear to be equally
common among Hispanic and Caucasian women and less common among
African American and Asian women. Minority women who are younger,
better educated, and more closely identified with middle-class values are at
increased risk for developing an eating disorder (Perez, Ohrt, & Hoek, 2016).
During the past several years, eating disorders have increased among all
U.S. social classes and ethnic groups. With today’s technology, the entire
world is exposed to the Western ideal. As this ideal spreads to non-Western
cultures, anorexia and bulimia will likely increase there as well.
ANOREXIA NERVOSA
Onset and Clinical Course
Anorexia nervosa typically begins between the ages of 14 and 18 years. In the
early stages, clients often deny having a negative body image or anxiety
regarding their appearance. They are pleased with their ability to control their
weight and may express this. When they initially come for treatment, they
may be unable to identify or to explain their emotions about life events such
as school or relationships with family or friends. A profound sense of emptiness is common.
As the illness progresses, depression and lability in mood become more
apparent. As dieting and compulsive behaviors increase, clients isolate
themselves. This social isolation can lead to a basic mistrust of others and
even paranoia. Clients may believe their peers are jealous of their weight loss
and may believe that family and health care professionals are trying to make
them “fat and ugly.”
For clients with anorexia, about 30% to 50% achieve full recovery, while
10% to 20% remain chronically ill. Compared to the general population,
clients with anorexia are six times more likely to die from medical
complications or suicide. Clients with the lowest body weights and longest
durations of illness tended to relapse most often and have the poorest
outcomes. Clients who abuse laxatives are at a higher risk for medical
complications. Table 20.2 lists common medical complications of eating
disorders.
Treatment and Prognosis
Clients with anorexia nervosa can be difficult to treat because they are often
resistant, appear uninterested, and deny their problems. Treatment settings
include inpatient specialty eating disorder units, partial hospitalization or day
treatment programs, and outpatient therapy. The choice of setting depends on
the severity of the illness, such as weight loss, physical symptoms, duration of
binging and purging, drive for thinness, body dissatisfaction, and comorbid
psychiatric conditions. Major life-threatening complications that indicate the
need for hospital admission include severe fluid, electrolyte, and metabolic
imbalances; cardiovascular complications; severe weight loss and its
consequences; and risk for suicide. Short hospital stays are most effective for
clients who are amenable to weight gain and who gain weight rapidly while
hospitalized. Longer inpatient stays are required for those who gain weight
more slowly and are more resistant to gaining additional weight. Outpatient
therapy has the best success with clients who have been ill for fewer than 6
months, are not binging and purging, and have parents likely to participate
effectively in family therapy. Cognitive–behavioral therapy (CBT) can also be
effective in preventing relapse and improving overall outcomes (Costa &
Melnik, 2016).
Medical Management
Medical management focuses on weight restoration, nutritional rehabilitation,
rehydration, and correction of electrolyte imbalances. Clients receive
nutritionally balanced meals and snacks that gradually increase caloric intake
to a normal level for size, age, and activity. Severely malnourished clients
may require total parenteral nutrition, tube feedings, or hyperalimentation to
receive adequate nutritional intake. Generally, access to a bathroom is
supervised to prevent purging as clients begin to eat more food. Weight gain
and adequate food intake are most often the criteria for determining the
effectiveness of treatment.
Psychopharmacology
Several classes of drugs have been studied, but few have shown clinical
success. Amitriptyline (Elavil) and the antihistamine cyproheptadine
(Periactin) in high doses (up to 28 mg/day) can promote weight gain in
inpatients with anorexia nervosa. Olanzapine (Zyprexa) has been used with
success because of its antipsychotic effect (on bizarre body image distortions)
and associated weight gain. Fluoxetine (Prozac) has some effectiveness in
preventing relapse in clients whose weight has been partially or completely
restored (Davis & Attia, 2017); however, close monitoring is needed because
weight loss can be a side effect.
