Case study: Eating disorder in a 10-year-old girl
Case Study appears in JCAPN from time to time. The column spotlights specific nursing care problems and subsequent interventions for a variety of patient populations. The discussion that follows each case study will enhance the depth of the analysis and lend a theoretical spin to the clinical intervention.
All client/patient names and situations are altered to preserve confidentiality. Readers are urged to submit cases that exemplify a nursing care problem or intervention. Discussants will be chosen for their expertise in the subject material.
Lisa is a 10-year-old female with mixed Caucasian and Native-American ethnicity. Her fourth grade teacher consuited with the clinical nurse specialist assigned to work with the school system via a local community mental health center. With an office in the school building, the nurse had easy access to students and to teachers who had concerns or questions about particular students.
Mrs. G, Lisa’s teacher, sought help from the clinical nurse specialist after noticing a dramatic change in Lisa’s weight over the first 10 weeks of the school year. Lisa had begun the year as a somewhat overweight, cheerful youngster with dark hair and bright green eyes who excelled at school and had a reputation as a perfectionist in her work.
While Lisa’s schoolwork remained exemplary, her mood and appearance had changed dramatically. She preferred to stay in the classroom at recess and read, her social contacts with female peers lessened, and Mrs. G noticed that Lisa no longer ate lunch. She was observed giving most of her lunch away and nibbling at a small piece of fruit or vegetable.
Mrs. G estimates that Lisa lost between 20 and 30 lb in 10 weeks and was looking very thin and gaunt. Her clothes no longer fit, and her hair appeared dry and strawlike.
When questioned, Lisa denied there were any problems at home or in the classroom. Mrs. G called Lisa’s mother, who worked as an evening nurse in a local hospital. An only child, Lisa was cared for by a neighbor during the evenings when her mother was at work. Lisa’s father had left the home when she was quite young, and she never spoke of him.
Lisa’s mother had agreed to meet with Mrs. G but noted she was quite pleased that Lisa had lost some weight since “she was getting a little fat.” She scheduled a meeting for the following week, the first available time the mother was willing to speak to the teacher.
Meanwhile, Mrs. G noticed Lisa was beginning to fall asleep in the classroom, and her grades had slipped slightly. Mrs. G could not pinpoint why she was so worried about Lisa but believed something was dreadfully wrong.
Case Discussion: Lisa
Dieting is common among females in our weightconscious culture. Forty percent of American women report they are dieting (Eating disorders-Part II, 1997). Recently a survey (Eating disorders-Part II) was conducted with girls in grades five through eight; 31% of the girls said they were dieting, while 9% said they had sometimes abstained from eating. Of these girls, 5% reported they sometimes self-induced vomiting. Dieting also is a common precipitating factor in eating disorders (Glod, 1998). The typical pattern for the onset of anorexia nervosa is that the person begins a diet and then continues to restrict eating after the desired weight is achieved. The person who develops anorexia becomes preoccupied with body shape and weight during this process. Most often, onset begins during adolescence, when the body is undergoing normal physiologic changes; how much these changes associated with puberty contribute to the onset of anorexia is unknown (Glod).
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) provides four main criteria for the diagnosis of anorexia nervosa: The individual is unwilling to gain weight at or above a weight considered the normal minimum for height and age; weight has fallen to 15% below the normal range expected for the individual; the individual has an extreme fear of being fat or adding pounds, even though s/he is below expected weight; disturbances in body image related to either weight or shape of body are present, self-esteem is unduly influenced by the disturbance in body image, or the individual denies the potential seriousness of complications resulting from very low weight. If past menarche, females have amenorrhea for at least three cycles. In younger patients, there may be no weight loss but instead a gain in height without a corresponding increase in weight. In a prepubertal female, menarche may not occur (APA). There are two subtypes for anorexia nervosa: restricting, in which weight loss is accomplished though dieting, fasting, or excessive exercise; and binge-eating/purging, in which the person routinely binge eats or purges or does both during the episode of anorexia (APA).
