Anorexia Nervosa: in Adolescents

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A D O L E S C E N T H E A LT H S E R I E S
Anorexia nervosa
in adolescents:
An overview
BY KATHLEEN PETERSON, PhD, RN, PCPNP-BC,
AND REBECCA FULLER, RN-BC
Abstract: Anorexia nervosa (AN) is an DX, 16, WAS ADMITTED with anorexia nervosa (AN)
eating disorder that is difficult to treat,
after unsuccessful outpatient treatment. She had intention-
and relapse is common. This article ally lost 30 lb over 6 months by restricting her nutritional
addresses management strategies and intake and counting calories. DX met the inclusion criteria
nursing interventions for adolescents for hospital admission following evaluation of her vital
diagnosed with AN.
signs, height, weight, body mass index (BMI), serum elec-
trolytes, and nutritional status.
Keywords: adolescents, AN, anorexia
nervosa, binge-eating, BMI, body mass
AN is a potentially life-threatening eating disorder in
index, eating disorders, purging which patients experience extreme fears of gaining weight
and altered perceptions of their body.1,2 First recognized
in France in 1874, AN describes the symptoms associated with self-starvation and a preoccu-
pation with weight.1 According to a national representative survey of adolescents ages 13 to
18, the incidence of AN in both males and females was 0.3% and the median age at onset was
12.3 years.3 AN has the highest mortality of all mental health disorders, typically resulting
from complications of starvation or suicide.4
Using a case history, this article focuses on AN in adolescents and discusses current treat-
ment approaches and appropriate nursing interventions.
ROY SCOTT
24 l Nursing2019 l Volume 49, Number 10 www.Nursing2019.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Three key features stance, a petite adolescent who has Risk factors
According to The Diagnostic and Statis- parents with a similar frame may Why do some adolescents develop
tical Manual of Mental Health Disorders, fall into a low percentile without AN and other eating disorders while
5th edition (DSM-5), an AN diagnosis an AN diagnosis. Similarly, clini- others do not? Eating disorders such
requires each of the following three cians must assess deviations from as AN are caused by combinations of
key features:5 individual growth trajectories, even behavioral, biological, genetic, psycho-
• persistent self-restriction of energy if the patient’s weight has not fallen logical, and environmental or cultural
intake, leading to significant weight to dangerous levels; for example, an influences.1 The following factors may
loss adolescent patient whose weight has put individuals at increased risk for
• an intense fear of gaining weight, dropped from the 75th percentile to developing an eating disorder.1,5,9,10
or persistent behavior that interferes the 25th percentile for his or her age, Biological factors include:
with weight gain presenting with other essential signs • female gender
• a disturbance in self-perceived and symptoms of AN. • a family member diagnosed with
weight or shape. The DSM-5 describes two sub- an eating disorder and/or mental
Determining a BMI percentage types of AN: the restricting type and health disorder
according to patient age is important the binge-eating or purging type.5 • a history of dieting.
in assessing adolescents for AN. The Both are characterized by a 3-month Psychological factors include:
CDC offers a BMI calculator and time frame. • obsessive-compulsive disorder
instructions (see Resources). Patients • In restricting type, patients achieve (OCD) and behavioral inflexibility
under the 5% margin for BMI with weight loss primarily through • perfectionism
age are considered underweight.6 dieting, fasting, and/or excessive • body image dissatisfaction
One study suggested a BMI below the exercise.8 • anxiety and/or depression.
10th percentile may result in the mal- • Patients diagnosed with binge- Environmental or cultural factors
nourishment associated with AN.7 eating or purging type have engaged include:
Healthcare providers must also in recurrent episodes of self-induced • immersion in a culture that values
follow trends specific to the in- vomiting or the misuse of laxatives, thinness
dividual patient’s weight. For in- diuretics, or enemas.8 • participation in modeling, ballet,
wrestling, gymnastics, or other
activities that encourage thinness
Resources • teasing and bullying
• a limited social network.
Academy for Eating Disorders: Resources
Studies of twins have demonstrat-
www.aedweb.org/resources/resources/fast-facts
ed an estimated AN heritability be-
Centers for Disease Control and Prevention: BMI percentile calculator for
tween 33% and 84%.11 Research is
child and teen
ongoing regarding whether specific
www.cdc.gov/healthyweight/bmi/calculator.html
chromosomes have a role in the
Children’s Hospital of Orange County: Eating disorders (medical stabilization)
development of AN.11
care guideline
www.choc.org/wp/wp-content/uploads/careguidelines/EatingDisordersCare
Guideline.pdf Pathophysiology
Adolescents with AN often present
Toledo Center for Eating Disorders: Eating Disorder Inventory-3 (EDI-3) scale
with significant weight loss and a
descriptions. Psychological Assessment Resources (PAR)1
http://toledocenter.com/wp-content/uploads/2015/10/EDI-3-Scale.pdf preoccupation with food and weight.
They may restrict certain foods or
Mayo Clinic: Teen eating disorders: tips to protect your teen
calories and develop food rituals.
www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-eating-
disorders/art-20044635 These individuals may refuse foods
they once enjoyed, refuse to eat so-
National Association of Anorexia Nervosa and Associated Disorders
cially with family and friends, and
https://anad.org
overexercise to extremes.
National Eating Disorders Association
The excessive restriction of calo-
www.nationaleatingdisorders.org
ries may impede growth and stop
The Center for Eating Disorders at Sheppard Pratt: A collection of supportive menstruation in female adolescents.
and informative books, websites, blogs and helpful organizations
Combined with an emphasis on
www.eatingdisorder.org/eating-disorder-information/resources
exercise, these restrictions lead to

