In this lesson we are diving into mental health with a look at anorexia nervosa. If you struggle with this disorder, and thinking about it triggers disordered eating behaviors, please proceed with caution, or avoid altogether. Your mental health is more important than any nursing school exam.

Anorexia Overview

Anorexia nervosa is a disorder in which a restriction of caloric intake leads to a body weight that is significantly lower than expected for the individual’s age, sex and state of physical health. There are two types of anorexia. The restricting type and the binging/purging type. It is important to note that the binging/purging type of anorexia is not the same DSM-5 diagnosis as bulimia…they are different.

An individual with binging/purging anorexia will repeatedly binge eat and purge by vomiting or using laxatives. This individual may also exercise excessively following a binge. The key difference between the individual with bulimia and the individual with this subtype of anorexia is that individuals with anorexia show long term weight suppression as a key component of their illness. Individuals with bulimia are often normal or higher than normal body weight.

The other type of anorexia is restricting type. It is characterized by dieting, fasting and exercising excessively. There is no purging and no binge-eating with this type.

Anorexia is more common in females than males, with a ratio of about 10:1. The exact pathophysiology is unknown, but evidence suggests that genetic and environmental factors may come into play. Additionally, the evidence shows that individuals with anorexia nervosa have altered brain function and structure including deficits in dopamine and/or serotonin, activation of the corticolimbic system (which controls fear and appetite), and lowered activity in areas of the brain that control habitual behaviors.

Diagnostic Criteria for Anorexia

In order to meet the diagnostic criteria for anorexia, the following criteria must be met:

  • A restriction of caloric intake that leads to a BMI less than 18.5
  • An intense fear of weight gain
  • Displaying behaviors that prevent weight gain such as excessive exercise and/or purging
  • Having a distorted perception of their own weight or body shape in spite of weight loss

Now that you have a baseline overview of anorexia, let’s dive into it in more detail using the Straight A Nursing LATTE Method.

L: How will the patient LOOK?

The L in LATTE refers to more than just the patient’s physical appearance. It’s an overall view of how the individual presents, what they state as their symptoms, and what you notice about them.

The individual with anorexia will typically display the following psychological characteristics:

  • Preoccupation with food that can be obsessive. This can include fear of some foods and extreme restriction of foods.
  • Food-related rituals such as refusing to mix foods, cutting food into tiny pieces or chewing food and spitting it out instead of swallowing.
  • Overestimation of calorie consumption.
  • A worry of or avoidance of eating in public.
  • Exercise rituals and restlessness.
  • Denial of disease process and/or resistance to treatment.
  • Perfectionism/inflexible thinking and a need for control of their environment.
  • Poor sleep, depression and/or inhibited expression.
  • Anxiety and/or difficulty regulating emotions.
  • Behavioral rigidity, such as only purchasing food from certain stores.
  • Difficulty with decision making, verbal learning, memory and motor function.
  • Non-suicidal self-injury (cutting skin picking, burning).
  • An unrealistic perception of their own body weight
  • Fear of weight gain despite continued weight loss
  • Patients often equate being thin with their self-worth and can be a disruptive way to cope with emotional problems.
  • Many patients do not want treatment initially or think it is even warranted. Some may view anorexia as a lifestyle choice and fear the weight gain associated with treatment.

Physical signs/symptoms:

  • Overall impression: The individual will usually be very thin and may have edema of the extremities due to a variety of factors. These include protein losses and third spacing of fluid, hormonal changes, rapid refeedings, electrolyte imbalances, and abuse of diuretics, diet pills and laxatives. Additionally you will likely notice a loss of muscle mass with the individual complaining of weakness and fatigue. These individuals often wear baggy clothing or multiple layers and complain of often being cold.
  • Neurological: the patient may be irritable and complain of headaches or syncope.
    Cardiovascular: They could display cardiovascular signs such as bradycardia, hypotension, orthostatic hypotension and even arrhythmias. They may complain of palpitations and even chest pain, which is due to loss of cardiac muscle.
  • Respiratory: Shortness of breath, respiratory muscle weakness, and reduced aerobic capacity.
  • Gastrointestinal: The patient may complain of constipation is disease is moderate to severe. Delayed gastric emptying (gastroparesis) can cause gas, bloating, early fullness, nausea or vomiting.
  • Hematological: Severely ill patients may have anemia, leukopenia or thrombocytopenia, with petechiae or purpura on the extremities.
  • Dermatological: Possible signs include delayed wound healing, dry skin (xerosis), itching, erythema, hyperpigmentation, fine downy body hair, hair loss, yellowing of the skin due to excess carotene levels, acrocyanosis (cold and/or blue hands/feet). The hypercarotenemia that occurs with anorexia is not fully understood, though some possible causes are thought to be malfunctions in lipid metabolism, a high consumption of foods rich in carotenoids, and higher concentrations of circulating carotenoids relative to the amount of body fat.
    Patients with the purging type of anorexia nervosa may have tooth enamel erosion or calluses on their hands or knuckles from using them to purge.