Psychotherapy
Family therapy may be beneficial for families of clients younger than 18
years. Families who demonstrate enmeshment, unclear boundaries among
members, and difficulty handling emotions and conflict can begin to resolve
these issues and improve communication. Family therapy is also useful to
help members be effective participants in the client’s treatment. Family-based early intervention can prevent future exacerbation of anorexia when families
are able to participate in an effective manner. However, in a dysfunctional
family, significant improvements in family functioning may take 2 years or
more.
Individual therapy for clients with anorexia nervosa may be indicated in
some circumstances; for example, if the family cannot participate in family
therapy, if the client is older or separated from the nuclear family, or if the
client has individual issues requiring psychotherapy. Therapy that focuses on
the client’s particular issues and circumstances, such as coping skills, self-
esteem, self-acceptance, interpersonal relationships, and assertiveness, can
improve overall functioning and life satisfaction. CBT, long used with clients
with bulimia, has been adapted for adolescents with anorexia nervosa and
used successfully for initial treatment as well as relapse prevention. Enhanced
cognitive–behavioral therapy (CBT-E) has been even more successful than
CBT. In addition to addressing the body image disturbance and
dissatisfaction, CBT-E addresses perfectionism, mood intolerance, low self-
esteem, and interpersonal difficulties (Calugi, El Ghoch, & Dalle Grave,
2017).
BULIMIA NERVOSA
Onset and Clinical Course
Bulimia nervosa usually begins in late adolescence or early adulthood; 18 or
19 years is the typical age of onset. Binge eating frequently begins during or
after dieting. Between binging and purging episodes, clients may eat
restrictively, choosing salads and other low-calorie foods. This restrictive
eating effectively sets them up for the next episode of binging and purging,
and the cycle continues.
Clients with bulimia are aware that their eating behavior is pathologic, and
they go to great lengths to hide it from others. They may store food in their
cars, desks, or secret locations around the house. They may drive from one
fast-food restaurant to another, ordering a normal amount of food at each but
stopping at six places in 1 or 2 hours. Such patterns may exist for years until
family or friends discover the client’s behavior or until medical complications
develop for which the client seeks treatment.
Follow-up studies of clients with bulimia show that as many as 25% or
more are untreated. Clients with bulimia had 45% full recovery, while 23% remained chronically ill (Call et al., 2017). One-third of fully recovered
clients relapse. Clients with a comorbid personality disorder tend to have
poorer outcomes than those without. The death rate from bulimia is estimated
at 3% or less.
Most clients with bulimia are treated on an outpatient basis. Hospital
admission is indicated if binging and purging behaviors are out of control and
the client’s medical status is compromised. Most clients with bulimia have
near-normal weight, which reduces the concern about severe malnutrition, a
factor in clients with anorexia nervosa.
Treatment and Prognosis
Cognitive–Behavioral Therapy
CBT has been found to be the most effective treatment for bulimia. This
outpatient approach often requires a detailed manual to guide treatment.
Strategies designed to change the client’s thinking (cognition) and actions
(behavior) about food focus on interrupting the cycle of dieting, binging, and
purging and altering dysfunctional thoughts and beliefs about food, weight,
body image, and overall self-concept. Web-based CBT, including face time
with a therapist, has been effective as well as traditionally delivered CBT.
Smartphone applications (apps) for eating disorder self-management are also
promising and highly acceptable to user groups (Kim et al., 2018).
Psychopharmacology
Since the 1980s, many studies have been conducted to evaluate the
effectiveness of medications, primarily antidepressants, to treat bulimia.
Drugs, such as desipramine (Norpramin), imipramine (Tofranil), amitriptyline
(Elavil), nortriptyline (Pamelor), phenelzine (Nardil), and fluoxetine (Prozac),
were prescribed in the same dosages used to treat depression (see Chapter 2).
In all the studies, the antidepressants were more effective than were the
placebos in reducing binge eating. They also improved mood and reduced
preoccupation with shape and weight; however, most of the positive results
were short term. It may be that the primary contribution of medications is
treating the comorbid disorders frequently seen with bulimia.
