The three main eating disorders are anorexia nervosa, bulimia nervosa, and binge eating disorder (American Psychiatric Association, 2013). Some behaviors do not meet the specifications for full-blown eating disorders but do cause problems with food intake. They are categorized under other specified feeding or eating disorder and unspecified feeding or eating disorder (Walsh & Sysko, 2009).

Individuals with anorexia nervosa refuse to maintain a minimally normal weight for height and express intense fear of gaining weight. The term anorexia is a misnomer, because loss of appetite is rare. Some people with anorexia nervosa restrict their intake of food; others engage in binge eating and purging. Individuals with bulimia nervosa engage in repeated episodes of binge eating followed by inappropriate compensatory behaviors, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. These disorders are characterized by a significant disturbance in the perception of body shape and weight (Sysko et al., 2012). Individuals with binge eating disorder engage in repeated episodes of binge eating, after which they experience significant distress. These individuals do not regularly use the compensatory behaviors that are seen in patients with bulimia nervosa. Although individuals who start binge eating may be of normal weight, repeated bingeing inevitably causes obesity in this cohort. Box 18-1 identifies characteristics of anorexia nervosa, bulimia nervosa, binge eating, and other specified feeding and eating disorders.

BOX 18-1 CHARACTERISTICS OF EATING PROBLEMS

ANOREXIA NERVOSA	BULIMIA NERVOSA	BINGE EATING
• Intense fear of weight gain • Distorted body image • Restricted calories with significantly low BMI • Subtypes: • Restricting (no consistent bulimic features) • Binge/eating/purging type (primarily restriction, some bulimic behaviors)	• Recurrent episodes of uncontrollable binging • Inappropriate compensatory behaviors: vomiting, laxatives, diuretics, or exercise • Self-image largely influenced by body image	• Recurrent episodes of uncontrollable binging without compensatory behaviors • Binging episodes induce guilt, depression, embarrassment or disgust

Hospitalization for anorexia nervosa is often necessary due to the life-threatening effect that starvation has on the body. Inpatient treatment may be required for people with bulimia nervosa, especially if they have co-occurring depression and suicidal ideation. See criteria for hospitalization for these disorders in Box 18-2. People with binge eating disorder are not typically hospitalized for the eating disorder but may require psychiatric treatment for other disorders. Additionally, binge eating disorder results in a vast array of physical problems that often require inpatient treatment.

BOX 18-2 CRITERIA FOR HOSPITAL ADMISSION OF PATIENTS WITH EATING DISORDERS

Physical criteria

• Weight loss over 30% over 6 months

• Rapid decline in weight

• Inability to gain weight with outpatient treatment

• Severe hypothermia due to loss of subcutaneous tissue or dehydration (temperature lower than 36° C or 96.8° F)

• Heart rate less than 40 beats per minute

• Systolic blood pressure less than 70 mm Hg

• Hypokalemia (less than 3 mEq/L) or other electrolyte disturbances not corrected by oral supplementation

• Electrocardiographic changes (especially arrhythmias)

Psychiatric criteria

• Suicidal or severely out-of-control, self-mutilating behaviors

• Out-of-control use of laxatives, emetics, diuretics, or street drugs

• Failure to comply with treatment contract

• Severe depression

• Psychosis

• Family crisis or dysfunction

Epidemiology

For women, the lifetime incidence of anorexia nervosa, bulimia nervosa, and binge eating disorder is 0.9%, 1.5%, and 3.5%, respectively; and the lifetime incidence for men is 0.3%, 0.5%, and 2% (Hudson et al., 2007). It is extremely difficult to determine the specific number of people afflicted with eating disorders since fewer than half seek health care for their illness. With revised criteria for the eating disorders, these statistics can be expected to change in coming years. Most eating disorders begin in the early teens to mid-20s although they commonly occur following puberty, with bulimia occurring in later adolescence. Anorexia nervosa may start early (between ages 7 and 12), but bulimia nervosa is rarely seen in children younger than 12 years.

Comorbidity

Comorbidity for patients with eating disorders is more likely than not. (Treasure et al., 2010). In a replication of the National Comorbidity Survey, respondents with anorexia nervosa, bulimia nervosa, and binge eating disorder also met criteria for at least one of the core DSM IV disorders at rates of 56%, 94%, and 79%, respectively (Hudson et al., 2007).