Bulimia nervosa is defined as having two or more episodes of binge eating every week for at least 3 months and the use of inappropriate ways of avoiding weight gain from bingeing (APA, 1994). A binge consists of rapid ingestion of large amounts of food during a specific period of time that is unequivocally more than the average person would consume in the same amount of time and under the same circumstances. In addition, the individual has a sense of being unable to control the bingeing. The binge is followed by some form of inappropriate compensation, such as laxative use, diuretics, self-induced vomiting, excessive exercise, fasting, or enemas to rid the body of unneeded calories so that weight is maintained. In addition, self-esteem is negatively influenced by the body shape and weight of the individual with bulimia (APA). Bulimia also has two subtypes: purging type, in which the individual uses self-induced vomiting, laxatives, diuretics, or enemas; and the nonpurging type, in which the individual uses other types of inappropriate methods to rid the body of unnecessary calories such as excessive exercise or fasting but does not use the mechanisms associated with purging (APA). Since Lisa lost between 20 and 30 lb, bulimia nervosa can be ruled out as her diagnosis.
The typical eating disorder develops in young females during adolescence; it also may develop before menarche or during adulthood (Heebrink, Sunday, & Halmi, 1995). Bulimia nervosa tends to occur later in adolescence. Its prevalence varies. Levine (1987) found that between 1 and 6 of every 200 girls will develop anorexia before the age of 21. This means about 1% to 6% of all teenage and college-age women will develop anorexia, and 5% to 8% will develop bulimia (Grothaus, 1998). While boys occasionally develop the disorder, the prevalence of males with anorexia is much lower, about 1.8 per 100,000 (Steiner & Lock, 1998), and approximately 1% to 2% of all boys will be bulimic during their high school years (Levine). Evidence exists that certain athletes are prone to eating disorders, especially if the sport accentuates leanness for improving performance. For example, gymnastics, wrestling, ballet, and figure skating all require leanness for best performance, and anorexia and bulimia are more common among participants in these disciplines (Garner,1993).
The central feature of anorexia nervosa is an abnormally low weight, usually achieved by restricting the number of calories consumed (Garner, 1993). The anorectic adolescent pursues thinness and often is in denial about the seriousness of the weight loss. Typical development of anorexia nervosa starts with a diet or other process, such as excessive exercise, to reduce weight. Often the individual will report having been teased for being fat or wanting to accomplish something that required a leaner look, such as trying out for cheerleading. Once the process of dieting leads to the desired goal, the individual begins to think that maybe just a few more pounds would look even better, so she continues the behavior. Although the individual refuses to eat, s/he continues to have a good appetite, at least in the beginning (Eating disorders-Part I, 1997). In this respect, the term anorexia is a misnomer. The anorectic individual is proud of the ability to lose weight and may feel superior to others who are not dieting. Once cell starvation begins to occur, the person’s cognitive abilities may be affected, and the process of self-starvation may make it difficult to reverse the process.
Multiple theories exist about the etiology of anorexia nervosa. It probably is multifactorial in origin. Three types of predisposing factors interact, resulting in anorexia, according to Garner (1993). These three types of factors are individual, including biological and psychological, familial, and cultural factors (Garner).
One problem with the research into psychological origins of anorexia nervosa, according to Garner (1993), was that the research was typically conducted on nonrepresentative samples and only after the disorder develops. In addition, rarely did published research include a control group of patients with other psychiatric disorders. Steiner and Lock (1998) made the same point, stating that since patients in most eating-disorder studies tended to come from specialized eating-disorder clinics, often the studies had a greater number of seriously ill patients than would be found in a representative sample.
Personality traits in anorexia nervosa tend to be studied in nonrepresentative samples and after the disorder has developed, so it was difficult to say if the traits preceded the illness or were a part of the illness. People with anorexia nervosa have been described as introverted, constricted, obsessional, compulsive, and reticent (Pryor & Wiederman, 1998). Pryor and Wiederman studied personality features of anorexia and bulimia and found that an inhibited or avoidant personality style was found in about half the adolescents with eating disorders, regardless of diagnosis. Anorectic adolescents demonstrated more compulsivity than bulimic teens.