History
Family members often describe clients with anorexia nervosa as perfectionists with above-average intelligence who are achievement-
oriented, dependable, eager to please, and seeking approval before onset
of the condition. Parents describe clients as being “good, causing us no
trouble” until the onset of anorexia. Likewise, clients with bulimia are
often focused on pleasing others and avoiding conflict. Clients with
bulimia, however, often have a history of impulsive behavior such as
substance abuse and shoplifting as well as anxiety, depression, and
personality disorders (Schultz & Videbeck, 2013).
General Appearance and Motor Behavior
Clients with anorexia appear slow, lethargic, and fatigued; they may be
emaciated, depending on the amount of weight loss. They may be slow to
respond to questions and have difficulty deciding what to say. They are
often reluctant to answer questions fully because they do not want to
acknowledge any problem. They often wear loose-fitting clothes in layers,
regardless of the weather, both to hide weight loss and to keep warm
(clients with anorexia are generally cold). Eye contact may be limited.
Clients may turn away from the nurse, indicating their unwillingness to
discuss problems or to enter treatment.
Clients with bulimia may be underweight or overweight but are
generally close to expected body weight for age and size. General
appearance is not unusual, and they appear open and willing to talk.
Mood and Affect
Clients with eating disorders have labile moods that usually correspond to
their eating or dieting behaviors. Avoiding “bad” or fattening foods gives
them a sense of power and control over their bodies, while eating, binging,
or purging leads to anxiety, depression, and feeling out of control. Clients
with eating disorders often seem sad, anxious, and worried. Those with
anorexia seldom smile, laugh, or enjoy any attempts at humor; they are
somber and serious most of the time. In contrast, clients with bulimia are
initially pleasant and cheerful as though nothing is wrong. The pleasant
façade usually disappears when they begin describing binge eating and
purging; they may express intense guilt, shame, and embarrassment.
Thought Processes and Content
Clients with eating disorders spend most of the time thinking about dieting, food, and food-related behavior. They are preoccupied with their
attempts to avoid eating or eating “bad” or “wrong” foods. Clients cannot
think about themselves without thinking about weight and food. The body
image disturbance can be almost delusional; even if clients are severely
underweight, they can point to areas on their buttocks or thighs that are
“still fat,” thereby fueling their need to continue dieting. Clients with
anorexia who are severely underweight may have paranoid ideas about
their family and health care professionals, believing they are their
“enemies” who are trying to make them fat by forcing them to eat.
Sensorium and Intellectual Processes
Generally, clients with eating disorders are alert and oriented; their
intellectual functions are intact. The exception is clients with anorexia
who are severely malnourished and showing signs of starvation, such as
mild confusion, slowed mental processes, and difficulty with
concentration and attention.
Judgment and Insight
Clients with anorexia have limited insight and poor judgment about their
health status. They do not believe they have a problem; rather, they
believe others are trying to interfere with their ability to lose weight and to
achieve the desired body image. Facts about failing health status are not
enough to convince these clients of their true problems. Clients with
anorexia continue to restrict food intake or to engage in purging despite
the negative effect on health.
In contrast, clients with bulimia are ashamed of the binge eating and
purging. They recognize these behaviors as abnormal and go to great
lengths to hide them. They feel out of control and unable to change, even
though they recognize their behaviors as pathologic.
Self-Concept
Low self-esteem is prominent in clients with eating disorders. They see
themselves only in terms of their ability to control their food intake and
weight. They tend to judge themselves harshly and see themselves as
“bad” if they eat certain foods or fail to lose weight. They overlook or
ignore other personal characteristics or achievements as less important
than thinness. Clients often perceive themselves as helpless, powerless,
and ineffective. This feeling of lack of control over themselves and their
environment only strengthens their desire to control their weight.
Roles and Relationships
Eating disorders interfere with the ability to fulfill roles and to have
satisfying relationships. Clients with anorexia may begin to fail at school,
which is in sharp contrast to previously successful academic performance.
They withdraw from peers and pay little attention to friendships. They
believe that others will not understand, or fear that they will begin out-of-
control eating with others.
Clients with bulimia feel great shame about their binge eating and
purging behaviors. As a result, they tend to lead secret lives that include
sneaking behind the backs of friends and family to binge and purge in
privacy. The time spent buying and eating food and then purging can
interfere with role performance both at home and at work.