A: How do you ASSESS the patient?

  • Assess for all the physiological signs described in the “L” component of LATTE, paying careful attention to intentions of self harm, blood pressure, oxygen saturation, respiratory compromise or cardiac dysfunction. In other words, anything that would require immediate attention.
  • Assess the patient’s height, weight and BMI with the understanding that patient reports may be unreliable…use a scale.
  • Ask the patient about recent weight changes, exercise habits, eating habits, food restrictions and ritualistic behaviors. Always do so in a nonjudgmental way.
  • Assess the patient’s self-esteem, perception of their weight, and for any fear of weight gain.
  • Ask the patient if they have habits of self harm or thoughts of self harm, such as cutting or suicidal ideation.
  • Assess the patient’s medical and psychiatric history. Most individuals with anorexia have a history of mental health disorders such as depression, anxiety, OCD, substance use disorders, body dysmorphic disorder, phobias around swallowing or weight gain, and even PTSD.
  • Ask female patients about their menstrual cycle, including the last date and regularity. Weight loss can contribute to secondary amenorrhea.
  • Assess the patient for use of OTC meds like laxatives or diet pills.
  • Monitor the patient’s intake and output, as well as eating patterns.

T: What TESTS will be conducted?

Screenings are often utilized to assess individuals for anorexia. These screenings include questions like, “Do you believe yourself to be fat when others say you are thin?”, “Do you ever eat in secret” and “Do you suffer with or have you ever suffered in the past with an eating disorder.”

Lab tests will be conducted to assess for common complications including anemia, leukopenia, electrolyte imbalances, disrupted renal and liver function and hypothyroidism.

An X-ray may be conducted to evaluate for loss of bone density secondary to starvation

An EKG will be conducted to assess for dysrhythmias.

T: What TREATMENTS will be provided?

The treatment for anorexia will involve a team of medical professionals that includes doctors, dieticians, mental health experts and possibly also social workers. The underlying psychological issues must be addressed while the patient receives nutrition therapy, with a goal of reaching and maintaining a healthy weight. Individuals can receive care in the outpatient setting, but will require inpatient care if the condition is not improving or their life is in danger.

Care of patients with anorexia is not limited to therapy and nutrition, they can often require complex medical care as well. Medications you may see utilized in anorexia are:

  • Metoclopramide: This medication is used for gastroparesis. It speeds gastric emptying and stimulates the stomach to contract.
  • Laxatives may be needed if the individual has constipation. Polyethylene glycol is commonly used, and if that doesn’t work, then lactulose may be added.
  • Vitamins, minerals, fluids and electrolytes will all be needed.
  • Psychopharmacology will be utilized to address underlying disorders, and commonly includes SSRIs such as fluoxetine. Olanzapine, which is an antipsychotic and mood stabilizer is sometimes used in acutely ill individuals who are not responding to other treatment. It has the added benefit of helping to increase weight.

A key component of the care of these individuals is the use of behavior contracts. These are written documents that the patient signs as a pledge to change their disruptive, disordered or unproductive behavior. When the patient agrees to the terms, they can be quite effective and are used frequently in the mental health setting.

Some key nursing interventions include:

  • Encourage positive eating and exercise habits as well as adequate hydration.
  • Monitor the individual during and after meals, including accompanying them to the bathroom to prevent purging.
  • Provide reassurance and support about the patient’s body image. Encourage expression of feelings and activities that boost self esteem.
  • Encourage the patient to focus on their food and not engage in other activities while eating.
  • Encourage family support (Peterson & Fuller, 2019).

E: How do you EDUCATE and EVALUATE for this condition?

