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Learning Objectives

By the end of this section, you will be able to:

  • List risk factors associated with and etiology of anorexia nervosa
  • Plan nursing care for clients in treatment for anorexia nervosa
  • Discuss nursing implications for the therapeutic relationship and milieu management in care of clients diagnosed with anorexia nervosa

The self-induced restriction of food, due to fear of weight gain, that results in weight lowering to below the normal parameters for age and height is called anorexia nervosa (APA, 2023a). The disorder is characterized by extreme restriction of food intake below the daily requirements causing very low body weight. In adults, this typically presents with a body mass index (BMI), a value that is calculated from an individual’s height and weight (Figure 20.2), under 18.5 (APA, 2023a). In children, this would present as notable deficits in height and weight compared with children in their age group with a BMI under the fifth percentile (Costandache et al., 2023). The height and weight with the lowest risk for mortality is called ideal body weight. It has been used as a method of risk assessment by dietitians and researchers, calculated using height-weight tables (Chichester et al., 2021). Though widely used in sports and health statistics, some variances, such as body measurements and musculature, may require further exploration, according to Chichester et al. (2021).

BMI parameters may not apply to athletes, body builders, or people who exercise a lot because a BMI may be higher in athletes due to their increased muscle mass. Also, BMI measurements are based on anthropometric measurements of White people. Body fat distribution differs by race and ethnicity, such as among Hispanic, Black, East Asian, and South Asian populations. Furthermore, the American Medical Association indicates that BMI should not be used as a sole determinant of health and risk. Rather, it should be used in conjunction with measurements of body adiposity index, relative fat mass, waist circumference, and visceral fat, as well as considerations of body composition, genetic factors, metabolic factors, and other measures (American Medical Association, 2023).

BMI chart showing correlation between height and weight and BMI levels with labels showing Underweight BMI <18,5, Normal range BMI 18,5-25, Overweight BMI 25-30, Obese BMI >30
Figure 20.2 Body mass index is a ratio of height to weight that can be used as one piece of data to determine healthy body weight. (credit: modification of work from Psychology 2e; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Anorexia is divided into two categories: restricting type anorexia, where weight loss is achieved by dieting, fasting, or extreme exercise; or binge eating/purging type anorexia, where binge eating is followed by purging through self-induced vomiting or misuse of laxitives, diuretics, or enemas to achieve weight loss. To distinguish the binge eating/purging seen with anorexia from bulimia, there must be low body weight where the BMI is <18 (Jain & Yilanli, 2023).

Clients with anorexia have an extreme fear of gaining weight and have disruptive issues with their body image that may be caused by cognitive distortions, or negatively biased errors in thinking patterns (Rnic et al., 2016). A type of distortion seen with eating disorders like anorexia is called thought-shape fusion, where there are altered beliefs about food, weight, and shape (Wyssen et al., 2017). For example, people with anorexia may change their estimates of how much they weigh or how big they are just because they thought about a particular food.

Clients with anorexia may present with symptoms affecting several body systems. For example, a common symptom seen with clients with anorexia is the presence of soft, fine hair that typically covers the face and back of newborns called lanugo. It can be found on the skin of clients with anorexia and is caused by the body’s attempt to conserve heat during starvation (Mehler & Brown, 2015). Other symptoms associated with anorexia can be found in Table 20.1.

Body System Symptom(s)
Integumentary Lanugo, hair loss, dry skin, pruritus
Neurological Mood changes like irritability
HEENT Abnormal closure of the eyelids
Gastrointestinal Constipation, bloating, pancreatitis, hepatitis dysphagia, delayed gastric emptying
Cardiac Edema, bradycardia, cool peripheries, hypotension, mitral valve prolapse, arrhythmias
Pulmonary Pneumonia, respiratory failure, emphysema, spontaneous pneumothorax
Hematologic/Electrolyte Pancytopenia, hypokalemia, hyponatremia
Musculoskeletal Osteopenia/osteoporosis
Endocrine Infertility, amenorrhea, growth delays, delayed puberty, thyroid dysfunction, hypoglycemia, increased cortisol levels, neurogenic diabetes insipidus
Table 20.1 Symptoms Associated with Anorexia (Mehler & Brown, 2015; Kit Tan et al., 2022)

Risk Factors for Anorexia Nervosa

Anorexia nervosa most commonly affects persons AFAB aged thirteen to twenty-five and has a prevalence of approximately 0.5 to 1 percent (Sim et al., 2010). The etiology of anorexia nervosa involves the complex interplay of psychological, environmental, and genetic factors that are often precipitated by stressful life events during adolescence or early adulthood (APA, 2023b). Having personality traits like perfectionism or being obsessive-compulsive is associated with the development of anorexia nervosa and can increase the risk for developing the eating disorder.