Physiological and Self-Care Considerations
The health status of clients with eating disorders relates directly to the
severity of self-starvation or purging behaviors or both (see Table 20.2). In
addition, clients may exercise excessively, almost to the point of
exhaustion, in an effort to control weight. Many clients have sleep
disturbances, such as insomnia, reduced sleep time, and early-morning
wakening. Those who frequently vomit have many dental problems, such
as loss of tooth enamel, chipped and ragged teeth, and dental caries.
Frequent vomiting may also result in mouth sores. Complete medical and
dental examinations are essential.
Establishing Nutritional Eating Patterns
Typically, inpatient treatment is for clients with anorexia nervosa who are
severely malnourished and for clients with bulimia whose binge eating and
purging behaviors are out of control. Primary nursing roles are to
implement and supervise the regimen for nutritional rehabilitation. Total
parenteral nutrition or enteral feedings may be prescribed initially when a
client’s health status is severely compromised.
When clients can eat, a diet of 1,200 to 1,500 calories/day is ordered,
with gradual increases in calories until clients are ingesting adequate
amounts for height, activity level, and growth needs. Typically, allotted
calories are divided into three meals and three snacks. A liquid protein
supplement is given to replace any food not eaten to ensure consumption
of the total number of prescribed calories. The nurse is responsible for
monitoring meals and snacks and often initially will sit with a client
during eating at a table away from other clients. Depending on the
treatment program, diet beverages and food substitutions may be
prohibited, and a specified time may be set for consuming each meal or
snack. Clients may also be discouraged from performing food rituals such as cutting food into tiny pieces or mixing food in unusual combinations.
The nurse must be alert for any attempts by clients to hide or to discard
food.
After each meal or snack, clients may be required to remain in view of
staff for 1 to 2 hours to ensure they do not empty the stomach by vomiting.
Some treatment programs limit client access to bathrooms without
supervision, particularly after meals, to discourage vomiting. As clients
begin to gain weight and become more independent in eating behavior,
these restrictions are reduced gradually.
In most treatment programs, clients are weighed only once daily,
usually upon awakening and after they have emptied the bladder. Clients
should wear minimal clothing, such as a hospital gown, each time they are
weighed. They may attempt to place objects in their clothing to give the
appearance of weight gain.
Clients with bulimia are often treated on an outpatient basis. The nurse
must work closely with clients to establish normal eating patterns and to
interrupt the binge-and-purge cycle. He or she encourages clients to eat
meals with their families or if they live alone, with friends. Clients should
always sit at a table in a designated eating area, such as a kitchen or dining
room. It is easier for clients to follow a nutritious eating plan if it is written
in advance and groceries are purchased for the planned menus. Clients
must avoid buying foods frequently consumed during binges, such as
cookies, candy bars, and potato chips. They should discard or move to the
kitchen food that was kept at work, in the car, or in the bedroom.
Identifying Emotions and Developing Coping Strategies
Because clients with anorexia have problems with self-awareness, they
often have difficulty identifying and expressing feelings (alexithymia).
Therefore, they often express these feelings in terms of somatic
complaints, such as feeling fat or bloated. The nurse can help clients begin
to recognize emotions such as anxiety or guilt by asking them to describe
how they are feeling and allowing adequate time for response. The nurse
should not ask, “Are you sad?” or “Are you anxious?” because a client
may quickly agree rather than struggle for an answer. The nurse
encourages the client to describe his or her feelings. This approach can
eventually help clients recognize their emotions and connect them to their
eating behaviors.
NURSING INTERVENTIONS
For Eating Disorders
• Establishing nutritional eating patterns
• Sit with the client during meals and snacks.
• Offer liquid protein supplement if client is unable to complete
meal.
• Adhere to treatment program guidelines regarding restrictions.
• Observe the client following meals and snacks for 1 to 2 hours.
• Weigh the client daily in uniform clothing.
• Be alert for attempts to hide or discard food or inflate weight.
• Helping the client identify emotions and develop non–food-related
coping strategies
• Ask the client to identify feelings.
