She is constantly cold, her circulation has worsened, she has anaemia and she finds she is very rigid in relation to her eating disorder behaviours. The importance of holistic care that is patient focused and includes families and carers cannot be underestimated. And support needs to continue.
All too often it is assumed that once a patient has restored weight and can eat normally again, they are well enough to no longer require support. There are often issues related to low confidence, difficulty socialising with friends, re-engaging in education, employment or hobbies. For those whose eating disorder has become chronic, it can be helpful to have an agreed plan of care for periods of crisis or relapse.
This has been especially helpful in cases where people say one thing but mean another.
For example, when someone tells their care co-ordinator to stop coming. What they often mean is that they are scared of being weighed or having to make changes and their eating disorder is telling them to keep the help at a distance when really they want the support. A key message is also to emphasise that there is always hope, no matter how long a person has been ill. It might be full recovery or learning to manage symptoms to improve quality of life. There are occasions when a sufferer will tell you they do not want to get better.
This can be hard for the professional to accept and even harder for the family, but it is important to always have hope. In these circumstances, it is important to focus on what the patient can manage, which might be an agreement on support to stabilise, but be aware that pushing can be unhelpful.
Talking therapies such as specialist CBT and self-help programmes can be useful in helping the patient understand how their thoughts affect their behaviours. A recent document published by the Parliamentary and Health Service Ombudsman highlights the need to address the following issues to improve services: Epidemiology of eating disorders: incidence, prevalence and mortality rates.
Current Psychiatry Reports ; Eating Disorders Recognition and Treatment. London; NICE nice. Lifetime and month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors, BMC Medicine biomedcentral. Kings Guide for Eating Disorders kcl. Ignoring the alarms: How NHS eating disorder services are failing patients. Finally, print the email you have received, along with the article and certificate and include both in your CPD portfolio.
Skip to main content. This site is intended for health professionals only. Clinical Clinical news, views and education for practice nurses. Picture quiz - viral presentations. Search form Search. Supporting patients with eating disorders. By Mandy Scott, Eating disorder specialist. Weight loss is not the only symptom in anorexia Anorexia nervosa has the highest mortality rate of any psychiatric illness, either through the physical health complications or suicide. Digestive problems. Withdrawn, isolative behaviours. Weight changes.
Wearing of baggy clothes.
After obtaining the initial vital signs, obtain a height and weight. Starting with the head, note the hair's condition and presence of hair loss. Common hair condition findings include dry and brittle hair, often with split ends. Hair loss becomes more common the longer the patient maintains a poor nutritional state. Next, inspect facial features. Is there fine hair present not only over the patient's face, but also over the rest of his or her body? This fine hair called lanugo develops as the patient loses the subcutaneous fat layer and, therefore, the ability to insulate and maintain the body's temperature.
Do the patient's eyes appear sunken? Are his or her cheekbones visible? Loss of facial muscles and the subcutaneous fat layer can cause a patient with anorexia nervosa to have a skeletal facial appearance. Does the patient complain about sensitivity to noises or lights? The central nervous system won't function without the proper nutritional glucose and electrolyte levels. Hypersensitivity to noise and light, as well as the inability to focus and concentrate, commonly affect these patients.
Other areas of the head assessment include assessing the parotid glands and mouth. Parotid gland enlargement occurs if the patient purges frequently. The mouth, as well as other mucous membrane areas of the body, may become dry due to dehydration. Common signs of dehydration include cracked lips and furrows in the tongue. Dehydration can also cause swallowing difficulties. After assessing the patient's head, assess his or her neck.
The neck assessment should include inspecting and palpating the thyroid gland and noting the presence of any glandular enlargements. Thyroid function tests should also be performed. A triiodothyronine deficiency is often seen in patients with anorexia nervosa, which can lead to bradycardia, sluggish reflexes, dry skin, cold intolerance, and various hair abnormalities. Next, begin the chest and cardiovascular system assessment with a visual inspection.