In an empirical study, Strober (1981) compared female adolescents with anorexia to female adolescents with affective disorders or conduct disorders and found the anorectic adolescents were more likely to be self-regulating, more socially conscientious and conforming, more interpersonally inhibited, and less emotionally demonstrative than young females with either of the other two psychiatric diagnoses.
A common theme in the psychology and psychiatric literature was that the anorectic person used self-starvation as a form of self-punishment, with the unconscious goal of pleasing the internalized parent who was viewed as requiring harsh restrictions (Eating disorders-Part I, 1997). Most anorectic females were well-behaved, often perfectionists, straight A students, who were quite sensitive to rejection and tended to be obsessive worriers. Some suggested these young women were responding to their developing bodies, issues of sexuality, and independence when they began to fast. Fast and self-starvation allowed the young anorectic woman to regain a sense of control over herself and others. At the same time, she was able to feel successful and proud of her accomplishments in losing weight, which she was able to do better than others around her (Eating disorders-Part I). Other psychodynamic theories suggested the underlying psychological issues were related to separation-individuation issues within the family (Eating disordersPart I).
Relationship to other psychiatric disorders. Garner (1993) reported that depression was a common comorbid illness in anorexia nervosa. Lifetime prevalence rates ranged from 25% to 89%, depending on which study was read (Halmi et al., 1991; Herpertz-Dahlmann, Wewetzer, Henninghaussen, & Remschmidt, 1996; Herzog, Keller, Sacks, Yeh, & Lavori, 1992). HerpertzDahlmann et al. found lower prevalence rates, but the subjects in their study were 3 to 6 years younger than the subjects in other studies noted. Morbidity for affective disorders typically increases with age (Heebrink et al., 1995), which may account for some of the differences. Rastam (1992) found that the mood disorders commonly found in anorexia nervosa did not precede the eating disorder, although the depression did correlate with anorexia nervosa. Herzog et al. reported that based on their study of a large sample of adults and adolescents, 63% of all patients with eating disorders had a lifetime affective disorder. Patients with mixed anorectic and bulimic features had the highest rates of depression. In contrast, Sunday, Reeman, Eckert, and Halmi (1996) conducted a 10-year outcome study of individuals with adolescent onset of anorexia nervosa. The subjects in this study did not show significant psychopathology 10 years after treatment, unless they also could be diagnosed with a concurrent eating disorder. In thinking about the links between depression and eating disorders, it is important to remember that depressive symptoms can be a consequence of starvation and the concomitant problems that accompany anorexia nervosa. Mood often improved after nutritional status significantly improved (Garner, 1993).
Favaro and Santonastaso (1997) studied suicidality in eating disorders, using 495 patients with emotional disorders. An interview included questions about lifetime self-destructive behaviors and, for most of the patients, questions were asked about drug and alcohol abuse and childhood sexual abuse. Patients answered on a fivepoint Likert scale. Sixteen percent of people with bingepurging type anorexia and 9% of those with restrictive type anorexia had a history of suicide attempts. Anorectics who attempted suicide tended to be older, weighed less, and had been ill for longer than nonattempters. The anorectics who had made suicide attempts tended to have had more treatment failures, greater obsessional thinking, and concomitant drug or alcohol abuse than nonattempters. In Favaro and Santonastaso’s study, a history of child sexual abuse was linked to increased self-wounding but not to increased suicide attempts.