• Self-monitoring using a journal
• Relaxation techniques
• Distraction
• Assist the client in changing stereotypical beliefs.
• Helping the client deal with body image issues
• Recognize benefits of a more near-normal weight.
• Assist in viewing self in ways not related to body image.
• Identify personal strengths, interests, and talents.
• Providing client and family education (see “Client and Family
Education: For Eating Disorders”)
Self-monitoring is a cognitive–behavioral technique designed to help
clients with bulimia. It may help clients identify behavior patterns and
then implement techniques to avoid or replace them (Richards, Shingleton,
Goldman, Siegel, & Thompson-Brenner, 2016). Self-monitoring
techniques raise client awareness about behavior and help them regain a
sense of control. The nurse encourages clients to keep a diary of all food
eaten throughout the day, including binges, and to record moods,
emotions, thoughts, circumstances, and interactions surrounding eating
and binging or purging episodes. In this way, clients begin to see
connections between emotions and situations and eating behaviors. The
nurse can then help clients develop ways to manage emotions, such as
anxiety, using relaxation techniques or distraction with music or another activity. This is an important step toward helping clients find ways to cope
with people, emotions, or situations that do not involve food. Keeping a feelings diary.
Dealing with Body Image Issues
The nurse can help clients accept a more normal body image. This may
involve clients agreeing to weigh more than they would like, to be healthy,
and to stay out of the hospital. When clients experience relief from
emotional distress, have increased self-esteem, and can meet their
emotional needs in healthy ways, they are more likely to accept their
weight and body image.
The nurse can also help clients view themselves in terms other than
weight, size, shape, and satisfaction with body image. Helping clients to
identify areas of personal strength that are not food-related broadens
clients’ perceptions of themselves. This includes identifying talents,
interests, and positive aspects of character unrelated to body shape or size.
Providing Client and Family Education
One primary nursing role in caring for clients with eating disorders is
providing education to help them take control of nutritional requirements
independently. This teaching can be done in the inpatient setting during
discharge planning or in the outpatient setting. The nurse provides
extensive teaching about basic nutritional needs and the effects of
restrictive eating, dieting, and the binge-and-purge cycle. Clients need
encouragement to set realistic goals for eating throughout the day. Eating
only salads and vegetables during the day may set up clients for later
binges as a result of too little dietary fat and carbohydrates.
For clients who purge, the most important goal is to stop. Teaching
should include information about the harmful effects of purging by
vomiting and laxative abuse. The nurse explains that purging is an
ineffective means of weight control and only disrupts the neuroendocrine
system. In addition, purging promotes binge eating by decreasing the
anxiety that follows the binge. The nurse explains that if clients can avoid
purging, they may be less likely to engage in binge eating. The nurse also
teaches the techniques of distraction and delay because they are useful
against both binging and purging. The longer clients can delay either
binging or purging, the less likely they are to carry out the behavior.
CLIENT AND FAMILY EDUCATION
For Eating Disorders
Client
• Basic nutritional needs
• Harmful effects of restrictive eating, dieting, and purging
• Realistic goals for eating
• Acceptance of healthy body image
Family and Friends
• Provide emotional support.
• Express concern about the client’s health.
• Encourage the client to seek professional help.
• Avoid talking only about weight, food intake, and calories.
• Become informed about eating disorders.
• It is not possible for family and friends to force the client to eat. The
client needs professional help from a therapist or psychiatrist.
The nurse explains to family and friends that they can be most helpful
by providing emotional support, love, and attention. They can express
concern about the client’s health, but it is rarely helpful to focus on food
intake, calories, and weight.
Evaluation
The nurse can use assessment tools such as the Eating Attitudes Test to
detect improvement for clients with eating disorders. Both anorexia and
bulimia are chronic for many clients. Residual symptoms such as dieting,
compulsive exercising, and experiencing discomfort when eating in a
social setting are common. Treatment is considered successful if the client
maintains a body weight within 5% to 10% of normal with no medical
complications from starvation or purging.