Can you visualize each rib? Does the female patient have breast atrophy? Starvation will lead to a skeletal appearance, often with the rib cage appearing to protrude out of the chest. Does an ECG reveal abnormalities, such as arrhythmias and bradycardia? Deficient electrolytes, especially potassium, can lead to improper contraction of the heart muscle. After assessing the cardiovascular system, begin the respiratory assessment.
Assess the quality of respirations for adventitious breath sounds. Respiratory infections commonly occur in these patients due to a depleted immune system and malnutrition. Aspiration pneumonia can also occur if the patient purges. The abdominal and gastrointestinal GI assessment comes next, including listening for the presence of bowel sounds and assessing for abdominal pain and cramping. The patient with anorexia nervosa will often complain of ongoing stomach pain. Although he or she may deny feeling hungry, ongoing stomach pain may be hunger pangs.
Constipation is often an issue for patients with anorexia nervosa either because of dehydration or minimal food ingestion. Intestinal peristalsis slows when minimal food digestion occurs.
An inadequate amount of food consumed will lead to little waste production, which often results in laxative use. If the patient with anorexia nervosa admits to laxative usage, then a more complete upper and lower GI assessment should occur with a focus on whether an ulceration or perforation of the intestines has occurred. Remember that the patient with anorexia nervosa desires to keep consumed substances to a minimum; therefore, he or she will strain when defecating in an effort to remove all consumed substances.
Straining may lead to the exacerbation of hemorrhoids, rectal fissures, and blood in the stool. Anorexia also affects the urinary system. Minimal fluid intake will lead to dehydration. Urine becomes more concentrated as dehydration continues. This can then lead to the development of a urinary tract infection. Flank pain may indicate the presence of renal calculi, another common adverse reaction of dehydration and decreased fluid consumption.
Renal failure may begin if the patient withholds fluids for a long period of time. The most common gynecologic consequences include amenorrhea, infertility, and menstrual irregularity. A decreased libido in both male and female patient also occurs. The musculoskeletal assessment involves assessing and testing for osteoporosis and bone density. A calcium deficiency commonly occurs as a result of little or no dairy products in the diet.
In severe anorexia nervosa, osteoporosis can begin to develop in patients as young as age Severe anorexia nervosa may also cause a loss of muscle mass, which will lead to weakness. Muscle injury, especially to the legs or knees, develops if the patient excessively exercises.
Muscle weakness and deterioration may necessitate the need to physically support the patient, even when he or she uses a wheelchair. Finally, assess for edema when inspecting the lower legs and feet. As these patients begin to consume more food and calories, they often begin to retain fluids. This fluid increase usually begins as pedal edema but will eventually lead to congestive heart failure if not monitored and corrected. Including lab tests in the assessment of the patient with anorexia nervosa is vital because they help determine his or her nutritional and hydration status.
Many hematologic abnormalities may appear in the patient's lab test profile. The usual problems include anemia, leukopenia, and thrombocytopenia.
The reversibility of medical consequences depends on nutrition returning to a normal level and having no permanent organ damage present. Medical management focuses on weight restoration, nutritional rehabilitation, rehydration, and correction of electrolyte imbalances. Patients should receive nutritionally balanced meals and snacks that gradually increase caloric intake. Severely malnourished patients may require total parenteral nutrition or tube feedings to receive adequate nutritional intake.
Once the individual is physically and nutritionally stable, a treatment plan is tailored to meet his or her needs. The treatment plan includes nutritional counseling, medical care and monitoring, psychotherapy, and medications. Nutritional counseling will assist with meal planning and weight maintenance.
Medical care needs to be ongoing to help maintain the individuals' physical well-being. The most common types of psychotherapy include individual, group, and family-based therapy. Cognitive behavioral therapy and compassion-focused therapy may also be used to help monitor moods; develop problem-solving skills; and address shame, self-criticism, and self-directed hostility.
