These disorders predominantly affect adolescents both male and female and cause great suffering and frustration to families, friends, and loved ones. However, there is an increased incidence of eating disorder diagnosis in midlife, and often these are an exacerbation of a previously established dormant form of anorexia. Treating these disorders can pose a formidable challenge to the health care system. The two primary categories of eating disorders discussed in this section are anorexia nervosa and bulimia nervosa. Comorbid personality disorders frequently occur among patients with an eating disorder and account for approximately 50% of individuals with anorexia and 95% with bulimia. Some of the more prominent co-occurring disorders are the mood and anxiety disorders, substance use disorders, body dysmorphic disorders, personality disorders, posttraumatic stress disorder, and impulse-control disorders, to name a few. Most people associate eating disorders with females, but up to 10% (or more) of people with eating disorders are males.

The DSM-5 (2013) has added binge-eating disorder (BED) to the category of eating disorders. BED is diagnosed when individuals engage in repeated episodes of binge eating after which they experience significant distress.

BED is a psychiatric disorder. Obesity is a medical disorder. According to the National Association of Anorexia Nervosa and Associated Disorders, the individual with BED experiences insatiable cravings at any time day and night; the disorder is thought to be rooted in poor body image and low self-esteem and tied to dysfunctional thoughts (ANAD, 2013). Anxiety, depression, and personality disorders often co-occur in BED. These individuals do not regularly use the compensatory behaviors (vomiting, use of laxatives) seen in bulimia nervosa. It is thought to account for 20% to 40% of individuals who seek treatment for obesity.

The diagnosis of anorexia nervosa is based on psychological and physical criteria. Psychological criteria include an intense fear of gaining weight or becoming fat and a gross disturbance in body image. Cardinal symptoms for anorexia nervosa include dangerously low body weight measurements relative to age and gender of the patient (Ibrahim, 2013).

Most cases of anorexia nervosa are seen in adolescent female patients, with more than 80% to 85% of cases developing between 13 and 20 years of age. Although most individuals with anorexia nervosa are adolescents, the disorder is being diagnosed in preadolescents, adults, and even older adults. Males account for approximately 19% to 30% of the younger patients diagnosed with anorexia nervosa. The issues and treatment modalities remain the same for both men and women.

Characteristically, patients with anorexia are emaciated, but they still feel “fat” and want to hide their “ugly, fat body.” Patients with this disorder might have ritualistic eating patterns and compulsive behaviors; often feel hopeless, helpless, and depressed; and might feel that the only control they can exert in their life is through the food they eat. Anorexia nervosa is called the “deadly disease” because the mortality rate is higher with these individuals than in the general population. Besides starvation, death is also related to substance abuse and suicide. There is also a surprising increased rate of death from natural causes such as cancer.

People with this disorder use two methods to control weight:

2. The restrictive approach uses low calorie intake and exercise (restricting type).

The course of anorexia can be:

• Nutritional rehabilitation with relapses

• An unremitting course resulting in death

The disease has a mortality rate of 5% (most studies) to 20% (long-term studies on ultimate mortality rate over 20 years or longer). Death occurs from starvation, fluid and electrolyte imbalance, or suicide in chronically ill patients. Elliot (2007) has identified favorable and negative prognostic indicators for anorexia nervosa:

b. Return of menses

c. Good premorbid school/work history

2. Negative prognostic indicators:

b. Multiple hospitalizations

c. Male

d. Being married

e. Premorbid disturbed family adjustment in childhood

f. Co-occurring psychiatric condition(s)

• Poor social adjustment with some areas of high functioning (e.g., intellectual)

• Odd food habits (hoarding, hiding food [e.g., in pockets, under plate])

• Hyperactivity (compulsive and obsessive exercise and/or secretive physical activity in an attempt to burn calories)

• Mood and/or sleep disturbances

• Obsessive-compulsive behaviors (e.g., eating only one pea at a time, arranging and rearranging food on the plate before each bite, or cutting food into tiny pieces and chewing each piece excessively)