Child sexual abuse, which is seen as an increasingly common explanation for other psychiatric problems, has been suggested as an explanation for eating disorders. The connection has not been confirmed, and some recent studies seemed to negate this as a distinct underlying factor (Eating disorders-Part I, 1997). Herzog, Staley, Carmody, Robbins, and van der Kolk (1993) investigated the relationships of child sexual abuse and eating disorders. Higher rates of comorbid psychiatric disorders were present, with eating disorders in those patients who had experienced child sexual abuse. The rate of child sexual abuse in the sample, however, was not extraordinary compared to the rates for other psychiatric disorders. Perhaps the comorbid psychiatric disorders were more closely related to the child sexual abuse than to eating disorders (Herzog et al.).
Anxiety also has been identified as a common comorbidity with anorexia nervosa. Halmi et al. (1991) estimated the lifetime prevalence of social phobias at about 25% of patients with anorexia nervosa. Rastam (1992) reported that 35% of anorectic patients had a comorbid obsessive-compulsive disorder. The symptoms of anxiety, depression, and obsessionality were most elevated when the person was most underweight. As weight increased to a more normal level, the severity of these symptoms decreased (Pollice, Kaye, Greeno, & Weltzin, 1997).
There were inconsistencies in the findings of personality disorders as comorbid disorders in patients with anorexia nervosa, according to Garner (1993). Piran, Lerner, Garfinkel, Kennedy, and Brouilette (1988) report that 33% of anorectics who restrict their eating develop avoidant personality disorders, while about 40% of anorexic-bulimic patients develop borderline personality disorders. Herzog et al. (1992) report, however, that personality disorders are rare comorbidities of anorexia nervosa. The use of psychoactive medications in the treatment of anorexia nervosa has been studied primarily with adults who have the disorder, but the use of pharmacologic agents in treating adolescents is relatively untested (Steiner & Lock, 1998). During the acute phase, psychiatric medications are of limited help. In the adult population, antidepressants and low doses of neuroleptics have been used most often. Neuroleptics have been used to combat severe obsessional or psychoticlike thinking and for anxiety. A major problem with neuroleptics, however, is that they may result in binge induction and there is little benefit in using them when compared to control groups (Steiner & Lock).
Genetics. A few twin studies have been done focusing on discovering a genetic vulnerability for anorexia nervosa (Bakan, Birrngham, & Goldner, 1991; Garfinkel & Garner, 1992; Holland, Sicotte, & Treasure, 1988). While these studies suggested there were some types of genetic factors in the transmission of anorexia nervosa, the nature of the factors transmitted was still uncertain. Data on twins reared together in the same home did not clearly differentiate between genetic transmission and the effects of the environment. It remained unclear if the genetic link was a specific vulnerability or whether the genetic factor was a more indirect link to the disorder, such as a propensity to becoming overweight or to a certain type of personality (Garner, 1993). Hsu (1990) noted there seemed to be a genetic link between chemical dependency and eating disorders, and Root, Fallon, and Friedrich (1986) reported that depression and eating disorders seemed to be related genetically.
Eating disorders tend to run in families, as do many other psychiatric disorders. The rate of anorexia among close female relatives of women with anorexia is 2% to 10% (Eating disorders Part I, 1997). When comparing groups of patients with an eating disorder with groups of patients with other psychiatric disorders, the eatingdisorders group had a 20% to chance of having a family member with an eating disorder, while the psychiatric patients with other diagnoses had a 6% chance of having a family member with an eating disorder (Eating disorders-Part I). Halmi et al. (1991) discovered that female first-degree relatives of women with anorexia nervosa had a significantly higher risk of developing an eating disorder during their lifetime. These studies that demonstrated increased familial incidence of eating disorders lent credence to the notion that at least a vulnerability to the disorder was transmitted genetically.
Neuroendocrine and metabolic abnormalities. The various endocrine abnormalities associated with anorexia nervosa resulted from disturbances in the hypothalamic-pituitary-gonadal axis (Garner, 1993). Abnormalities in the neurotransmitters and hormones that usually act to balance energy output with food intake might be one cause of eating disorders. Neural pathways leading from the hypothalamus regulate levels of sex hormones, thyroid hormones, and adrenal cortisol. All these hormones affect body weight, mood, appetite, and the stress response. Serotonin and norepinephrine are two neurotransmitters found in the hypothalamic neural pathways. Serotonin has been shown to be quite low in the starving phase of anorexia; it increases to greater than average amounts, however, when the person’s weight returns to normal (Eating disorders-Part I, 1997.
