Page 66 Complete Your CE Test Online - Click Here Nursing consideration: Anorexia nervosa and bulimia nervosa can occur at the same time. In such cases starvation may occur in conjunction with extreme exercising, laxative abuse, diuretic abuse, and/or self-induced vomiting[9] . It is important to make clients, families, and professional colleagues aware that anorexia nervosa and bulimia nervosa can occur simultaneously. Not everyone is aware of this and it is important that appropriate education and treatment be provided. Incidence and prevalence of anorexia nervosa Anorexia nervosa is found in 5 to 10% of the population. About 95% of those affected are women[9] . Anorexia nervosa usually begins during adolescence or young adulthood and rarely begins prior to puberty or after the age of 40. However, cases of both early (prior to puberty) and late (after the age of 40) onset have been reported[1] . The disease is most prevalent in post-industrialized, high-income countries including the United States, many European countries, Australia, New Zealand, and Japan[1] . In the United States, the prevalence of anorexia nervosa is rather low among Latinos, African-Americans, and Asians. However, it should be noted that the utilization of mental health services among these populations is lower than other groups, which may not accurately reflect the occurrence of the disease[1] . It is estimated that anorexia occurs in 5 to 10% of the population, with most cases occurring in women. However, the occurrence in males is significantly increasing[6,9] . Prognosis varies but is better if clients are diagnosed early and seek help voluntarily. Mortality ranges from 5 to 15%, which is the highest mortality associated with a mental health disorder. One-third of these deaths are due to suicide[9] . Nursing consideration: It is imperative that nurses teach clients and families to monitor for suicidal ideation and actions. Possible causes and risk factors of anorexia nervosa The exact etiology of anorexia nervosa is unknown. Research shows that onset is often linked to a stressful life event, such as leaving home for college[1] . Other examples of such life events include moving, divorce, or the death of a loved one[10] . Other issues have been linked to the development of anorexia nervosa. Risk factors for the development of the disease include the following factors[1,9,10] : ● ● When a person participates in extreme dieting, changes may occur in how the brain and the body’s metabolism work. These changes may predispose someone to the development of an eating disorder. ● ● Genetics may make a person more vulnerable to the development of anorexia nervosa. A family history of eating disorders, obesity, or mood disorder such as anxiety or depression seems to increase the risk of developing the disease. ● ● Certain personality traits, such as low self-esteem, low self- confidence, and/or a drive for perfectionism are linked to anorexia nervosa development. ● ● Some cultural issues seem to play a role in the disease’s development. For example, teenagers and young adults may feel a need to be thin because of peer pressure, societal expectations, and/ or media emphasis on what the “ideal” woman (or man) should look like. Cultures that associate being thin with being attractive may help to trigger the disorder. ● ● Other mental health disorders such as obsessive-compulsive disorder, depression, and anxiety have been associated with the development of anorexia nervosa. Nursing consideration: Some experts believe that refusing to eat is an effort to gain or regain control over one’s life. The resulting disease process is a manifestation of that attempt to control[9] . CLINICAL PRESENTATION Clinical presentation of anorexia nervosa can vary depending on the severity of the illness[2] . The most obvious clinical finding is significant weight loss that is self-induced and greater than 15% of minimally acceptable weight for age and height[2] . 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