In individuals 13 to 18 years of age, anorexia nervosa is associated with oppositional defiant disorder (Swanson et al., 2011). For this age group, bulimia and binge eating mood and anxiety disorders are strongly associated with mood and anxiety disorders.

Personality disorders occur more often in the eating-disordered population than the general population. In particular, obsessive-compulsive personality disorder represents only 8% of the general population but accounts for 22% of anorexia nervosa restricting type. Borderline personality disorder occurs in 6% of the general population but represents 25% of anorexia nervosa binge eating purging type and 28% of bulimia nervosa patients (Sansone & Sansone, 2011).

Overeating is frequently noted as a symptom of an affective disorder (e.g., atypical depression). Higher rates of affective and personality disorders are found among binge eaters. Binge eaters report a history of major depression and anxiety disorders significantly more often than non–binge eaters, with lifetime rates of 45.3% to 65.2% (Swanson et al., 2011).

Etiology

Childhood trauma and sexual abuse have been reported in 20% to 50% of patients with eating disorders, and those patients with reported abuse have poorer outcomes from treatment than those who don not. Physical neglect, emotional abuse, and sexual abuse have been found to be significant predictors for eating disorders (Kong & Bernstein, 2009).

The eating disorders—anorexia nervosa, bulimia nervosa, and binge eating disorder—are actually entities or syndromes and are not considered to be specific diseases. It is not known if they share a common cause and pathology; therefore, it may be more appropriate to conceptualize them as syndromes on the basis of the cluster of symptoms they present (Halmi, 2011). A number of theories attempt to explain eating disorders. Because binge eating disorder has been newly defined, little comparative research has been done to show how this pattern of eating is similar to the others in etiology or progression.

Biological factors

Genetic

There is a strong genetic link for eating disorders. In fact, a literature search of relevant studies has suggested that the heritability of anorexia nervosa is 60% (Bienvenu et al., 2011). A genetic vulnerability may lead to poor affect and impulse control or to an underlying neurotransmitter dysfunction, but no single causative gene has been discovered to date. The most recent research suggests that there is a gene-environmental interaction that may be responsible for the prevalence of the eating disorders (Campbell et al., 2011).

Neurobiological

Research demonstrates that altered brain serotonin function contributes to dysregulation of appetite, mood, and impulse control in the eating disorders. These patients consistently exhibit personality traits of perfectionism, obsessive-compulsiveness, and dysphoric mood, all of which are modulated through serotonin pathways in the brain. Because these traits appear to begin in childhood—before the onset of actual eating-disorder symptoms—and persist into recovery, they are believed to contribute to a vulnerability to disordered eating (Kaye & Strober, 2009).

Tryptophan, an amino acid essential to serotonin synthesis, is only available through diet. A normal diet boosts serotonin in the brain and regulates mood. Temporary drops in dietary tryptophan may actually relieve symptoms of anxiety and dysphoria and provide a reward for caloric restriction; however, continued malnutrition will result in a physiological dysphoria. This cycle of temporary relief, followed by more dysphoria, sets up a positive feedback loop that reinforces the disordered eating behavior (Kaye et al., 2009). This dietary need for tryptophan may account for the fact that antidepressants that boost serotonin do not improve mood symptoms until after an underweight patient has been restored to 90% of optimal weight.

Newer brain imaging capabilities allow for better understanding of the etiological factors of anorexia nervosa. Much research has focused on the changes that occur in the brains of patients during the active phase of the eating disorder and after a period of recovery. Comparing brain images will help researchers to distinguish between the physiological effects of starvation and the pathology associated with the disorder (Kaye et al., 2009).

Psychological factors

Because anorexia nervosa was observed primarily in girls approaching puberty, early psychoanalytic theories linked the symptoms to an unconscious aversion to sexuality. Throughout the 20th century many authors examined the family dynamics of these patients and concluded that a failure to separate from parents and a rebellion against the maternal bond explained the disordered eating behaviors. Further work by Bruch in the 1970s explored the symptoms as a defense against an overwhelming feeling of ineffectiveness and powerlessness. Even with these theories of unconscious processes, therapies based on this understanding have not made a major impact (Caparrotta & Ghaffari, 2006).