Cultural Context

Anorexia Nervosa in Persons Assigned Male at Birth

Eating disorders are one of the most gendered mental health disorders, so eating disorders in persons assigned male at birth (AMAB) were not recognized until recently (Gorrell & Murray, 2019). Anorexia nervosa has a lifetime prevalence in persons AMAB of 0.1 to 0.3 percent in community-based samples, but though anorexia is more commonly seen in persons assigned female at birth (AFAB) populations, it still affects persons AMAB populations (Gorrell & Murray, 2019). Physiological differences in persons AMAB can affect the way that they present with anorexia nervosa. For example, persons AMAB typically have less body fat with higher lean muscle mass, so protein breakdown can occur more quickly in persons AMAB who have less weight loss, resulting in ketosis (Mehler & Brown, 2015).

Persons AMAB can also present with findings like small testes, decreased sexual drive, and declines in testosterone levels that may differ from common findings seen in persons AFAB. It is important to consider these factors when caring for clients with eating disorders to ensure provision of inclusive care.

Genetics and Physiological Factors

Anorexia nervosa is a complex eating disorder that involves several factors. Genetic factors, such as having a first-degree relative with anorexia nervosa and/or having a first-degree relative with a mental health disorder, have been found to be risk factors. Twin studies have also shown an increased risk of developing anorexia nervosa (APA, 2023b). Paolacci et al. (2020) found a strong genetic component for anorexia nervosa due to gene sharing. Therefore, monozygotic twins who may share 100 percent of genetic material have a higher likelihood of developing anorexia than dizygotic twins.

Social Factors

There are several social factors associated with anorexia nervosa. Societal emphasis on being thin can place unreasonable standards related to body image that can lead to disordered eating. What is portrayed in the media plays an essential role in establishing beauty standards that promote thin bodies. This has been found to be a factor in body dissatisfaction that can lead to anorexia (Aparicio-Martinez et al., 2019).

Negative beliefs about eating disorders can even occur with health-care providers like nurses. Body shaming can be detrimental to people with eating disorders, leading to challenges such as poor treatment compliance and low self-esteem (Brelet et al., 2021).

A history of trauma has also been associated with the development of anorexia. The incidence of post-traumatic stress disorder in individuals with anorexia is estimated to be between 10 percent and 47 percent, indicating that traumatic experiences can be common with anorexia (Sjögren et al., 2023).

Mental Health Comorbidities

Clients with anorexia nervosa often have other comorbid mental health conditions. The DSM-5 lists several common conditions seen with anorexia nervosa that include bipolar disorder, depression, anxiety, obsessive-compulsive disorder, alcohol use disorder, and substance use disorder (APA, 2013b). Anxiety and obsessive disorders are also risk factors that increase the risk for developing anorexia nervosa in the first place (APA, 2013b).

Nursing Care Planning

Nurses can encounter clients with anorexia in various treatment settings, including psychiatric units for stabilization, or in the community. Nurse care planning for anorexia should focus on restoring body weight, replacing needed nutrition/electrolytes, and treating any underlying mental health issues to help establish a healthy relationship with food.

Clinical Judgment Measurement Model

Clinical Judgment Measurement Model Sample Care Plan for a Client with Anorexia Nervosa

This sample care plan uses the steps of the CJMM.

