Page 67 Complete Your CE Test Online - Click Here 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. If the client with anorexia nervosa is also purging, calluses on the knuckles and abrasions and scars on the backs of the hands may be evidence of tooth injury that occurred during self-induced vomiting. Additional evidence of self-induced vomiting includes dental caries and oral or pharyngeal abrasions[9] . Nursing consideration: The gravity of the clinical picture depends on the severity and extent of the disorder. These signs and symptoms are a reflection of the pathophysiology of the disease. Nurses must be able to correlate signs and symptoms with disease pathology in order to facilitate treatment and promote wellness. Pathophysiology Anorexia nervosa can lead to a state of near starvation. As a result, the body struggles to find sources of nourishment to maintain homeostasis and therefore fat stores are exhausted, adipose tissue is depleted and muscle mass is lost[12] . Lack of body fat can lead to a decrease in body temperature and intolerance to cold[9,12] . Alterations in body temperature and cold intolerance are also manifestations of metabolic changes caused by the disease process[9,12] . Here is a summary of the clinical manifestations of potential metabolic changes. Hypothyroidism Hypothyroidism exists when the thyroid gland fails to produce adequate amounts of certain hormones. Signs and symptoms of hypothyroidism that may be seen in clients with anorexia nervosa include[12,13] : ● ● Fatigue. ● ● Cold intolerance. ● ● Dry skin. ● ● Muscle weakness and muscle aches. ● ● Pain, swelling, and stiffness of the joints. ● ● Thinning hair. ● ● Bradycardia. ● ● Memory problems. ● ● Depression. There are a number of potential complications related to hypothyroidism including[9,12,13] : ● ● Cardiac problems: Effects of hypothyroidism on the cardiac system include slowing the heart rate (bradycardia), heart enlargement, heart failure, impaired pumping ability of the heart, and elevated LDL (bad) cholesterol. ● ● Mental health problems: Depression may develop early in the course of hypothyroidism and become worse over time. Hypothyroidism can also cause a decrease in mental functioning. ● ● Peripheral neuropathy: If hypothyroidism is not controlled/treated over a long period of time, peripheral nerve damage can occur. Signs of peripheral nerve damage include numbness and tingling of affected extremities. ● ● Infertility: Inadequate levels of thyroid hormone interfere with ovulation and impair fertility. Cardiac problems Anorexia nervosa can adversely affect the cardiovascular system. Clients may exhibit[9,12] : ● ● Bradycardia. ● ● Hypotension. ● ● Loss of cardiac muscle mass. ● ● Arrhythmias. ● ● Cardiac arrest.