EVIDENCE-BASED PRACTICE

Does Viewing Pro-Anorexia Websites Predict Development of an Eating Disorder?

Custers, K., & Van den Bulck, J. (2009). Viewership of pro-anorexia websites in seventh, ninth and eleventh graders. European Eating Disorders Review, 17(3), 214–219. doi: 10.1002/erv.910.

Problem

With the increased use of the Internet to find information, more adolescents are exposed to websites that promote behaviors common to anorexia nervosa, called “pro-ana” sites. Other studies have shown that children with eating disorders are known to visit these sites, but little is known about the overall characteristics of viewers of these sites.

Purpose of the study

The purpose of this study was to identify the frequency of girls and boys viewing these sites and also to determine if there is a relationship between the attitudes of these viewers and known predictors of anorexia nervosa.

Methods

This qualitative study sampled 711 boys and girls enrolled in the seventh, ninth, and eleventh grades in a single, assembly-type testing session in Flanders, Belgium. The study included questions about how often they visited pro-ana websites and their attitudes toward the existence of these sites. There were also questions that measured the student’s drive for thinness, perfectionism, body mass index, and perception of their own appearance. A logical regression was used to test the relationship between gender, grade, and attitude toward pro-ana sites with the actual prevalence of visiting these websites. Another analysis examined the correlation between prevalence of viewing these websites and the drive for thinness, perception of appearance, and perfectionism.

Key findings

• Both girls and boys admit to visiting pro-ana websites.

• Only one fourth of the participants regard these websites as totally unacceptable.

• Girls who have visited pro-ana sites have a higher drive for thinness and perfectionism.

• Visiting pro-ana sites is significantly correlated with predictors of anorexia nervosa.

Implications for nursing practice

Visiting pro-anorexia websites is not without risks. They attract both boys and girls but are more often viewed by girls. These websites provide adolescents with a social support community that can reinforce attitudes and behaviors that are consistent with disordered eating patterns. Patients with anorexia nervosa often try to rationalize their food choices as a lifestyle and not a mental disorder with life-threatening consequences. It is more difficult to change this attitude when the online environment provides “evidence” for the truth of this belief.

Currently, cognitive-behavioral theorists suggest that eating disorders are based on learned behavior that has positive reinforcement. For example, a mildly overweight 14-year-old has the flu and loses a little weight. She returns to school, and her friends say, “Wow, you look great.” Now she purposefully strives to lose weight. When people say, “Wow, you look really skinny,” she hears, “Wow, you look great.” Her behavior is powerfully reinforced by these comments despite the fact that her health is at risk.

Family theorists maintain that eating disorders are a problem of the whole family, but research has not been able to determine any definitive family characteristics specific to the eating disorders. In general, family therapies focus on facilitating emotional communication and conflict resolution (le Grange et al., 2010).

Environmental factors

Studies have shown that culture influences the development of self-concept and satisfaction with body size. The Western cultural ideal that equates feminine beauty to tall, thin models has received much attention in the media as an etiology for the eating disorders. However, research has not proven a direct relationship between social ideals portrayed in the media and the development of an eating disorder. It is known that peer behaviors and attitudes may contribute to the body dissatisfaction that all eating disordered patients feel (Eisenberg & Neumark-Sztainer, 2010; Ferguson et al., 2011).

The rate of obesity in the United States is at an alarming level, as 35.5% of adult women and 15% of 2- to 19-year-old girls are obese (Ogden et al., 2012). Record numbers of men and women are on diets to reduce body weight, but no study has been able to explain why only an estimated 0.3% to 3% of the population develops an eating disorder. Research has not proven a direct relationship between social ideals portrayed in the media and the development of an eating disorder; however, peer behaviors and attitudes may contribute to the body dissatisfaction that all eating-disordered patients feel (Eisenberg & Neumark-Sztainer, 2010; Ferguson et al., 2011).

Anorexia nervosa

Application of the nursing process

Assessment

Anorexia nervosa is a serious psychiatric disorder. Box 18-3 lists several thoughts and behaviors associated with anorexia nervosa, and Table 18-1 identifies clinical signs and symptoms of anorexia nervosa along with their causes.