CJMM Step Notes
  • BMI=17.5
  • Excessive weight loss
  • Amenorrhea
  • Lanugo
  • Hypokalemia
Priority problem
  • Imbalanced nutrition
  • Client will increase BMI to ≥18.5
  • Client will verbalize understanding of daily recommended calorie goal
  • Daily weights
  • Dietitian consult
  • Ensure replacements between meals
  • To ensure adequate weight gain
  • To assist with daily caloric needs and healthy eating habits/choices
  • To help increase weight and restore nutrients
  • Client’s BMI increased to 19 during admission

Nurses should be aware that anorexia nervosa can have life-threatening complications and has a high mortality rate. Estimates show that 10 percent of people with anorexia nervosa die within ten years of its onset (Rikani et al., 2013). Starvation and suicide are the two leading causes of death in people with anorexia nervosa (National Institute of Mental Health [NIMH], 2023). Starvation can cause severe electrolyte imbalances in addition to dehydration, renal dysfunction, and cardiac issues. Suicide is the second leading cause of death in anorexia nervosa clients, so it is important to screen people with anorexia for suicidal thoughts (NIMH, 2023). Nurses can use tools like the nineteen-item Beck Scale for Suicide Ideation (BSI) to screen for suicide risk and measure the severity of their ideations and/or plan (Andreotti et al., 2020). Nurses can also provide clients with crisis information that includes the 988 and 911 emergency numbers.


Early detection of anorexia nervosa is essential and screening tools can be helpful in identifying clients with this eating disorder. Two common tools are the Sick Control One Fat and Food (SCOFF) questionnaire and the Eating Disorder Diagnostic Scale (EDDS). The SCOFF is a five-item questionnaire used to screen for eating disorders and has been proven to be effective in screening for anorexia nervosa (Kutz et al., 2020). It contains questions related to beliefs about weight and overeating that can be helpful in assessing clients with anorexia. The EDDS is a twenty-two-item self-report questionnaire that contains specific questions, using criteria from the DSM-5 to assess symptoms of eating disorders, including anorexia nervosa. It has also been proven to be effective in evaluating anorexia nervosa clients (Schaefer et al., 2019).


Sometimes referred to as weight restoration, refeeding is the starting of oral intake for clients with anorexia. Enteral or parenteral nutrition are not the first efforts unless the client is seriously ill or cannot tolerate oral intake. Refeeding is accomplished with slow, measured meals, snacks, and fluids with careful monitoring and ongoing emotional support. Clients may be physically uncomfortable consuming food during nutritional rehabilitation. Hospitalization is necessary if medical monitoring is required. Clients who are malnourished are also at risk for refeeding syndrome where rapid changes in their fluid volume and electrolytes cause complications like cardiac arrhythmias, delirium, coma, and even death (Sim et al., 2010).

Psychological treatment can be effective in treating clients with anorexia nervosa. Specialist Supportive Clinical Management (SSCM) and The Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) are commonly used as modalities (Costandache et al., 2023). SSCM is a treatment approach that involves both clinical management along with supportive individual psychotherapy. MANTRA is a treatment approach where people with anorexia can be supported by a therapist and other people with anorexia in a group setting.

Family-based therapies are considered first-line for children and adolescents with anorexia where the family takes an active role to support the client’s recovery (Sim et al., 2010). CBT has also been shown to be an effective approach that involves exploring cognitive processes that influence behaviors.


There are no FDA-approved medical treatments for anorexia nervosa. Medications used in anorexia nervosa help to manage symptoms and other comorbidities. For example, SSRIs, like fluoxetine, can assist clients with anorexia nervosa to manage underlying anxiety or depression. Antipsychotic medications like olanzapine may be used to promote weight gain and help manage obsessional thinking (Davis & Attia, 2017). Medications like laxitives can be used to manage symptoms of constipation, and potassium supplements can be used in clients with hypokalemia. Because clients with anorexia can have decreased bone density due to malnutrition, medications like alendronate can improve bone health (Davis & Attia, 2017). There is also promising research on using synthetic cannabinoid agonists like dronabinol to manage symptoms like nausea, vomiting, and decreased appetite (Davis & Attia, 2017).

Client’s Self-Help

The use of online, guided self-help interventions has been studied with anorexia nervosa and has been found to be a feasible way to help clients with the disorder (Cardi et al., 2020). There are a variety of online options available, but all online tools are not created equally, so it’s important to review sites to ensure that they are a good fit for the client. Evidence supports that personal guidance from an expert, such as a nurse, can help clients find the best self-help resources and increase compliance with interventions (Rohrbach et al., 2022). This may also be a way to reach out to those who are suffering with anorexia nervosa but may be reluctant to seek care. The National Eating Disorders Association provides information on eating disorders, including treatment options, support opportunities, and screening tools to assess risk (NEDA, 2023a).

