AN is a disease, like asthma is a disease. It is not dieting, a strong wish to be thin, or malingering. People afflicted with AN have within their minds two realities. One reality is a normal and healthy one. Just like you and I, those who suffer from AN want to be happy, healthy, and normal. The other reality is best understood as a phobia, a state of immense fear and concern. In AN, the phobia is that of loss of control, leading to obesity. Just like a phobia of going outside, AN has far-reaching implications. The phobia of personal obesity leads to changes in exercise, eating, unusual behaviors, and AN almost constant state of fear, anxiety, and inability to cope with life. The weight loss that results from this phobic state can be life-threatening.

What causes anorexia nervosa?

Anorexia is a disease that occurs in about one in 100–200 women and about two in 1000 men. The onset of AN is preceded by weight loss. The weight loss may have occurred for any reason, e.g. dieting, travel, diarrhea, or after surgery. AN also requires a certain genetic make-up. AN cannot occur in those who do not have a genetic predisposition to the disease. Even with a genetic predisposition and weight loss, other factors, such as social, environmental, family, or psychological stressors, may be necessary for the disease to manifest itself.

Special considerations for history taking in eating disorder patients

Leave your office to meet the patient and observe their behavior with those who have accompanied them. Note their state of affect and ability to walk, then gait, weakness, and unsteadiness.

Certain elements of the history, such as those related to abuse or sexual issues, may best be left to a subsequent interview when rapport has been developed.

Instruct the patient to change in a private area, to keep on their underwear, and to wear the gown open to the back. Examining the patient while fully dressed may lead to failure to observe the degree of emaciation and other physical signs. It is preferable to perform the physical examination in the presence of a female trusted by the patient. Do not do rectal, pelvic, or breast examination as part of an eating disorder assessment physical examination.

Mental status examination

General appearance and behavior

Does the patient appear physically unwell, anxious, or depressed? Is he or she emaciated, or are they wearing clothes that obscure their figure? Is the patient restless? Many anorexic patients are unable to sit still or even sit, even when asked to do so, and continually jiggle their feet.

Speech

Is the patient communicative, or do they answer only briefly and reluctantly. Does the patient set out to justify their reasons for dieting? Do they avoid eye contact when asked potentially confrontational questions about eating, exercise, vomiting, or laxative abuse?

The medical symptoms and signs of AN and, although less serious, of other eating disorders are part of the illness, and hence it is more appropriate to think of them as medical manifestations rather than merely complications. Although the disorder usually starts in adolescence, its course is often prolonged; AN patients may be ill for many years, and the majority of severely ill AN patients are in early or mid adult life. Hence, AN is a matter of concern for adult physicians as well as for pediatricians and adolescent medicine specialists. Figure 4.1 shows a mnemonic that is useful for remembering the physical signs of eating disorders.

Manifestations result from starvation or from the behaviors adopted to induce it. They are not indicative of underlying pathology. The inexperienced clinician who undertakes unnecessary investigations to exclude all possible causes for each abnormal finding is doing the patient a disservice by delaying appropriate treatment. Rather, all clinicians should be aware of the wide range of physical abnormalities that are commonly found in anorexic patients (Table 4.1). Many of these abnormalities, such as decreased serum concentrations of gonadotropins and steroid sex hormones, alterations to the peripheral metabolism of thyroid hormone, and raised circulating concentrations of cortisol and growth hormone, are best regarded as physiological adaptations to the state of starvation and do not require treatment. However, some medical complications are not only clinically important but are also life-threatening; these require special attention.

Introduction

Caring for patients with dieting disorders can be one of the most challenging and rewarding roles for nurses. However, even for the most experienced clinician, it can also be frustrating, anxiety-provoking, and emotionally draining, and nurses must be aware of the potential for burnout and emotional over- or underinvolvement.

Nurses become many things to a patient with AN, most essentially someone who is familiar with the patient's feelings, ideas, emotions, routines, rituals, and behaviors. Nurses need to be skilled in recognizing and interpreting the physiological and psychological signs, symptoms, and complications of the disorder. It is imperative that they develop AN empathic, non-judgmental approach, and that they maintain clear professional boundaries — yet a nurse's job is to challenge fixed and unrealistic beliefs and to assist in the development of motivation to change, so it is necessary to form a strong and trusting bond. As well, nurses provide information, act as role models, and support the patient and their family through the recovery process.

In order to fulfill this challenging and difficult role, nurses need education, clinical supervision, support from management and administration, collaboration and communication with other nursing colleagues, and recognition from other members of the treatment team that the nurse's role is valuable and vital.

A team approach is vital for effective treatment of eating disorders. The specialist clinical dietitian, as part of the team, is the most qualified person to provide accurate education about nutrition, weight gain, weight maintenance, the resumption of normal eating, and the nutritional methods of avoiding the refeeding syndrome.

Nutrition treatment is not as simple as applying AN educational formula and handing out a diet sheet. Nutrition intervention is complex, and eating disorder patients are resistant to nutritional treatment. Compliance may be reduced by perceived coercion, psychiatric comorbidities such as borderline personality disorders, self-harm, and suicidality, and ethical issues such as the need to report at-risk children to the law. Dietary change may be dependent on the patient's psychological progress.

The objectives of this chapter are to:

• Review the range of dietetic interventions that are professionally acceptable to dietitians.

• List some methods of dealing with the emotional issues that are likely to occur during treatment.

• Promote self-care (supervision) for all dietitians working with eating disordered patients.

• Discuss distinctions between specialist and non-specialist dietitians.

Clinical boundaries

Discuss the therapeutic limitations of nutrition counseling and make clear the need for concurrent psychotherapy at the first interview.