BOX 18-3 THOUGHTS AND BEHAVIORS ASSOCIATED WITH ANOREXIA NERVOSA

• Terror of gaining weight

• Preoccupation with thoughts of food

• View of self as fat even when emaciated

• Peculiar handling of food: cutting food into small bits

• Pushing pieces of food around plate

• Possible development of rigorous exercise regimen

• Possible self-induced vomiting, use of laxatives and diuretics

• Cognition so disturbed that individual judges self-worth by his or her weight

TABLE 18-1

POSSIBLE SIGNS AND SYMPTOMS OF ANOREXIA NERVOSA

CLINICAL PRESENTATION	CAUSE
Low weight	Caloric restriction, excessive exercising
Amenorrhea	Low weight
Yellow skin	Hypercarotenemia
Lanugo	Starvation
Cold extremities	Starvation
Peripheral edema	Hypoalbuminemia and refeeding
Muscle weakening	Starvation, electrolyte imbalance
Constipation	Starvation
Abnormal laboratory values (low triiodothyronine, thyroxine levels)	Starvation
Abnormal computed tomographic scans, electroencephalographic changes	Starvation
Cardiovascular abnormalities (hypotension, bradycardia, heart failure)	Starvation, dehydration
	Electrolyte imbalance
Impaired renal function	Dehydration
Hypokalemia (low potassium)	Starvation
Anemic pancytopenia	Starvation
Decreased bone density	Estrogen deficiency, low calcium intake

Eating disorders are serious and in extreme cases can lead to death. Box 18-4 identifies a number of medical complications that can occur in individuals with anorexia nervosa and the laboratory findings that may result. Because the eating behaviors in these conditions are so extreme, hospitalization may become necessary (often via the emergency department).

BOX 18-4

MEDICAL COMPLICATIONS OF ANOREXIA NERVOSA

• Bradycardia

• Orthostatic changes in pulse or blood pressure

• Cardiac arrhythmias

• Prolonged QT interval and ST-T wave abnormalities

• Peripheral neuropathy

• Acrocyanosis

• Symptomatic hypotension

• Leukopenia

• Lymphocytosis

• Carotenemia (elevated carotene levels in blood), which produces skin with yellow pallor

• Hypokalemic alkalosis (with self-induced vomiting or use of laxatives and diuretics)

• Elevated serum bicarbonate levels, hypochloremia, and hypokalemia

• Electrolyte imbalances, which lead to fatigue, weakness, and lethargy

• Osteoporosis, indicated by decrease in bone density

• Fatty degeneration of liver, indicated by elevation of serum enzyme levels

• Elevated cholesterol levels

• Amenorrhea

• Abnormal thyroid functioning

• Hematuria

• Proteinuria

Data from Halmi, K. A. (2008). Eating disorders: Anorexia nervosa, bulimia nervosa, and obesity. In R. E. Hales, S. C. Yudofsky, & G. O. Gabbard (Eds.), Textbook of psychiatry (5th ed., pp. 762, 769–770). Washington, DC: American Psychiatric Publishing.

Fundamental to the care of individuals with eating disorders is establishing and maintaining a therapeutic alliance. This will take both time and diplomacy on the part of the nurse. In treating patients who have been sexually abused or who have otherwise been victims of boundary violations, it is critical that the nurse and other health care workers maintain and respect clear boundaries (Wright & Hacking, 2011).

General assessment

Individuals with the binge-purge type of anorexia nervosa may present with severe electrolyte imbalance (as a result of purging) and enter the health care system through admission to an intensive care unit. The patient with the restricting type of anorexia will be severely underweight and may have growth of fine, downy hair (lanugo) on the face and back. The patient will also have mottled, cool skin on the extremities and low blood pressure, pulse, and temperature readings, consistent with a malnourished, dehydrated state (see Table 18-1).

As with any comprehensive psychiatric nursing assessment, a complete evaluation of biopsychosocial function is mandatory. The areas to be covered include the patient’s:

• Perception of the problem

• Eating habits

• History of dieting

• Methods used to achieve weight control (restricting, purging, exercising)

• Value attached to a specific shape and weight

• Interpersonal and social functioning

• Mental status and physiological parameters

Self-assessment

When caring for the patient with anorexia, you may find it difficult to appreciate the compelling force of the illness, incorrectly believing that weight restriction, bingeing, and purging are self-imposed. If we see such self-destructive behaviors as choices, it is only natural to blame the patient for any consequent health problems. The common personality traits of these patients—perfectionism, obsessive thoughts and actions relating to food, intense feelings of shame, people pleasing, and the need to have complete control over their therapy—pose additional challenges.

