Page 83 Complete Your CE Test Online - Click Here Nursing consideration: The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes a subtype of anorexia nervosa characterized by periods of binge-eating and purging. Some persons with this subtype binge eat and purge by misusing laxatives, enemas, diuretics, or by self-inducing vomiting. Some persons with this subtype of anorexia do not binge, but regularly purge after eating only small amounts of food. It should be noted that crossover between the subtypes is not uncommon[1] . It is imperative that nurses know about this subtype and that clients may exhibit not only starvation behaviors, but also binging and purging behaviors. The DSM-5 identifies three “essential” characteristics of anorexia nervosa[1] : ● ● Persistent restriction of energy intake (nutrients that provide energy). ● ● Intense fear of getting fat or gaining weight or ongoing behaviors that interfere with gaining weight. ● ● Disturbance in perception of body image (disturbance in self- perceived weight or shape). The starvation-like behaviors associated with anorexia nervosa can cause significant, possibly life-threatening medical conditions. Although most of the physiological effects associated with malnutrition are reversible with proper treatment and nutritional rehabilitation, some effects, such as loss of bone mineral density, are not completely reversible[1] . A variety of medical conditions such as gastrointestinal disease, hyperthyroidism, cancers, and acquired immunodeficiency syndrome (AIDS) can cause significant, serious weight loss. However, persons with these problems do not display the essential characteristics of anorexia nervosa[1] . Occasionally, weight loss due to another medical condition is followed by the onset or recurrence of anorexia nervosa. Anorexia nervosa rarely develops in persons who have had bariatric surgery for obesity[1] . Co-existing mental health disorders and anorexia nervosa Several mental health disorders are associated with anorexia nervosa. It is important, therefore, to differentiate between certain mental health problems and anorexia nervosa as well as to determine if they co-exist: ● ● Avoidant/restrictive food intake disorder: People with this disorder may have serious nutritional deficiencies and/or significant weight loss but do not have a fear of weight gain, becoming fat, or a distorted body shape perception. Avoidant/restrictive food intake disorder (ARFID) is a fairly recent diagnostic category identified in the DSM-5. Persons with a diagnosis of ARFID have symptoms that do not meet the criteria for traditional eating disorder diagnoses, but still have significant problems with eating food. Signs and symptoms of ARFID generally appear in infancy or childhood, but may also continue into adulthood[1,11] . ● ● Bulimia nervosa: Bulimia nervosa is characterized by recurrent episodes of binge eating followed by inappropriate actions to avoid gaining weight, such as self-induced vomiting and abuse of laxatives and diuretics. However, a key difference between those persons suffering from anorexia nervosa and bulimia nervosa is that persons with bulimia nervosa generally maintain body weight at or above minimal normal levels[1] . ● ● Major depressive disorder: Females and males who suffer from anorexia nervosa may also suffer from major depressive disorder. However, the two problems do not necessarily co-exist. Significant weight loss may occur in persons with major depressive disorder. Of course, this does not mean that all persons who have major depressive disorder are also anorexic. The majority of persons affected by major depressive disorder do not have either an extreme need for excessive weight loss or a morbid fear of gaining weight[1,9] . ● ● Schizophrenia: Persons who have schizophrenia sometimes experience significant weight loss and have odd eating behaviors. However, they seldom show the extreme fear of weight gain and disturbance in body image perception necessary for a diagnosis of anorexia nervosa[1] . ● ● Substance abuse disorders: Substance abusers often experience weight loss because of poor nutritional intake. They usually do not fear gaining weight and do not display disturbances in body image. Persons who abuse substances that reduce appetite and lead to weight loss (i.e. cocaine) and also express fear of gaining weight should be carefully assessed for co-existing anorexia nervosa[1] . Some of the clinical features of social anxiety disorder (social phobia), obsessive-compulsive disorder (OCD), and body dysmorphic disorder may overlap with those of anorexia nervosa. For example[1] : ● ● Persons with social anxiety disorder may be embarrassed or even humiliated to be seen eating in public. Persons with anorexia nervosa who have social fears that are not related to eating may also have co-existing social anxiety disorder. ● ● Persons with OCD may have obsessions and compulsions that are food-related. If persons suffering from anorexia nervosa have obsessions and compulsions that are not related to food, an additional diagnosis of OCD may be necessary. ● ● Body dysmorphic disorder is an imagined flaw in appearance (i.e. ears are too big). An additional diagnosis of body dysmorphic disorder is warranted only if the imagined flaw is not related to body shape and size. General signs and symptoms Before proceeding to manifestations of physical pathophysiology, it is helpful to review generalized signs and symptoms of anorexia nervosa. These include[2,3,9] : ● ● Extreme thinness/weight loss to the point of emaciation. ● ● Intense fear of gaining weight and being fat. ● ● Ongoing, unremitting pursuit of weight loss and thinness. ● ● Belief that she/he is fat and must continue to lose weight. ● ● Distorted body image. ● ● Refusal to eat. ● ● Amenorrhea. ● ● Loss of bone density (osteopenia). ● ● Osteoporosis (brittle, fragile bones, due to failure of the body to keep up the manufacture of new bone mass compared to bone loss). ● ● Brittle hair and nails. ● ● Lanugo (growth of fine hair all over the body). ● ● Muscle wasting (atrophy). ● ● Muscle weakness. ● ● Anemia. ● ● Constipation (can be severe). ● ● Drop in body temperature. ● ● Cold intolerance. ● ● Fatigue. ● ● Sleep disturbances. ● ● Loss of scalp hair. ● ● Hypotension. ● ● Bradycardia. ● ● Infertility. ● ● Loss of libido. ● ● Atrophy of breast tissue.