Anorexia nervosa and bulimia nervosa | ACP Hospitalist
Medications, such as antidepressants and antianxiety drugs, can be helpful to control the mood and anxiety symptoms that often occur with anorexia nervosa. In general, bulimia nervosa involves episodic, uncontrolled, and compulsive rapid ingestion of large quantities of food over a short period of time binging. Following this, to rid the body of the excessive calories, the individual may engage in purging behaviors self-induced vomiting or the misuse of laxatives, diuretics, or enemas or other inappropriate compensatory behaviors, such as fasting or excessive exercise.
Head-to-toe assessment Obtain the patient's baseline vital signs and determine his or her ideal body weight range. Many patients with bulimia nervosa maintain an ideal body weight range and look healthy. Therefore, medical problems may not be immediately apparent. If the patient states that he or she is bulimic, ask about the method of binging and purging and how often it occurs. Although anorexia nervosa has been associated with some cognitive deficits as demonstrated on neuropsychological tests, many patients maintain good cognitive function and verbal fluency even when malnourished.
Heart muscle wasting, associated with arrhythmias and sudden death common in anorexia nervosa. Dental enamel erosions and gum disease. Recurrent vomiting washes mouth with acid and stomach enzymes; mineral deficiencies. Information from references 11 through Patients with eating disorders often engage in excessive physical activity despite bad weather, illness, or injury.
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A study found that approximately one-third of patients hospitalized for anorexia nervosa reported excessive i. Patients with bulimia nervosa may arrange complex schedules to accommodate episodes of binge eating and purging, often accompanied by frequent trips to the bathroom. In addition to excessive exercise, other methods of weight control include abuse of laxatives or diuretics. Frequent self-induced vomiting can contribute to parotitis, stained teeth or enamel erosions, and hand calluses.
As cachexia progresses, patients with anorexia nervosa lose strength and endurance, move more slowly, and demonstrate decreased performance in sports. Overuse injuries and stress fractures can occur. Bradycardia, orthostatic hypotension, and palpitations may progress to potentially fatal arrhythmias. Epigastric pain and a bloating sensation are common.
Laxative abuse causes hemorrhoids and rectal prolapse. Severe hypoglycemia may lead to seizures. Wounds heal poorly. Endocrine symptoms in anorexia nervosa include hypothermia feeling cold , delayed onset of menses or secondary amenorrhea, and osteopenia progressing to osteoporosis. More than one-half of patients with eating disorders meet criteria for a current or past episode of major depression.
Psychological symptoms include heightened emotional arousal, reduced tolerance of stress, emotional dysregulation, social withdrawal, and self-critical perfectionistic traits. Annual health supervision examinations and preparticipation sports physicals are ideal screening opportunities. In addition to weight, height, and body mass index measurements, a screening tool such as the SCOFF questionnaire Table 4 18 can be used. The first priority in the evaluation of patients with eating disorders is to identify emergency medical conditions that require hospitalization and stabilization.
Before the patient is weighed, a urine sample should be obtained to assess specific gravity for hydration status, pH level, ketone level, and signs of kidney damage. Weight, height, body mass index, and body temperature should be recorded. Because patients may wear extra clothes or hide heavy items to exaggerate their weight, they should be weighed wearing only underwear and a hospital gown. An attendant or parent may have to be present while they change. Clinicians may consider having patients face away from the scale so that they do not know their weight.
Blood pressure should be recorded with orthostatic vital signs. Electrocardiography and laboratory studies such as urinalysis with specific gravity, complete blood count, complete metabolic panel, amylase and lipase measurement, phosphorous and magnesium measurement, and thyroid function tests thyroid-stimulating hormone, thyroxine, free triiodothyronine should be performed promptly.
Family physicians can fill a central role in the monitoring and treatment of patients with eating disorders.
