Eating Disorders: Anorexia & Bulimia Nervosa

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Eating Disorders are illnesses that are characterized by irregular eating habits and extreme distress or concern about body weight or shape. Eating disturbances may involve inadequate or excessive food intake which can basically cause harm to a person’s well-being. The most common forms of eating disorders are anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, avoidant or restrictive food intake disorder (ARFID), and other specified feeding or eating disorder (OSFED). Read this study guide and learn more about eating disorders (anorexia nervosa and bulimia nervosa), its nursing care management, interventions, and assessment.

What are Eating Disorders? 

Eating disorders are characterized by a repeated disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly diminishes physical health or psychosocial functioning. Eating disorders can be viewed on a continuum, with clients with anorexia nervosa eating too little or starving themselves, client with bulimia eating chaotically, and clients with obesity eating too much.

  • 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 apparently 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.

Types of Eating Disorders

The most common eating disorders found in the mental health setting are anorexia nervosa, bulimia nervosa, binge-eating disorder, pica, rumination disorder, avoidant or restrictive food intake disorder (ARFID), and other specified feeding or eating disorder (OSFED).

  • Anorexia Nervosa. Anorexia nervosa is a life-threatening eating disorder characterized by the client’s refusal or inability 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.
  • Bulimia Nervosa. Bulimia nervosa, often simply called bulimia, is an eating disorder characterized by recurrent episodes (at least twice a week for 3 months) of binge eating followed by inappropriate compensatory behaviors to avoid weight gain such as purging, fasting, or excessively exercising.
  • Binge-Eating Disorder (BED). Binge-eating disorder is another eating disorder characterized by recurrent episodes of binge eating but it is not associated with the recurrent use of inappropriate compensatory behaviours as in bulimia nervosa, and does not occur exclusively during the course of bulimia nervosa, or anorexia nervosa methods to compensate for overeating, such as self-induced vomiting.
  • Pica. Pica is an eating disorder that involves persistent eating of non-nutritive substances such as hair, dirt, and paint chips for a period of at least one month.
  • Rumination disorder. Rumination disorder is characterized by repeatedly and persistently regurgitating food after eating, but it’s not due to a medical condition or another eating disorder such as anorexia nervosa, bulimia nervosa, binge-eating disorder, or avoidant/restrictive food intake disorder.
  • Avoidant/Restrictive Food Intake Disorder (ARFID). Avoidant or restrictive food intake disorder is an eating or feeding disturbance characterized by persistent failure to meet appropriate nutritional or energy needs due to having no interest in eating regarding food with certain sensory characteristics, such as color, texture, smell or taste; or fear of choking.
  • Other Specified Feeding or Eating Disorder (OSFED). Other specified feeding or eating disorders or (OSFED) are eating behaviors that cause clinically compelling distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders.

Causes

A specific cause for eating disorders is unknown; initially, dieting may be the stimulus that leads to their development.

  • Biologic factors. Studies of anorexia nervosa have shown that these disorders tend to run in families; genetic vulnerability also might result from a particular personality type or a general susceptibility to psychiatric disorders.
  • Developmental factors. Onset of anorexia nervosa usually occurs during adolescence or young adulthood; some researchers believe its causes are related to developmental issues.
  • Family influences. Girls growing up amid family problems and abuse are at higher risk for both anorexia and bulimia; disorders eating is a common response to family discord.
  • Sociocultural factors. Adolescents often idealize actresses and models as having the perfect “look” or body even though many of these celebrities are underweight or use special effects to appear thinner than they are; pressure from others also may contribute to eating disorders.

Statistics and Incidences

Obesity has been identified as a major health problem in the United States; some call it an epidemic. Millions of women are either starving themselves or engaging in chaotic eating patterns that can lead to death.

  • 30% to 35% normal-weight people with bulimia have a history of anorexia nervosa and low body weight, and about 50% of people with anorexia nervosa exhibit bulimic behavior.
  • More than 90% of cases of anorexia nervosa and bulimia occur in females (American Psychiatric Association, 2000).
  • The prevalence of both eating disorders is estimated to be 1% to 3% of the general population in the United States.

Clinical Manifestations

The following are the signs and symptoms of eating disorders:

Symptoms of anorexia nervosa include:

  • Fear of gaining weight or becoming fat even when severely underweight.
  • Body image disturbance.
  • Amenorrhea or absence of menstrual period.
  • Depressive symptoms such as depressed mood, social withdrawal, irritability, and insomnia.
  • Preoccupation with thoughts of food.
  • Feelings of ineffectiveness.
  • Inflexible thinking.
  • Strong need to control environment.
  • Limited spontaneity and overly restrained emotional expression.
  • Complaints of constipation and abdominal pain.
  • Cold intolerance.
  • Lethargy.
  • Emaciation.
  • Hypotension, hypothermia, bradycardia.
  • Hypertrophy of salivary glands.
  • Elevated BUN.
  • Electrolyte imbalances.
  • Leukopenia and mild anemia.
  • Elevated liver function studies.