malnourishment, causing protein fractures.15 Malnourishment may
deficiencies and disrupting the car- permanently change neurocognitive
diovascular, renal, gastrointestinal, functioning due to atrophy of the
endocrine, integumentary, hemato- gray and white matter.14 Cardiac

logic, and reproductive systems.11 complications include left ventricu-
Studies have demonstrated that lar atrophy and subsequent annular
malnutrition associated with AN also changes, leading to mitral valve

affects neuropsychological function- prolapse. Prolonged QT intervals
ing by reducing brain tissue.11 may increase the risk for cardiac
dysrhythmias and sudden death.14,15
Signs and symptoms The gastrointestinal system is
Nurses can identify physical signs affected as well, including possible
and symptoms, such as amenorrhea, dysphagia from weakened and un-
headaches, irritability, constipation, coordinated pharyngeal muscles,
syncope, dizziness, loss of muscle slowed gastric emptying, and chronic
mass, dry skin, and hair loss. Health- constipation.15 Additionally, AN af-
care providers conducting a physical fects the respiratory system, including
exam of patients with suspected AN abnormalities in pulmonary func-
should monitor vital signs for hypo- tion and potentially spontaneous
tension, bradycardia, hypothermia, pneumothorax.15 Similarly, the renal
and orthostatic changes greater than system may be affected, with patients
a 20 mm Hg decrease in systolic BP possibly developing dehydration and
or a 10 mm Hg decrease in diastolic Psychological recovery renal insufficiency related to self-
BP within 3 minutes of standing for patients with AN imposed fluid restriction. Other renal
from a supine position.12 includes improving self- abnormalities may include pyuria,
Other notable findings include proteinuria, and hematuria.11
esteem, developing better
hypercarotenemia, acrocyanosis, Hematologic complications, such as
lanugo, dependent edema, breast interpersonal relationships, anemia, leukopenia, and thrombocyto-
atrophy, scaphoid abdomen, and pa- and returning to a penia, may occur as a result of chang-
rotid swelling.11 Additionally, patients healthy lifestyle. es in the bone marrow.11 AN may also
with binging or purging type AN may cause abnormalities in a patient’s sense
have a calloused dorsum on their of taste, or dysgeusia, as well as a re-
dominant hand and eroded tooth Complications duced ability to determine sweetness
enamel.11,13 Individuals with AN may Some complications of the weight loss and an overperception of fat in foods.8
dress in baggy clothing or layers and and malnutrition associated with AN Additionally, patients with AN may
complain of feeling cold.1 will resolve with improved weight, experience complications related to
but others may be chronic. These is- the dermatologic system, including:8,15
Psychiatric comorbidities sues can affect every organ system • xerosis, or skin that is dry and scaly
Patients with AN often present with and occur at any weight.11 Endocrine • lanugo-like body hair, which is
mental health issues, including de- abnormalities may include the de- described as dark hair that is fine
pression, obsessive tendencies, social layed onset of puberty, amenorrhea, and downy
anxiety, separation anxiety, and pho- and permanent adversely affected fer- • telogen effluvium, or hair loss
bias such as the fear of swallowing or tility, often leading to greater reduc- • carotenoderma, or yellowing skin
gaining weight.1 Other common psy- tions and delays in reproduction • acne
chiatric disorders associated with AN across the patient’s lifespan.14-16 The • hyperpigmentation
include personality disorders and most common endocrine change re- • seborrheic dermatitis, which is
self-injurious behaviors.11 Some pa- lated to AN is reversion to a prepu- characterized by erythema and greasy
tients with restricting type AN may bertal state.15 Levels of cortisol and scales
present with OCD as well. Addition- other hormones may be elevated, and • acrocyanosis, in which a patient’s
ally, patients with binge-eating or hypoglycemia may occur.15 hands and feet are cold, blue, and
purging type AN may have alcohol After just 1 year, patients may sometimes sweaty
use disorder and other substance use experience decreased bone density, • perniosis, or painful or pruritic
disorders.5 leading to osteoporosis and fragility erythema
www.Nursing2019.com October l Nursing2019 l 27