Professional boundaries

• Work as a member of a team: before initiating any nutrition intervention, make certain that a doctor is following the patient medically on a regular basis and that psychological therapy is being carried out by a qualified practitioner. Emphasize the link between the patient's eating disorder and their emotional health in the dietetic sessions. Set AN upper limit of six dietetic sessions with a patient who is not engaged in a psychological intervention. This is to avoid clouding the dietetic intervention with emotional issues, to encourage psychological treatment, and to protect the patient against inadequate treatment.

• […]

Many of the physical symptoms of AN arerelated directly to the effects of semi-starvation, while other physical symptoms areassociated mainly with behavioral problems such as excessive exercising, vomiting, and purging. Table 5.1 lists the most common physical manifestations in AN. Table 5.2 lists the physical manifestations most commonly found in BN.

Edema

Case

A 25-year-old female gains 10 kg in seven days. She is extremely anxious and agitated and threatens to discharge herself against medical advice. The nurse asks you why she has gained so much weight.

Comment

During feeding, edema occurs due to volume depletion, low metabolic rate, behaviors such as vomiting and laxative, enema, and diuretic use, which cause the body to have high circulating hormones that promote the retention of fluid. Antidiuretic hormone is secreted by the pituitary, renin is secreted by the kidney, angiotension is formed in the blood, and aldosterone is produced by the adrenal gland. The amount of fluid that might be retained in a patient is impossible to predict, but it is often 3—5 kg of water. The fluid retention is much greater in patients with a history of binge—purge behavior or diuretic use.

If the patient is suspected of having edema, apply steady, firm pressure with the pad of your thumb over the skin covering the lower tibia, just about the ankle. After 15 seconds, a small pit will appear if edema is present.

Introduction

This section of the book is directed at a more selective audience than Parts I–IV. First, it deals with the specific roles that general practitioners, nurses, and dietitians play in the management of patients with AN and other eating disorders. Second, it provides a brief section on the essential information that should be given to patients, their families, and their friends. Third, it draws conclusions about the possible future direction of clinical work in eating disorders and to the possibility of prevention programs with AN appraisal of risk factors.

Dieting (restricting) and purging forms of anorexia nervosa

The diagnostic criteria that have been prescribed for AN and the other eating disorders have varied only slightly over the years, and the present form (see Tables 1.3–1.6) is essentially similar to when the disorders were first described. It is important to stress that these descriptions are simply lists of symptoms and signs that are commonly associated and that point to a similarity of course of others. They are not true definitions of an illness entity as is found in many instances elsewhere in medicine, i.e. an explanatory portrayal of etiological factors, pathology and physiopathology, derived manifestations, and a course of progression. Instead, they merely note physical, psychological, and behavioral features without a clear appreciation of their interrelationship. The most characteristic of the features of an eating disorder are the behavioral disturbances that the patient displays; it is these features that will be described here.

Anorexic behaviors, although all directed at either decreasing energy intake or increasing energy expenditure, are not uniform (Table 2.1). Some patients employ only the restrictive behaviors commonly associated with “normal” dieting, such as undereating, refusal of high-energy foods, and strenuous exercise. This is the “dieting” or “restricting” form of the illness; these patients differ from normal mainly in the extent of these behaviors and their inability to desist. Other patients also use vomiting and laxative or diuretic abuse. The presentation, then, is of the “purging” form of AN.

With the current shift in focus from tertiary services to primary and secondary services, and with estimates that up to 5% of women presenting to (or registered with) a general practitioner have AN eating disorder, the general practitioner's (GP) role in identifying, treating, and managing people with eating disorders is becoming increasingly important. In addition, it is particularly concerning that, because eating disorders are frequently concealed or denied, up to 50% of cases go unrecognized in a clinical setting. On a practical level, secondary prevention has been associated with improved outcome and reduced chronicity.

For patients with partial- and full-syndrome disorders, the most effective role that a GP can take is the role of care coordinator or case manager. As Keks notes, “There is no consensus as to what constitutes case management; [however] on AN individual patient level it means the coordination of care for patients who require a number of services from different providers.”

In some cases, the GP's main goal will be to build rapport and motivation for change before arranging referral to other health professionals for treatment. In other instances, where additional training has been undertaken, the GP may feel comfortable with taking on AN extended role. Alternatively, the GP may wish to limit actual practice to medical management but to take responsibility for coordinating associated services. AN essential component of every GP's role is the identification of the disorder as it presents in various developmental or formative stages.

Based on the physical, psychological, and developmental characteristics of childhood and adolescence, significant differences and similarities may be expected from the adult population. This summary focuses on the negative biological effects and sequelae of eating disorders in children and adolescents. These may encompass effects on growth and pubertal development, and medical complications of different organ systems, including morbidity and mortality. All organs are affected by the protein-calorie malnutrition associated with AN. Similarly, the malnutrition seen with BN results in medical sequelae. Table 9.1 lists the medical complications commonly associated with eating disorders in children and adolescents. In addition, investigations and measurement strategies to assess the medical impact of eating disorders are discussed.

Adolescence may be defined using many different parameters. Chronological age is used most widely in the literature. For the purpose of this chapter, the terms “adolescent” and “youth” will refer to the age group between 11 and 19 years of age. From the philosophical point of view, adolescence may be defined as a time of change that encompasses not only biological changes but also major psychological and social adjustments.

A vast literature related to medical complications in patients with eating disorders already exists for the adult population, serving as AN excellent source of reference for developing adolescents. Some of the previously highlighted differences between these two groups may be categorized based on the physiological hallmarks of adolescent development.