  • Teach patients the importance of adequate nutrition. Several small meals throughout the day may be easier to manage than three larger ones.
  • Teach the importance of limiting exercise.
  • Teach individuals with constipation to drink adequate water and fiber in their diet.
  • Teach patients with gastroparesis that their symptoms are not due to eating, and that weight gain will eventually resolve the condition. In the meantime, avoiding excessive amounts of fiber may also help.
  • Teach individuals with amenorrhea that it is still possible to get pregnant, and that they should use contraception to avoid unplanned pregnancy.
  • Because approximately 35-55% of patients relapse, teach the importance of attending all follow-up medical and psychiatric appointments.
  • Advise patients not to use medications inappropriately to induce weight loss such as diet pills or laxatives.

Expected outcomes will vary based on each patient situation, but some examples include:

  • The patient will stop losing weight and weight will begin to increase
  • Disordered eating and exercise patterns will cease
  • The individual will not purge after eating
  • The individual will set realistic goals about weight gain
  • The patient will participate in observed weighing daily
  • Electrolyte levels will normalize
  • The patient will be free of abnormal heart rhythms

Complications of Anorexia

The weight loss and significant malnutrition that occur with anorexia lead to a multitude of medical complications. In general, as the body becomes starved of calories and nutrition, this leads to a loss of cell volume and atrophy of organs and muscles.

Refeeding syndrome is one of the most dangerous complications of anorexia. It can occur after a period of prolonged starvation and involves abrupt and severe electrolyte disturbances that can lead to organ failure and death. This is a complex topic worthy of its own exploration, which I will cover in depth in a future article.

Other key complications of anorexia are Wernicke encephalopathy, endocrine abnormalities, renal insufficiency, cardiac arrhythmias, heart failure, cardiac arrest, brain atrophy, and death.
If you or someone you care about suffers from an eating disorder, please reach out to the National Eating Disorders Association (NEDA) for a wealth of free resources, online chat, and a toll-free help line. If you are in crisis, text NEDA to 741741 and you’ll be connected with a trained volunteer at Crisis Text Line. Crisis Text Line utilizes text messaging to provide free 24/7 support to individuals who are struggling with mental health.

References

Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-surgical nursing: Assessment and management of clinical problems (11th ed.). Elsevier, Inc.

Klein, D., & Evelyn, A. (2021, June 4). Uptodate. Anorexia Nervosa in Adults: Clinical Features, Course of Illness, Assessment, and Diagnosis; UpToDate. https://www.uptodate.com/contents/anorexia-nervosa-in-adults-clinical-features-course- of-illness-assessment-and- diagnosis?search=anorexia&source=search_result&selectedTitle=3~150&usage_type=d efault&display_rank=3

Lackner, S., Meier-Allard, N., Mörkl, S., Müller, W., Fürhapter-Rieger, A., Mangge, H., Zelzer, S., & Holasek, S. (2021). Hypercarotenemia in anorexia nervosa patients may influence weight balance: Results of a clinical cross-sectional cohort study. Frontiers in Psychiatry, 12, 2378. https://www.frontiersin.org/articles/10.3389/fpsyt.2021.758300/full

Mayo Clinic. (n.d.). Anorexia nervosa—Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/anorexia-nervosa/symptoms-causes/syc-20353591

Mehler, P. (2021, April 7). Uptodate. Anorexia Nervosa in Adults and Adolescents: Medical Complications and Their Management; UpToDate. https://www.uptodate.com/contents/anorexia-nervosa-in-adults-and-adolescents- medical-complications-and-their- management?search=anorexia&source=search_result&selectedTitle=1~150&usage_typ e=default&display_rank=1

Moore, C. A., & Bokor, B. R. (2021). Anorexia nervosa. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK459148/

O’Toole, J. (2016, June 23). Binge / purge anorexia vs. Bulimia: A DSM 5 update. Kartini Clinic for Children and Families. https://kartiniclinic.com/blog/post/binge-purge-anorexia-vs-bulimia-a-dsm-5-update/

Perry, S. E., & Olshansky, E. F. (2018). Maternal child nursing care (Sixth edition). Elsevier.

Peterson, K., & Fuller, R. (2019). Anorexia nervosa in adolescents: An overview. Nursing, 49(10), 24–30. https://doi.org/10.1097/01.NURSE.0000580640.43071.15

Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 19, DSM-IV to DSM-5 Anorexia Nervosa Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t15/

Yager, J. (2020, October 8). Uptodate. Eating Disorders: Overview of Epidemiology, Clinical Features, and Diagnosis; UpToDate. https://www.uptodate.com/contents/eating- disorders-overview-of-epidemiology-clinical-features-and- diagnosis?search=eating%20disorders&source=search_result&selectedTitle=1~150&us age_type=default&display_rank=1