COMMUNITY-BASED CARE
Treatment for clients with eating disorders usually occurs in community
settings. Hospital admission is indicated only for medical necessity, such as
for clients with dangerously low weight, electrolyte imbalances, or renal,
cardiac, or hepatic complications. Clients who cannot control the cycle of
binge eating and purging may be treated briefly in an inpatient setting. Other
treatment settings include partial hospitalization or day treatment programs,
individual or group outpatient therapy, and self-help groups.
MENTAL HEALTH PROMOTION
Nurses can educate parents, children, and young people about strategies to
prevent eating disorders. Important aspects include realizing that the “ideal”
figures portrayed in advertisements and magazines are unrealistic, developing
realistic ideas about body size and shape, resisting peer pressure to diet, improving self-esteem, and learning coping strategies for dealing with
emotions and life issues.
Healthy People 2020 (see Chapter 1) includes an objective to increase
comprehensive school education for a variety of topics, including unhealthy
dietary patterns and inadequate physical injury. This is in response to the
increasing epidemic of obesity in the United States, including young children
and adolescents.
The National Eating Disorders Association (2018) provides the following
suggestions to promote positive body image:
• Get rid of the notion that a particular diet, weight, or body size will
automatically lead to happiness and fulfillment.
• Learn everything you can about anorexia nervosa, bulimia nervosa, binge
eating disorder, and other types of eating disorders.
• Make the choice to challenge the false idea that thinness and weight loss
are great and that body fat and weight gain are horrible or indicate laziness,
worthlessness, or immorality.
• Avoid categorizing foods as “good/safe” versus “bad/dangerous.”
Remember that we all need to eat a balanced variety of foods.
• Stop judging yourself and others based on body weight or shape. Turn off
the voices in your head that tell you that a person’s body weight is an
indicator of their character, personality, or value as a person.
• Limit time on social media. Don’t read or listen to others’ negative
comments. Surround yourself with positive, supportive, real people.
• Become a critical viewer of the media and its messages about self-esteem
and body image. Don’t accept that the images that you see are the ideals
you should try to attain. Choose to value yourself based on your goals,
accomplishments, talents, and character. Avoid letting the way you feel
about your body weight and shape determine the course of your day.
School nurses, student health nurses at colleges and universities, and nurses
in clinics and doctors’ offices may encounter clients in various settings who
are at risk for developing or who already have an eating disorder. In these
settings, early identification and appropriate referral are primary
responsibilities of the nurse. Routine screening of all young women in these
settings would help identify those at risk for an eating disorder. Box 20.3
contains a sample of questions that can be used for such screening. Such early
identification could result in early intervention and prevention of a full-blown
eating disorder.
SELF-AWARENESS ISSUES
An emaciated, starving client with anorexia can be a shocking sight, and the
nurse may want to “take care of this child” and nurse her back to health.
When the client rejects this help and resists the nurse’s caring actions, the
nurse can become angry and frustrated and feel incompetent in handling the
situation.
The client initially may view the nurse, who is responsible for making the
client eat, as the enemy. The client may hide or throw away food or become
overtly hostile as anxiety about eating increases. The nurse must remember
that the client’s behavior is a symptom of anxiety and fear about gaining
weight and not personally directed toward the nurse. Taking the client’s
behavior personally may cause the nurse to feel angry and behave in a
rejecting manner.
Because eating is such a basic part of everyday life, the nurse may wonder
why the client cannot just eat “like everyone else.” The nurse may also find it
difficult to understand how a 75-lb client sees herself as fat when she looks in
the mirror. Likewise, when working with a client who binges and purges, the
nurse may wonder why the client cannot exert the willpower to stop. The
nurse must remember that the client’s eating behavior has gotten out of
control. Eating disorders are mental illnesses, just like schizophrenia and
bipolar affective disorder.
Points to Consider When Working with Clients with
Eating Disorders
• Be empathetic and nonjudgmental, though this is not easy. Remember the
client’s perspective and fears about weight and eating.
• Avoid sounding parental when teaching about nutrition or why laxative use
is harmful. Presenting information factually without chiding the client will
obtain more positive results.
• Do not label clients as “good” when they avoid purging or eat an entire
meal. Otherwise, clients will believe they are “bad” on days when they
purge or fail to eat enough food.