In your efforts to motivate such patients and take advantage of their decision to seek help and be healthier, take care not to allow encouragement to cross the line into authoritarianism and assumption of a parental role. A patient’s terror at gaining weight and her or his resistance to clinical interventions may engender significant frustration in the nurse struggling to build a therapeutic relationship and be empathetic. Guard against any tendency to be coercive in your approach, and be aware that one of the primary goals of treatment—weight gain—is the very thing the patient fears. When patients appear to be resistant to change, it is helpful to acknowledge the constant struggle that so characterizes the treatment.

ASSESSMENT GUIDELINES

Anorexia Nervosa

Determine whether:

1. The patient has a medical or psychiatric condition that warrants hospitalization (see Box 18-2).

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

3. Other medical conditions have been ruled out.

4. The patient is amenable to receiving or compliant with appropriate therapeutic modalities.

5. The family and patient need further teaching or information regarding the patient’s treatment plan (e.g., psychopharmacological interventions, behavioral therapy, cognitive therapy, family therapy, individual psychotherapy).

6. The patient and family desire to participate in a support group.

7. The patient and family have been provided referral to a support group.

Diagnosis

Imbalanced nutrition: less than body requirements is usually the most appropriate initial nursing diagnosis for individuals with anorexia and generates further nursing diagnoses. They include Decreased cardiac output, Risk for injury (electrolyte imbalance), and Risk for imbalanced fluid volume (which would have first priority when problems are addressed). Other nursing diagnoses include Disturbed body image, Ineffective coping, Chronic low self-esteem, and Powerlessness.

Outcomes identification

Outcomes are patient-centered and should always be developed in conjunction with the person diagnosed with anorexia nervosa or someone who can represent the person. To evaluate the effectiveness of treatment, outcome criteria are established to measure treatment results. The most important outcome is in the attainment of a safe weight. Table 18-2 identifies signs and symptoms commonly experienced with anorexia nervosa, offers potential nursing diagnoses, and suggests outcomes.

TABLE 18-2

SIGNS AND SYMPTOMS, NURSING DIAGNOSES, AND OUTCOMES FOR ANOREXIA NERVOSA

SIGNS AND SYMPTOMS	NURSING DIAGNOSES	OUTCOMES
Emaciation, dehydration, arrhythmias, inadequate intake, dry skin, decreased blood pressure, decreased urine output, increased urine concentration, weakness	Imbalanced nutrition: less than body requirementsDecreased cardiac output Risk for injury (electrolyte imbalance) Risk for imbalanced fluid volume	Nutrients are ingested and absorbed to meet metabolic needs; cardiac pump supports systemic perfusion pressure; electrolytes are in balance; fluids are in balance
Excessive self-monitoring, describes self as fat despite emaciation	Disturbed body image	Congruence between body reality, body ideal, and body presentation; satisfaction with body appearance
Destructive behavior toward self, poor concentration, inability to meet role expectations, inadequate problem solving	Ineffective coping	Demonstrates effective coping, reports decrease in stress, uses personal support system, uses effective coping strategies, reports increase in psychological comfort
Indecisive behavior, lack of eye contact, passive, reports feelings of shame, rejects positive feedback about self	Chronic low self-esteemPowerlessness	Verbalizes a positive level of confidence; makes informed life decisions, expresses independence with decision-making processes

From Herdman, T. H. (Ed.), (2012). Nursing diagnoses—Definitions and classification 2012-2014. Copyright © 2012, 1994-2012 by NANDA International. Used by arrangement with John Wiley & Sons Limited; Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (2013). Nursing outcomes classification (NOC) (5th ed.). St. Louis, MO: Mosby.