• Perfectionist

• Introverted; avoids intimacy and sexual activity

• Denies feelings of sadness or anger, and will often appear pleasant and compliant

• Although cachectic, patients see themselves as fat (a sign of an unrealistic body image)

• Families often have rigid rules and high expectations for their members

• Changes in cardiac status (e.g., bradycardia, hypotension, dysrhythmia)

• Dry, yellowish skin

• Amenorrhea, infertility

• Hair loss, possible presence of lanugo (fine body hair covering)

• Decreased metabolic rate

• Chronic constipation

• Fatigue and lack of energy

• Insomnia

• Loss of bone mass, osteoporosis

• In patients who vomit or use laxatives to purge, loss of tooth enamel and scarring of the back of the hand from inducing vomiting, and enlarged salivary glands might be seen. Serum amylase level is often elevated.

• Dehydration, edema

Determine if:

2. The family has information about the disease and knows where to get support.

3. The patient is amenable to attending appropriate therapeutic modalities and will be adherent.

4. Family counseling has been offered to the family or individual family members for support, or to target a family or individual family member’s problem.

5. A thorough physical examination with appropriate blood work has been done.

6. Other medical conditions have been ruled out.

7. The patient and family need further teaching or information regarding the treatment plan (e.g., psychopharmacological interventions, behavioral therapy, cognitive therapy, family therapy, individual psychotherapy). If the patient is a candidate for partial hospitalization, can the patient and family discuss their function?

8. The patient and family desire a support group; if yes, provide referrals.

Eating disorders have both physiological and psychological components. The aims of treatment are survival based:

• Restore healthy eating habits.

• Treat physical complications.

• Address dysfunctional beliefs.

• Intervene in those dysfunctional thoughts, feelings, and beliefs.

• Deal with affective and behavioral issues.

• Include family therapy when appropriate and possible.

• Teach relapse prevention.

• Normalization of eating behavior

• Change in the pursuit of thinness

• Prevention of relapse

2. Do a self-assessment, and be aware of your own reactions that might hinder your ability to help the patient. Some nurses might:

• Resent the patient, believing that the disorder is self-inflicted.

• Feel helpless to change the patient’s behavior, leading to anger, frustration, and criticism.

• Become overwhelmed by the patient’s problems, leading to feelings of hopelessness or setting rigid limits to feel more in control of the patient’s behavior.

• Be swept up into power struggles with the patient, resulting in angry feelings in the nurse toward the patient.

When any of these or other negative feelings toward the patient arise, supervision and/or peer review is needed to help shape the nurse’s perspective and lessen feelings of helplessness, guilt, need for control, frustration, or hopelessness.

3. When problems in the family contribute to the feeling of loss of control, family therapy has provided a significant improvement rate.

4. Individual therapy and group therapy are essential in treating patients with eating disorders. Treatment for anorexic patients often includes a behavior modification program, especially initially. Family therapy and family education are often key to a patient’s success.

5. Behavior therapy is often used to change the eating patterns of an anorexic patient who is seriously close to death. This is usually implemented after the patient has been tube fed to prevent death.

6. Refrain from focusing on the patient’s need to eat; recognize that other nonfood factors are the heart of the problem.

7. Monitor laboratory values, and report abnormal values to the primary clinician.

• Weight is maintained within a medically safe range

• Patient’s cardiac status will be within normal limits by (date).

• Patient will achieve 85% to 90% of ideal body weight.

• Patient will commit to long-term treatment to prevent relapse by (date).

• Patient will demonstrate regular independent nutritional eating habits by (date).

• Patient will be free from physical complications.

Patient will:

• Gain no more than _____ during the first week of refeeding, as decided by patient and health team

• Exercise in limited amounts only when assessed to be both nutritionally and medically stable

• Formulate with the nurse a nurse-patient contract facilitating a therapeutic alliance and a commitment to treatment on the part of the patient