• petechiae Many short, validated, and reliable • enhancing patient motivation to
• livedo reticularis, which is charac- tools are available to screen younger cooperate and participate in treatment
terized by circular patches that are patients for eating disorders, such as to restore healthy eating patterns
reddish or cyanotic in color the eating disorder examination ques- • providing education regarding
• paronychia, or inflammation or tionnaire, the eating disorder inven- nutrition and healthy eating habits
infection of the skin around the nail tory, and the eating attitudes test.1 • helping patients reassess and change
• pruritus Though preferred, outpatient ther- core dysfunctional cognitions, atti-

• striae distensae, which is character- apy is not always possible. Criteria tudes, motives, conflicts, and feelings
ized by erythematous or hypo- established by the Society for Adoles- • treating any associated psychiatric
pigmented patches cent Health and Medicine will assist comorbidities, including deficits in
• delayed wound healing. clinicians to decide whether hospi- mood, impulse regulation, self-
Many of these complications can talization is necessary (see Indications esteem, and behavioral issues
be appropriately addressed with in- for hospitalization).17 • enlisting family support and pro-
patient hospitalization to safely man- The Practice Guideline for the viding appropriate counseling and
age weight restoration. Conducted Treatment of Patients with Eating Dis- therapy
too rapidly, weight restoration may orders provides empirical evidence • preventing relapse.
lead to refeeding syndrome, a meta- for inpatient treatment of eating Many healthcare facilities that treat
bolic derangement characterized by disorders in adolescents.18 Critical adolescents with eating disorders have
severe fluid and electrolyte imbal- aspects of care include restoring institutional guidelines for consistency
ances that can lead to cardiac dys- fluid and electrolyte balance, im- in patient care. For example, the goals
rhythmias and sudden death.2 A proving nutritional status, monitor- for in-patient hospitalization at Boston
large-scale study demonstrated that a ing and enforcing any prescribed Children’s Hospital include weight
2 kg per week weight gain with ap- physical activity, monitoring vital gain and nutritional stabilization, vital
propriate medical monitoring was signs and weight, and monitoring signs and electrolyte stabilization,
safe for many patients.2 intake of food and fluid and output psychiatric consultation, and parental
of urine and bowel movements. The education. Nursing flowsheets and
Management guideline lists additional goals for protocols provide clear guidelines and
One 2015 practice parameter provides treating AN, including:18 ensure consistency of nursing care.14
an evidence-based approach to evaluate • restoring patients to a healthy weight
and treat eating disorders in adolescents.1 • treating any physical complications Nursing considerations
Nurses play a key role in evaluating
and treating adolescents with eating
Indications for hospitalization17 disorders such as AN and should take
One or more of the following justify hospitalization for adolescents with eating a nonjudgmental approach to patient
disorders, including AN: care. In school health settings or in
• 75% median BMI for age and gender primary care, nurses should determine
• dehydration the appropriate height and weight as
• electrolyte disturbances, such as hypokalemia, hyponatremia, and hypophos- estimated in the growth chart and re-
phatemia fer patients given evidence of growth
• ECG abnormalities, such as a prolonged QT interval or severe bradycardia
failure or extreme weight loss.1
• physiologic instability, such as significant hypotension, severe bradycardia, or
Part of a comprehensive evaluation
hypothermia
• arrested growth and development
is a physical and psychiatric evalua-
• unsuccessful outpatient treatment tion. Nurses assess patient eating
• acute food refusal patterns and body satisfaction, evalu-
• uncontrollable binge-eating and purging ating food intake, weight fluctua-
• acute medical complications of malnutrition, including syncope, seizures, heart tions, body image, and exercise. The
failure, and pancreatitis SCOFF questionnaire uses a series of
• psychiatric or physical comorbidities that prohibit or limit appropriate outpatient five questions to gauge patient risk
treatment, such as severe depression, suicidal ideation, OCD, and type 1 diabetes for eating disorders such as AN:11,19
mellitus • Do you make yourself sick because
Reproduced with permission from the Journal of Adolescent Health, 56, Society for Adolescent Health and you feel uncomfortably full?
Medicine, Golden NH, Katzman DK, et al., Position paper of the Society for Adolescent Health and Medicine:
medical management of restrictive eating disorders in adolescents and young adults, Pages No. 121-125, 2015, • Do you worry you have lost control
with permission from Elsevier.
over how much you eat?