Symptoms of bulimia nervosa include:

  • Recurrent episodes of binge eating.
  • Compensatory behavior such as self-induced vomiting, misuse of laxatives, diuretics, enema or other medications, or excessive exercise.
  • Self-evaluation overly influenced by body shape and weight.
  • Usually within normal weight range, possible underweight or overweight.
  • Restriction of total calorie consumption between binges, selecting low-calorie foods while avoiding foods perceived to be fattening or likely to trigger a binge.
  • Depressive and anxiety symptoms.
  • Possible substance use involving alcohol and stimulants.
  • Loss of dental enamel.
  • Chipped, ragged, or moth-eaten appearance of teeth.
  • basic testsIncreased dental caries.
  • Menstrual irregularities.
  • Dependence on laxatives.
  • Esophageal tears.
  • Fluid and electrolyte abnormalities.
  • Metabolic alkalosis (from vomiting) or metabolic acidosis (from diarrhea).
  • Mildly elevated serum amylase levels.

Assessment and Diagnostic Findings

The following diagnostic tests and assessment cues are commonly used for patients suspected with eating disorders:

  • Physical and mental status evaluation. 
  • Complete blood count (CBC). The hemoglobin levels are typically normal, although elevations are observed in states of dehydration; the white blood cell count (WBC) is typically low due to increased margination, and thrombocytopenia is also observed.
  • Blood chemistries. Hyponatremia (reflects excess water intake or the inappropriate secretion of antidiuretic hormone), hypokalemia (results from diuretic or laxative use), hypoglycemia (results from the lack of glucose precursors in the diet or low glycogen stores; low blood glucose may also be due to impaired insulin clearance), elevated blood urea nitrogen (renal function is generally normal except in patients with dehydration, in whom the BUN level may be elevated), Hypokalemic hypochloremic metabolic alkalosis (observed with vomiting), acidosis (observed in cases of laxative abuse).
  • Liver function tests. Liver function test results are minimally elevated, but levels encountered in patients with active hepatitis are not observed; albumin and protein levels are usually normal, because although the amount of food intake is restricted, it usually contains high-quality proteins.

Medical Management

Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte imbalances.

  • Nutritional rehabilitation and weight restoration. Clients receive nutritionally balanced meals and snacks that gradually increase caloric intake to a normal level for size, age, and activity.
  • Family-based therapy. Individuals with anorexia nervosa may respond best to family-based treatment, also known as the Maudsley method, an established therapeutic modality for achieving and maintaining remission from anorexia nervosa.
  • Cognitive behavioral therapy (CBT). CBT is an evidence-based, effective treatment for bulimia nervosa (BN); behavioral approaches to avoiding undesirable eating habits are used, including diary keeping; behavioral analyses of the antecedents, behaviors, and consequences (so-called ABCs) associated with binge eating and purging episodes; and exposure to food paired with progressive response prevention regarding binge eating and purging.
  • Interpersonal psychotherapy. Interpersonal psychotherapy (IPT) addresses specific issues in the interpersonal arena that create the context for and stimulate dynamic tensions that spur the patient’s symptoms; these generally encompass such processes as grief, role transitions, role conflicts or disputes, and interpersonal deficits.

Pharmacologic Management

Several classes of drugs have been studied, but few have shown clinical success.

  • Electrolyte supplements. Electrolyte repletion is necessary in patients with profound malnutrition, dehydration, and purging behaviors; repletion may be done orally or parenterally, depending on the patient’s clinical state.
  • Fat-soluble vitamins. Vitamins are used to meet necessary dietary requirements. They are utilized in metabolic pathways, as well as in deoxyribonucleic acid (DNA) and protein synthesis.
  • Antidepressants, SSRIs. These agents have been reported to reduce binge eating, vomiting, and depression and to improve eating habits, although their impact on body dissatisfaction remains unclear.

Nursing Management for Eating Disorders

Nursing care for a client with eating disorder include the following:

Nursing Assessment

Although anorexia and bulimia have several differences, many similarities are found when assessing.

  • History. Family members often describe clients with anorexia nervosa as perfectionists with above-average intelligence, achievement oriented, dependable, eager to please, and seeking approval before their condition began; clients with bulimia, however, often have a history of impulsive behavior such as substance abuse, shoplifting, as well as anxiety, depression, and personality disorders.
  • General appearance and motor behavior. Clients with anorexia appear slow, lethargic, and fatigued; they may be emaciated depending on the amount of weight loss; clients with bulimia may be underweight or overweight but are generally close to expected body weight for age and size.
  • Mood and affect. Clients with eating disorders have labile moods that usually correspond to their eating or dieting behaviors.
  • Though processes and content. Clients with eating disorders spend most of the time thinking about dieting, food, and food-related behavior.
  • Self-concept. Low self-esteem is prominent in clients with eating disorders.