Eating disorders have been shown to involve interrelationships among neurotransmitters, including norepinephrine; many of these same neurotransmitters and neural pathways are involved in depressive disorders (Irwin, 1993a). Irregularities in neuroregulatory systems that have been demonstrated in anorexia nervosa may result from the effects of anorexia nervosa rather than cause the disorder (Garner, 1993). The hormonal impact of these irregularities accounts for the cessation of menses or delay of menarche in females with anorexia nervosa.
Another theory is that the natural opioidlike substances (enkephalins and endorphins) produced in the brain may influence the course of eating disorders. Higher levels of these substances have been found in the cerebrospinal fluid of anorectic patients (Eating disorders-Part I, 1997). It is known that there is an increase in endorphin release during prolonged fasting. Patients are believed to get a high from fasting. Naltrexone is believed to block the high, thereby reducing the incentive for fasting (Preston, ONeal, & Talaga, 1994). In addition, some patients gain weight when naloxone, a drug similar to naltrexone, is administered (Eating disorders-Part I).
Early explanations of anorexia nervosa attributed the pathology to influences of the family. Mothers were described as intrusive, ambivalent, and dominant, while fathers were seen as passive and ineffectual (Vandereyecken, Kog, & Vanderlinden, 1989). Anorexia nervosa was sometimes seen as having a stabilizing effect on the family dynamics. Specific family interaction patterns that were observed included overprotectiveness, rigidity, enmeshment, and family avoidance of conflict. Vandereyecken et al. noted, however, that the family pathology may be the result of the disorder rather than a causative factor.
Some authors believe the notion of female slenderness in western culture has been promoted by various types of media that cast young, slim women as glamorous stars, and by sales campaigns that use slim, young women to sell various products, with the underlying theme that being thin results in true happiness (Rothblum, 1994; Vanderlinden, Norre, & Vandereycken, 1992). Young women desiring to be fashionable, successful, and happy exercised and dieted to achieve the thin look promoted by the media. Garner (1993) noted that the significance of cultural pressures on young women to achieve thinness has been recognized only recently. The desire to fashion one’s body to fit with the cultural norms was congruent with the cultural norms for accomplishment and self-actualization (Eating disorders-Part II, 1997). Rastam (1992) reported that a strong concern about being overweight seemed to predate the development of anorexia nervosa. The stigma associated with obesity and the ill-designed treatments for obesity have been considered a risk factor for eating disorders (Garner & Wooley, 1991). Huon, Brown, and Morris (1988) stated that anorexia nervosa seemed to have developed a positive public image, and the symptoms of anorexia nervosa were not viewed as abnormal or unusual by the general public.
Medical complications resulting from eating disorders can be life threatening. Cardiovascular, renal, and endocrine systems can be seriously impaired. Dehydration and/or hypokalemia may result in cardiac dysrhythmia and, if untreated, death. Vomiting can produce serious esophageal lacerations, which could lead to hemorrhage as well as major dental damage. The longterm medical complications of anorexia nervosa in youth are well known. Changes in growth hormone, hypothalamic hypogonadism, bone marrow hypoplasia, structural abnormalities of the brain, cardiac dysfunction, gastrointestinal difficulties, significant growth retardation, pubertal delay or interruptions, and peak bone mass reduction are potential complications from anorexia nervosa. Deaths from complications of anorexia nervosa are estimated to be about 6% to 15%, with half of these deaths resulting from suicide (Steiner & Lock, 1998).