• Have you lost more than 13 to 14 lb multidisciplinary approach, includ- normal limits, but her systolic BP
(one stone) in a 3-month period? ing a team of nurses, along with a decreased 40 mm Hg from a supine
• Do you believe yourself to be fat psychotherapist, a pediatrician, and a to a standing position. Her resting
when others say you are too thin? dietitian. Medications should be re- heart rate was 50 bpm.
• Would you say that food dominates served for comorbidities and patients She received consultations from
your life? who do not improve with psycho- child life, music therapy, social work,
Lab testing requirements include a social interventions.1 nutrition, and psychology. Per pro-
complete blood cell count; a compre- tocol, DX’s bathroom door remained
hensive metabolic panel; and kidney, Case study continued locked and no garbage receptacles
liver, and thyroid function studies. If DX, the patient introduced at the were kept in the room to prevent
applicable, nurses should also assess beginning of this article, expressed purging. Liquid nutrition was initially
menstrual history, and hormonal anxiety over nutrition and had lim- prescribed at 1,000 calories and in-
studies can help identify amenorrhea. ited her intake to 800 calories a day. creased by 500 calories daily until a
Additionally, dual-energy X-ray ab- Specifically, she voiced concerns caloric intake of 3,500 was reached.
sorptiometry for bone density may about “getting fat” and “not being DX consumed oral liquid nutri-
be beneficial for female patients able to finish meals.” Her psycho- tion without requiring enteral nutri-
with amenorrhea lasting longer than social assessment and unsuccessful tion. All meals were eaten in a dining
6 months and all male patients with outpatient treatment plan were also room designed to build rapport and
significant weight loss.1 considered. Further assessment support therapeutic communication
Severe malnourishment leads to a revealed that she excelled academi- for those with eating disorders. This
variety of complications as already cally and ran cross-country at a therapeutic milieu encourages pa-
described. Nurses are vital in the suburban high school. tients to express feelings while con-
emergency management of clinically DX entered a 17-day eating disor- suming nourishment. Per facility
unstable dysrhythmias, as well as der treatment program according to protocol, meals were ingested in a
cardiac arrest, hypothermia, and facility protocols, which outlined 30-minute time frame, during
fluid and electrolyte disturbances.1 nursing interventions, utilized a which the patient was monitored by
multidisciplinary approach to stabili- the nursing staff. Hydroxyzine was
Psychiatric evaluation zation, and coordinated follow-up prescribed before each meal due to
Adolescents with AN are often resis- outpatient care. The day of admis- visible patient anxiety.
tant to treatment and think that their sion was counted as day 0. During her first 3 days, DX’s
weight is normal. Psychological re- Upon admission, DX weighed weight increased to 41.2 kg (90.64
covery for patients with AN includes 40.9 kg (89.98 lb) and measured lb) and her orthostatic hypotension
improving self-esteem, developing 164.5 cm (5 ft 4 in), with a BMI of and lab results remained stable. On
better interpersonal relationships, 15.4. Adolescent females of her age day 3, DX began eating solid nutri-
and returning to a healthy lifestyle.11 and height should be eating about tion equivalent to 2,000 calories/