Planning

Planning is affected by the acuity of the patient’s situation. When a patient with anorexia is experiencing extreme electrolyte imbalance or weighs below 75% of ideal body weight, the plan is to provide immediate medical stabilization, most likely in an inpatient unit. If a specialized eating-disorder unit is not available, hospitalization on a cardiac or medical unit is usually brief, providing only limited weight restoration and addressing only the acute complications (e.g., electrolyte imbalance and dysrhythmias) and acute psychiatric symptoms (e.g., significant depression). With the initiation of therapeutic nutrition, malnourished patients may need treatment on a medical unit, owing to refeeding syndrome, a potentially catastrophic treatment complication involving a metabolic alteration in serum electrolytes, vitamin deficiencies, and sodium retention (Kohn, et al., 2011)

Once a patient is medically stable, the plan addresses the issues underlying the eating disorder. These psychological issues are usually addressed on an outpatient basis. The plan of care will include individual, group, and family therapy as well as psychopharmacological therapy during different phases of the illness. The nature of the treatment is determined by the intensity of the symptoms—which may vary over time—and the experienced disruption in the patient’s life.

Discharge planning is a critical component in treatment. Often, family members benefit from counseling. The discharge planning process must address living arrangements, school, work, the feasibility of independent financial status, applications for state and/or federal program assistance (if needed), and follow-up outpatient treatment.

Implementation

Acute care

Typically, a patient with an eating disorder is admitted to the inpatient psychiatric facility in a crisis state. The initial focus depends on the results of a comprehensive assessment. Any acute psychiatric symptoms, such as suicidal ideation, are addressed immediately. The nurse is challenged to establish trust and monitor the eating pattern.

Psychosocial interventions

After working through acute symptoms, the patient with anorexia begins a weight restoration program that allows for incremental weight gain. Based on the patient’s height, a treatment goal is set at 90% of ideal body weight, the weight at which most women are able to menstruate.

As patients begin to re-feed, they ideally participate in the unit”s milieu. In this setting, the patient should feel accepted and safe from judgmental evaluations. The focus should be on the eating behavior and underlying feelings of anxiety, dysphoria, low self-esteem, and lack of control. Discussions about physical appearance should be approached carefully because comments may be misinterpreted, as demonstrated in the first vignette on the next page.

CONSIDERING CULTURE

Latinas’ Paradoxical Body Images

The literature reports conflicting findings regarding Latinas’ body image and body satisfaction. Some research has suggested that Latina women are more tolerant of a curvy body shape than are white women. However, another line of investigation argues that Latinas may actually face greater concerns regarding their body image with more fear of weight gain than their white counterparts. This study attempted to examine body satisfaction among a cohort of Latinas as well as their beliefs and attitudes regarding mainstream American cultural ideals. All the participants actually reported a preference for a body shape thinner than they actually considered themselves to have. However, they were also more accepting of a heavier, curvy body shape as a Latina ideal. Further study may help nurses understand the influence of cultural perceptions of body shape on patients” attitudes toward their own body image and their desire to maintain a healthy weight.

Viladrich, A., Yeh, M. C., Bruning, N., & Weiss, R. (2009). Do real women have curves? Paradoxical body image among Latinas in New York City. Journal of Immigrant and Minority Health, 11(1), 20–28.

VIGNETTE

Alicia, a 17-year-old cheerleader, did not come to treatment for weight loss until she fainted at a football game. She insisted that she only needed to “get more energy, not get fat.” When the nurse pointed out that Alicia’s ribs were clearly visible and that her backbone looked like a skeleton, Alicia grinned and said, “Thank you.”

Pharmacological interventions

There are no drugs approved by the U.S. Food and Drug Administration (FDA) for the treatment of anorexia nervosa, and research does not support the use of pharmacological agents to treat the core symptoms (Treasure et al., 2010). The selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), however, has proven useful in reducing obsessive-compulsive behavior after the patient has reached a maintenance weight. Unconventional antipsychotic agents such as olanzapine (Zyprexa) may be helpful in improving mood and decreasing obsessive behaviors and resistance to weight gain (Treasure et al., 2010) but are not well accepted by patients who are frightened by the side effect of weight gain with this classification of drugs.

Integrative medicine

Patients with eating disorder may benefit by a number of complementary alternative medicine therapies (Breuner, 2010). A comprehensive treatment plan can include the usual medical and nutritional interventions along with the beneficial effects of massage, biofeedback, acupuncture, or yoga to manage mood. It is also important that the nurse ask if patients are taking herbals, such as St. John’s wort for depression, valerian for sleep, and chamomile for anxiety. Patients will need proper guidance and education to assist them when they choose to add these therapies to their recovery program.