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Chapter 21
Nursing care of the patient with
•
anorexia nervosa

'Always preoccupied with his or her physique, pubertal development

and attractiveness, the adolescent today has an added worry, the fear
of being a fat person in a society that values slenderness.' (Schmidt
and Duncan, 1974).

INTRODUCTION
Anorexia nervosa is an eating disorder that is characterized by severe and
prolonged dieting. Self-imposed dieting results in severe weight loss, which
threatens life and the individual's ability to function in society. The condition
can occur in males or females usually within the age range 10-30 years.
However, primary anorexia (i.e. anorexia occurring for the first time) is more
common among females of adolescent age who predominantly come from
middle class social backgrounds.
The physical picture is one of emaciation; amenorrhoea occurs and the
body is cov:~red in fine downy hair.
Anorexia is not usually a disorder that affects the patient alone; the patient
may be expressing in a visible way a problem that affects the whole family. The
dieting behaviour often begins during adolescence and may arise out of the
person's inability to cope with the uncertainties of leaving childhood and
becoming an adult. The patient's parents may be unduly rigid or repressive
about sexual matters. Sexuality may be presented as something disgusting or
frightening, or the vulnerability of women and the ill intentions of men may be
emphasised.
Unconsciously, the patient may link eating with sexual behaviour. There
may be an attempt to avoid adolescent sexuality by returning to an early stage
of pre-pubertal development when the body was thin and child like. Food may
be seen as a means of controlling sexual impulses, as a way of arresting sexual
development and of achieving an identity.
Anorexic behaviour may also be a substitute for the usual adolescent
behaviour of defying parental values and authority and moving towards
independence.
The patient does not view the behaviour as self-destructive, and the concern
with weight and body image is almost of delusional proportions. Despite the
person's emaciated state the body is perceived as being fat and, when viewed in
a mirror, parts of the body are seen rather than the whole. Thus the thighs may
be seen as 'heavy' or the abdomen 'distended'.
The person is often quite euphoric about the ability to refuse food.
Some anorexics engage in periods of rigid starvation, alternating with binges
of over-eating. Enormous amounts of food are consumed in response to pangs
P. Martin (ed.), Psychiatric Nursing
© Peggy Martin and the Individual Contributors 1987
 NURSING CARE OF THE PATIENT WITH ANOREXIA NERVOSA 231

of hunger, sometimes with dangerous consequences. Because the idea of

fatness fills the person with feelings of guilt, fear and disgust, vomiting is
induced to relieve the guilt.
The person will often use diuretics, laxatives and enemas to help to achieve
weight loss and to expend energy through vigorous exercise. It is not uncommon
for the anorexic person to be very knowledgeable about the nutritional content
and calorific values of food.
The anorexic person may be treated on an out-patient basis but, if there is a
failure to achieve target weight, then hospitalisation may be necessary. Hos-
pitalisation offers a controlled environment in which the food intake and
output can be monitored. Furthermore, separation from the family may reduce
factors that contribute to the condition.
Motivation and a willingness to accept treatment are of course important. In
extreme cases, where the condition threatens a person's life, pressure must be
placed on them to accept treatment. When the person achieves weight gain,
many of their distressing symptoms disappear and they are able to view their
problems from a more rational perspective.

PATIENT PROFILE
Gale Kogan developed anorexia nervosa at the age of 17. She became
concerned about her weight while at college, where she was sometimes
teased about her plumpness.

The Kogan family enjoyed their food but they tended to be 'fussy
eaters'. Mr Kogan had always been a vegetarian and prepared his own
food. Mrs Kogan read anything and everything about food that she could
lay her hands on. She blamed her husband's peculiar eating habits for
denying her the opportunity of trying out recipes from her enormous
collection of cookery books. Despite her interest in food, Mrs Kogan was
essentially a plain cook. Mealtimes were frequently used for the exchange
of sarcastic comments between herself and Mr Kogan, and Gale was
encouraged to take her mother's side in the subsequent arguments that
arose.