Nursing Implications

Nurses play a vital role in managing clients with anorexia nervosa. Clients who are severely malnourished are at risk for fatal complications that the nurse must quickly assess. Nurses in the outpatient setting can help screen and assess clients for eating disorders and determine if they need additional evaluation or interventions. The American Psychological Association provides an interactive screening/assessment tool for eating disorders that can be used in clinical decision making (APA, 2023a). Nurses caring for clients in the treatment setting will closely monitor for things like refeeding syndrome, cardiac arrhythmias, and other complications that can occur in clients with anorexia nervosa. Suicide risk is also high in clients with anorexia, so nurses must be sure to assess for suicidal ideations.

Therapeutic Relationship

Establishing a therapeutic relationship with clients with anorexia nervosa is essential to help facilitate their recovery and provide support. The nurse must establish an alliance with the client to confront the disease process. Lev Ari et al. (2024) and Hartley et al. (2022) acknowledged the therapeutic relationship is key to the best outcomes in mental health care. Nurses can establish a therapeutic relationship by establishing rapport with the client, being nonjudgmental, and ensuring that they are competently implementing interventions to help improve the clients’ health status and provide client-centered care.

Nurses’ reactions can affect therapeutic relationships with clients who suffer from eating disorders like anorexia. It may be difficult and even frustrating for nurses to care for complex clients with anorexia who engage in self-starvation that can lead to fatal complications. It is important for nurses to provide nonjudgmental care and to adequately assess each client’s mental health status. An example of providing nonjudgmental care can be when a client with anorexia who appears emaciated talks about the desire to lose more weight. Instead of telling the client that they do not need to lose weight, nurses can encourage them to talk about their feelings related to their weight. An essential part of recovery from anorexia is receiving support that includes managing comorbid mental health conditions like anxiety and depression along with body image issues. It is important for nurses to remember that anorexia nervosa involves an abnormal disturbance in attitudes and behaviors related to food so these clients will need support to help reorder their thought processes and behaviors to healthy patterns.

Nurse Mentoring

Finding support from colleagues through nurse mentorship has been proven to be effective in increasing nurse competence in managing clients with complex health conditions (Hookmani et al., 2021). Nurses with experience managing clients with eating disorders can offer knowledge and demonstrate skills to other nurses who may have less experience to help increase their competence. For example, preceptors can provide their clinical experience on how to manage clients with eating disorders. Nurse educators who teach about eating disorders can mentor nurses working with these clients and provide current and relevant information.

Milieu Management

The American Nurses Association’s essential standards for psychiatric nursing includes the responsibility of nurses to maintain a therapeutic milieu for clients to help aid in their recovery (Belsiyal et al., 2022). Milieu therapy involves clients practicing everyday activities like eating, in a structured environment that is facilitated by the nurse. Providing a safe, structured, healing environment can be beneficial for clients with anorexia who may need to implement behavioral changes to help restore their health.

Safe Environment

Treatment of eating disorders can require different levels of care ranging from community treatment, day programs, residential facilities, or hospitalization (Peckmezian & Paxton, 2020). Clients with severe complications from anorexia nervosa may require hospital care. They may deprive themselves of food and nutrients and engage in purging that can lead to severe malnutrition and starvation that can be fatal. These clients are also at high risk for suicide, so it is important to help maintain a safe environment, both in a treatment setting, and, in the community (NIMH, 2023). Clients should be screened for suicide risk, followed by the implementation of interventions to ensure safety, such as removing harmful objects that can be used for self-harm, providing one-on-one care for clients at high risk, and having clients at high risk monitored carefully. Behaviors that need to be watched for in suicidal clients include self-injurious behaviors, like cutting, reporting suicidal thoughts, and attempting suicide (Mereu et al., 2022). At discharge, it is important that clients are provided with resources to help them if they have suicidal thoughts. Transitional and residential treatment options are also available to manage clients who are at risk for self-harm.


Caring for clients with anorexia requires teamwork. Delegation of tasks by nurses is essential to providing quality care and can help decrease the workload. Tasks like obtaining weight and vital signs can be delegated to assistive personnel. This can allow more time for the nurse to focus on tasks like medication administration and care planning. Nurses can also coach assistive personnel on providing nonjudgmental care by showing compassion.


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