20.1 Psychological, Social, and Physiological Factors

Personality Development

Personality traits can play a key role in the development and progression of eating disorders. For instance, studies have shown that individuals with eating disorders tend to have high levels of perfectionist traits that can cause things like obsession with weight, rigidity around eating, and unusually high expectations (Holland et al., 2013). In fact, perfectionism has been implicated as one of the strongest risk factors associated with eating disorders (NEDA, 2023a).

Family Dynamics and Parenting

Family dynamics and parenting can influence the development of eating disorders. Studies have shown that family dynamics that include conflict, poor communication, and issues with boundaries can impact some disorders (Zanella & Lee, 2022). Several studies conducted in children also found a connection with parenting styles and eating disorders. Authoritarian (very strict) and permissive (less strict) parenting styles have been shown to have a significant effect on eating patterns leading to behaviors like calorie restriction (Ramsewak et al., 2022). For example, people who grow up in a very permissive household may find it easier to engage in disordered eating behaviors if they are not being monitored as much.

Adverse Events of Childhood

Adverse events that occur in childhood have been discovered as a risk factor for eating disorders. Adverse events include things such as child abuse, neglect, or households where substances are abused (Yoon et al., 2022). Because adverse childhood events can be common in people with eating disorders, screening for adverse childhood events should be a standard part of any plan of care. Screening tools like the ten-item Adverse Childhood Experiences (ACE) Questionnaire can screen for exposure to abuse, neglect, and other household dysfunction that can influence the development of eating disorders (Kovács-Tóth et al., 2022; Kovács-Tóth et al., 2023).

Peer Influence

Peer and social factors can have an effect on eating disorders. As children grow and develop, peers become more influential in their lives. Studies have shown that influence from peers can lead to disordered eating patterns such as excessive dieting, fasting, and binge eating (Keel et al., 2013). There are also several social factors associated with a higher risk of developing eating disorders. These include things such as weight stigma, bullying, loneliness, and generational cultural trauma (NEDA, 2023a). Generational cultural trauma starts when one generation endures a distressing event and then the effects of that trauma pass to the next generation.

Societal pressure to achieve an “ideal body” can also influence behaviors seen with eating disorders, such as excessive dieting and exercising. Social media and television can increase a person’s risk for developing an eating disorder and can lead to stress and issues with body image (NEDA, 2023a).

Biological and Genetic Factors

There are several biological factors that can increase the risk of developing eating disorders. For example, the hypothalamus regulates appetite in the brain, and contributes to neurotransmitter function, specifically involving serotonin and norepinephrine. Neurotransmitter dysfunction may contribute to eating disorders (Riva, 2016). Studies also have found that growth spurts, illness, athletic training, and having type 1 diabetes can lead to the development of eating disorders (NEDA, 2023a). These conditions/situations often require that clients check their weight frequently, focus on food labels and content, and report on weight at doctor’s visits, which shines a light on weight and body that increases the frequency of eating disorders.

Another risk factor associated with eating disorders is heritability, defined as how much genes influence differences in traits. Twin studies have found heritability as high as 58 percent in anorexia nervosa, 57 percent in binge eating disorder, and as high as 83 percent in bulimia nervosa (Thornton et al., 2011). Family studies have shown an increase in the lifetime risk of developing some eating disorders if there is a first-degree relative with the disorder (Thornton et al., 2011). Having a first-degree relative with a mental health condition, such as anxiety, depression, or addiction, can also increase an individual’s chances of developing an eating disorder (NEDA, 2023a). Because genetic factors can influence eating disorders, it is important to obtain a thorough family history during nursing assessment.