A psychotherapist or psychiatrist usually is involved. Eating disorder specialists, often with backgrounds in psychiatry or adolescent medicine, are ideally involved but may not be available in some locations. A dietitian can help select nutritious and calorie-rich foods. For youth, it is critical to involve their schools. Most states require formal plans that spell out special accommodations, such as snack breaks in class or allowances for missed school, to allow equal educational opportunities for students with medical disabilities.
Treatment success may be dependent on developing a therapeutic alliance with the patient, involvement of the patient's family, and close collaboration within the treatment team. Additional online resources for the treatment team, patient, and family are listed in eTable A. Indications for hospitalization include significant electrolyte abnormalities, arrhythmias or severe bradycardia, rapid persistent weight loss in spite of outpatient therapy, and serious comorbid medical or psychiatric conditions, including suicidal ideation.
Reprinted with permission from Campbell K, Peebles R. Eating disorders in children and adolescents: state of the art review. The focus of initial treatment for patients who have anorexia nervosa with cachexia is restoring nutritional health, with weight gain as a surrogate marker. Feeding tubes may be needed in severe cases when the patient has a high resistance to eating. Refeeding syndrome can occur in a malnourished individual when a rapid increase in food intake results in dramatic fluid and electrolyte shifts, and is potentially fatal.
Thus, hospitalization should be considered for initial treatment of any seriously malnourished patient to allow for daily monitoring of key markers such as weight, heart rate, temperature, hydration, and serum phosphorus level. Nutritional Intervention and Weight Restoration. Patients with anorexia may eat only kcal a day, whereas the average daily caloric requirement for a sedentary adolescent is 1, kcal for females and 2, kcal for males. Initiation or resumption of menses is an important marker of biologic health in females.
For growing adolescents, the goal weight may need to be adjusted every three to six months. Weight gain may not begin until caloric intake significantly exceeds sedentary requirements. Strenuous physical activity and sports should be restricted. Nutritional guidance focuses on healthy food intake and regaining the energy needed to resume activities. Although calorie counting is important, it generally should not be discussed with the patient. Daily menus should include three full meals and a structured snack schedule that is monitored by parents or the school nurse. A multivitamin plus vitamin D and calcium supplements are recommended.
Psychotherapy is the foundation for successful treatment of an eating disorder. Family-based treatment the Maudsley method is one of the more promising approaches for adolescents with anorexia nervosa. Clinical trials have shown significant improvement in bulimia nervosa with cognitive behavior therapy and interpersonal psychotherapy. Alternate adjunctive therapies such as equine therapy based on the idea that caring for horses through grooming and other interactions is healing may hold promise, although they are not evidence-based therapies.
Studies have shown only limited benefit of medications in the treatment of anorexia nervosa. Antidepressants, including selective serotonin reuptake inhibitors SSRIs , may help mitigate symptoms of depression and suicidal ideation in patients with anorexia nervosa. However, they have not proved beneficial in facilitating weight restoration or preventing relapse.
If psychotropic medications are attempted, the patient should be closely monitored, possibly in an inpatient or residential setting, and supervised by a psychiatrist or eating disorder specialist. In patients with bulimia nervosa, studies have suggested SSRIs may be beneficial in decreasing the frequency of binge eating and purging. Data Sources : Literature searches on Ovid Medline were performed.
Key terms were anorexia nervosa, bulimia nervosa, eating disorder, etiology, diagnosis, signs and symptoms, and treatment. The search included meta-analyses, randomized controlled trials, clinical trials, and review articles. The search was limited to human, English, and full text. Subsequent Ovid Medline searches were conducted looking for specific topics such as zinc and eating disorders. Additional searches included the archives for the journals Pediatrics and American Family Physician , Agency for Healthcare Research and Quality evidence reports, the Cochrane database, the National Guideline Clearinghouse database, the U.
Search dates: November 18, ; December 1, ; July 14, ; and October 22, Already a member or subscriber? Log in. Address correspondence to Brian C.
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Practice guideline for the treatment of patients with eating disorders.