Outpatient psychosocial interven- 2,200 calories daily with a BMI be- day. She was able to meet small
tions may be effective for this patient tween 18.5 and 24.5.20 goals with assistance from the
population, including family-based Before she was weighed, DX com- nursing staff.
treatment. This consists of 10 to 20 pleted a measured void, removed DX followed the eating disorder
family therapy sessions over a 6- to all clothing, and donned a hospital treatment plan as prescribed over
12-month period and empowers par- gown. Her weight and orthostatic BP the course of the next 10 days. Her
ents to take charge of their adolescent’s were monitored daily until discharge. weight increased to 43.1 kg (94.82
weight restoration. Cognitive behav- A neurologic evaluation revealed that lb), and her orthostatic BP changes
ioral therapy may also be helpful.1 DX was alert and oriented with co- decreased to less than 10 mm Hg.
Psychiatric hospitalization pro- herent thought processes. Although She developed relationships with the
grams, partial hospitalization, and she was experiencing anxiety and nursing staff and participated in mu-
residential programs may be consid- depression, she had no suicidal sic therapy and other therapeutic
ered if outpatient interventions are ideation. The nursing staff obtained groups conducted by child life spe-
unsuccessful or unavailable. Devel- results of her ECG and serum elec- cialists. DX worked with a dietitian
opmental awareness and sensitivity trolytes upon admission, as well as an to develop healthy eating habits and
are essential in providing skilled care abdominal X-ray that revealed consti- received passes to leave the hospital
for adolescents with eating disorders. pation requiring laxatives. Her ECG for short periods with her family,
Healthcare facilities should utilize a and electrolyte values were within which allowed them to encourage
www.Nursing2019.com October l Nursing2019 l 29

her prescribed nutrition outside of REFERENCES 13. National Institute of Mental Health. Eating
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College at Brockport, State University of New York.
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The authors and planners have disclosed no potential
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at-risk adolescents and encouraging Pediatric disorders of orthostatic intolerance.
early treatment. ■ Pediatrics. 2018;141(1):e20171673. DOI-10.1097/01.NURSE.0000580640.43071.15
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24 l Nursing2019 l Volume 49, Number 10 www.Nursing2019.com

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

26 l Nursing2019 l Volume 49, Number 10 www.Nursing2019.com

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

endocrine, integumentary, hemato- gray and white matter.14 Cardiac

malnutrition associated with AN also changes, leading to mitral valve

www.Nursing2019.com October l Nursing2019 l 27

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

• pruritus Though preferred, outpatient ther- core dysfunctional cognitions, atti-

28 l Nursing2019 l Volume 49, Number 10 www.Nursing2019.com

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

www.Nursing2019.com October l Nursing2019 l 29

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

> For more than 115 additional continuing-education articles related to

Anorexia nervosa in adolescents: An overview

30 l Nursing2019 l Volume 49, Number 10 www.Nursing2019.com

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