Nursing Diagnosis

Nursing diagnoses for clients with eating disorders include the following:

Nursing Care Planning and Goals

Nursing care plans and goals for clients with eating disorders:

For the main article, visit: 7 Eating Disorders: Anorexia Nervosa and Bulimia Nursing Care Plans.

  • The client will establish adequate nutritional eating patterns.
  • The client will eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics.
  • The client will demonstrate coping mechanisms not related to food.
  • The client will verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
  • The client will verbalize acceptance of body image with stable body weight.

Nursing Interventions

Nursing interventions for clients with eating disorders are:

  • Establishing nutritional eating patterns. When clients can eat, a diet of 1200 to 1500 calories per day is ordered, with gradual increases in calories until clients are ingesting adequate amounts for height, activity level, and growth needs; 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; after each meal or snack, clients may be required to remain in view of staff for 1 to 2 hours to ensure that they do not empty the stomach by vomiting.
  • Identifying emotions and developing coping strategies. 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.
  • Dealing with body image issues. The nurse can help clients to 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; helping clients to identify areas of personal strength that are not food related broaden’s client’s perceptions of themselves.

Evaluation

Goals are met as evidenced by:

  • The client was able to establish adequate nutritional eating patterns.
  • The client was able to eliminate use of compensatory behaviors such as excessive exercise and use of laxatives and diuretics.
  • The client was able to demonstrate coping mechanisms not related to food.
  • The client was able to verbalize feelings of guilt, anger, anxiety, or an excessive need for control.
  • The client was able to verbalize acceptance of body image with stable body weight.

Documentation Guidelines

Documentation in a client with eating disorder include:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Practice Quiz: Eating Disorders

Nursing practice questions for Eating Disorders. For more practice questions, visit our NCLEX practice questions page.

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1. Nurse Naomi observes Ashley who is hospitalized on an eating disorder unit during mealtimes and for 1 hour after eating. An explanation for this intervention is:

A. To reinforce the behavioral contact
B. To prevent purging behaviors
C. To develop a trusting relationship
D. To maintain focus on the importance of nutrition

1. Answer: B. To prevent purging behaviors.

  • Option B: Ashley may experience increased anxiety during treatment and, therefore, may resume behaviors designed to prevent weight gain, such as vomiting or excessive exercise.

2. Caroline is diagnosed with anorexia nervosa and is admitted to the special eating disorder unit. The initial treatment priority for her is:

A. To promote the client’s independence
B. To determine her current body image
C. To identify family interaction patterns
D. To initiate a refeeding program

2. Answer: D. To initiate a refeeding program.

  • Option D: The physical need to reestablish near-normal weight takes priority because of the physiologic, life-threatening consequences of anorexia.

3. Nurse Donald is planning a psychoeducational discussion for a group of adolescent clients with anorexia nervosa. Which of the following topics would Nurse Donald select to enhance understanding about central issues in this disorder?

A. Peer pressure and substance abuse
B. Self-esteem and self-control
C. Anger management
D. Parental expectations

3. Answer: B. Self-esteem and self-control

  • Option B: Self-esteem and self-control are central issues for clients with eating disorders. Such clients feel a loss of self-control over their life and experience diminished self-esteem and severe doubts about their self-worth.

4. Nurse Eugenia understands that her client Michelle who is bulimic feels shame and guilt over binge eating and purging. This disorder is therefore considered:

A. Ego-dystonic
B. Ego-enhancing
C. Ego-syntonic
D. Ego-distorting

4. Answer: A. Ego-dystonic.

  • Option A: An ego-dystonic disorder is one in which the client views behaviors or symptoms as incongruent with self-image and therefore feels guilt, shame, and distress about the symptoms.
  • Option C: An ego-syntonic disorder is one which the client views behaviors as congruent with her self-image (as in anorexia nervosa).

5. The psychoanalytic theory explains the etiology of anorexia nervosa as:

A. Family dynamics that lead to enmeshment of members
B. The achievement of secondary gain through control of eating
C. The incorporation of thinness as an ideal body image
D. A conflict between mother and child over separation and individualization

5. Answer: D. A conflict between mother and child over separation and individualization.

  • Option D: According to psychoanalytic theory, early mother-child dynamics lead to difficulty with a child establishing a sense of separateness from the mother. Control of eating becomes one area in which the child establishes a sense of independence.

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