From the description of Lisa given by her teacher, a tentative diagnosis of anorexia nervosa can be made, although other disorders need to be ruled out. More information is needed, however, to make the differential diagnosis. Weight loss may be a symptom of serious medical problems, such as AIDS, Crohn’s disease, or cancer. It also may be related to other psychiatric disorders, such as depression, schizophrenia, or social phobias where the phobia is related to eating in public (Glod, 1998). Before making the diagnosis of anorexia nervosa, the clinical nurse specialist (CNS) will need to ascertain if Lisa is experiencing a distorted body image/fear of gaining weight, which is diagnostic of an eating disorder (Glod). In order to further assess Lisa’s problem, the CNS will need to develop an alliance with Lisa’s mother and gain permission from her to work with Lisa.
In the case study, Lisa’s teacher Mrs. G believed that something was dreadfully wrong with Lisa and arranged to meet with the mother. This meeting will be the starting point for working with Lisa and her mother. Irwin (1993b) stressed the importance of building trust with not only the patient with anorexia but also the family, especially when the patient lives at home. The mother’s statement that she was pleased with Lisa’s weight loss could potentially set up an adversarial relationship between the teacher and the mother, since Mrs. G is worried about Lisa. Mrs. G may need some help from the CNS to understand the mother’s position before meeting with Lisa’s mother. There are various reasons Lisa’s mother might have made this statement.
Perhaps Lisa has been wearing extra layers of clothing to disguise her weight loss. Since Lisa’s mother works evenings, she may be asleep when Lisa is getting ready for school, and Lisa is probably asleep when her mother returns from work. Her mother actually may have very little waking time with Lisa. Since eating disorders have increased incidence among female family members, it is possible that Lisa’s mother has an eating disorder herself and has not recognized the seriousness of Lisa’s problem. Or perhaps, as Huon and colleagues (1988) suggested, her mother had developed a positive image of anorexia and doesn’t view Lisa as having any type of problem.
In the meeting with Lisa’s mother, Mrs. G needs to keep in mind that this mother is doing the best for Lisa that she currently knows how to do. Mrs. G could take the approach of asking Lisa’s mother how she sees Lisa at this time and what the mother is thinking in terms of Lisa’s certain health status. Mrs. G can share her specific concerns, including the fact that Lisa’s grades are beginning to slip and that she is falling asleep in class. To support the teacher, the CNS should be available during the meeting but should not join in without the teacher asking the mother’s permission to bring the CNS into the meeting. The teacher might suggest having the CNS join them, to provide more specialized information about the possible diagnoses that could be causing Lisa’s symptoms.
Once the CNS has been invited to join the meeting and has developed some rapport with the mother, the CNS can discuss some possible diagnoses for Lisa’s condition and determine if Lisa has had a recent physical. As part of the discussion, the CNS should find out more about the caretaking arrangements with the neighbor to rule out the possibility of sexual abuse.
Part of the diagnostic process for Lisa will be a physical examination to rule out some of the possible medical conditions identified earlier. The patient’s distorted body image related to weight is distinctive to the eating disorder. So if Lisa believes she is still not underweight and is still fat, or denies the potential seriousness of her weight loss, the diagnosis will be anorexia nervosa. A few other psychiatric disorders may have somewhat similar problems and should be ruled out. For example, in body dysmorphic disorder, there may be distinct body image distortions that include feeling fat and overweight, but usually without a weight loss. A significant weight loss can occur in depression, but the depressed patient is aware of the loss and acknowledges the seriousness of the problem is that she has fallen far below a normal weight.
After gaining permission from the mother and after a physical examination, the CNS can arrange to meet with Lisa during the school day to assess the situation and plan out a strategy for her treatment. The neighbors who care for Lisa in the evenings may need to be included in planning for ways to manage Lisa’s eating at dinner. The CNS will be able to monitor Lisa’s weight as part of the treatment plan and may set up a plan with Mrs. G to monitor her lunchtime eating. Fortunately, Lisa is quite young, and the early diagnosis and treatment of anorexia in young patients shows the greatest success.
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Author contact: kathleen.scharer sc.edu, with a copy to the Editor: Poster@ta.edu
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