Environmental Factors

Environment can play a role in the development of eating disorders, particularly exposure to media. Studies in adolescents have revealed a correlation between an increase in technology use like social media, the internet, TV, and video games with an increase in eating disorders (Mora et al., 2022). Other environmental factors, such as experiencing stress, have also been shown to influence eating disorders. In twin studies, stress experienced by one twin has been proven to be highly influential in that twin developing an eating disorder (Steiger & Booij, 2020). There have also been studies conducted on the prenatal environment related to eating disorders. These studies found that exposure to things like natural disasters experienced by mothers during the third trimester showed an increase of children who later exhibited symptoms for eating disorders due to maternal stress (Steiger & Booij, 2020). Assessing prenatal history and environmental factors like technology use are essential when caring for clients at risk of developing eating disorders.

Nursing Assessment

Nursing assessments should be holistic and not only focus on caring for physical needs but on the whole person. Assessing clients’ psychological, emotional, and social needs is essential to the management of eating disorders (Corral-Liria et al., 2022). Clients with eating disorders may have experienced trauma or have poor family dynamics that may be revealed during a nursing assessment. Clients with eating disorders may also have other underlying mental health disorders like depression and anxiety, so it is important to identify any mental health symptoms. Nurses should assess psychological factors like perfectionism, body image dissatisfaction, and inflexible behaviors. Examples that may be revealed during an assessment include:

• having unrealistic expectations for themselves
• reporting high levels of dissatisfaction with their body
• feeling like there is only one right way to do things

Nurses should also assess emotional factors and history of anxiety disorders. Common anxiety disorders associated with eating disorders are:

• generalized anxiety disorder
• social phobia
• obsessive-compulsive disorder

Nurses should also be sure to assess social factors that can influence eating disorders, such as bullying, social isolation, and history of generational trauma.

Collaborative Care

Caring for clients with eating disorders requires a collaborative approach. There are several disciplines that will be involved in care, including nurses, dietitians, social workers, and other specialists like psychiatrists. Some clients with eating disorders will require medications to manage their mental health comorbidities. Medications used may include antidepressants, antipsychotics, anti-nausea medications, antianxiety medications, and stimulants (Himmerich et al., 2021). Some medications like benzodiazepines and lisdexamfetamine are controlled substances that require special care to ensure safety and prevent misuse. Nurses who administer controlled medications to clients will need to ensure that they follow agency-specific protocols, which can include keeping the medication in a locked area.

Nursing Process and Plan of Care

Caring for clients with eating disorders requires nurses to use clinical reasoning to competently work with clients and involve them in their plan of care. Consider this example of using clinical reasoning when caring for clients with eating disorders:

• Recognizing cues: Nurses should be able to recognize cues that may indicate the need for immediate medical attention. Nurses can obtain helpful data from multiple sources to help assess clients with eating disorders. An example would be getting a history of the clients’ disordered eating and collecting height and weight measurements that reveal abnormalities. It could also include collecting vital signs that may reveal abnormalities, like hypotension, in clients who are severely malnourished.
• Analyzing cues: If a nurse sees a cue that is concerning, they need to be able to determine what requires further evaluation. This process involves connecting cues with possible concerns. For example, they could correlate inadequate nutrition with the low body weight obtained during admission. It could also include relating findings like inadequate cardiac output as evidenced by low blood pressure that can occur with malnourishment.
• Prioritizing hypotheses: After analyzing cues, the nurse can determine which cues need to be addressed first or immediately. For example, if a client is severely malnourished and has a very low blood pressure, addressing the low blood pressure would be a priority.
• Generating solutions: Once the nurse determines the priority, they can begin to plan interventions needed to manage the client. Examples of actions that could be taken for a severely malnourished client with a low blood pressure are administering fluids that may be ordered for blood pressure or nutritional supplements to address the low body weight.
• Taking action: The nurse can take action by implementing interventions or contacting providers who are needed for orders to address the clients’ health concerns. For example, if there is no order for fluids or medications to address the low blood pressure, the nurse could contact the attending provider.
• Evaluating outcomes: After implementing interventions or actions, the nurse can determine if the actions helped the situation and if they achieved the intended outcome. For example, if the intended outcome of giving fluids was to increase the client’s blood pressure, the nurse would assess the client’s blood pressure and document the findings. The nurse collaborates with the client and the health-care team throughout the process.