18 EATINGDISORDERS 437
their weight. Clients with the restricting subtype
lose weight primarily through dieting, fasting, or ex-
cessively exercising. Those with the binge eating and
purging subtype engage regularly in binge eating fol-
lowed by purging. Binge eatingmeans consuming a
large amount of food (far greater than most people
eat at one time) in a discrete period of usually 2 hours
or less. Purgingmeans the compensatory behaviors
designed to eliminate food by means of self-induced
vomiting or misuse of laxatives, enemas, and diuret-
ics. Some clients with anorexia do not binge but still
engage in purging behaviors after ingesting small
amounts of food.
Clients with anorexia become totally absorbed in
their quest for weight loss and thinness. The term
“anorexia” is actually a misnomer: these clients do
not lose their appetites. They still experience hunger
but ignore it and signs of physical weakness and fa-
tigue; they often believe that if they eat anything,
they will not be able to stop eating and will become
fat. Clients with anorexia often are preoccupied with
food-related activities such as grocery shopping, col-
lecting recipes or cookbooks, counting calories, creat-
ing fat-free meals, and cooking family meals. They
also may engage in unusual or ritualistic food be-
haviors such as refusing to eat around others, cutting
food into minute pieces, or not allowing the food they
eat to touch their lips. These behaviors increase their
sense of control. Excessive exercise is common; it
may occupy several hours a day.
Anorexia nervosa typically begins between 14 to
18 years of age. In the early stages, clients often deny
that they have anxiety regarding their appearance or
a negative body image. They are very pleased with
their ability to control their weight and may express
this. When they initially come for treatment, they
may be unable to identify or to explain their emotions
about life events such as school or relationships with
family or friends. A profound sense of emptiness is
common.
As the illness progresses, depression and lability
in mood become more apparent. As dieting and com-
pulsive behaviors increase, clients isolate themselves.
This social isolation can lead to a basic mistrust of
others and even paranoia. Clients may believe that
their peers are jealous of their weight loss and may
think that family and health care professionals are
trying to make them “fat and ugly.”
In a long-term outcome study of clients with
anorexia nervosa, Zipfel, Lowe, Reas, Deter & Herzog
(2000) found that after 21 years, 50% had recovered
fully, 25% had intermediate outcomes, 10% still met
all the criteria for anorexia nervosa, and 15% had
died of anorexia-related causes. In another study,
clientswith the lowest body weights and longest
durations of illness tended to relapse most often and
have the poorest outcomes (Herzog, Dorer & Keel,
1999). Clients who abuse laxatives are at a greater risk
for medical complications (Turner, Batik & Palmer,
2000). Table 18-1 lists common medical complications
of eating disorders.Bulimia Nervosa
Bulimia nervosa,often simply called bulimia, is an
eating disorder characterized by recurrent episodes
(at least twice a week for 3 months) of binge eating
followed by inappropriate compensatory behaviors to
avoid weight gain such as purging (self-induced vom-
iting or use of laxatives, diuretics, enemas, or emet-
ics), fasting, or excessively exercising (APA, 2000).
The amount of food consumed during a binge episode
is much larger than a person would normally eat.
The client often engages in binge eating secretly. Be-
tween binges, the client may eat low-calorie foods or
fast. Binging or purging episodes are often precipi-Maggie, 15 years old, is 5 feet 7 inches and weighs
92 pounds. Though it is August, she is wearing sweat-
pants and three layers of shirts. Her hair is dry, brittle, and
uncombed, and she wears no makeup. Maggie’s family
physician has referred her to the eating disorders unit
because she has lost 20 pounds in the last 4 months and
her menstrual periods have ceased. She also is lethargic
and weak yet has trouble sleeping. Maggie is an avid
ballet student and believes she still needs to lose more
weight to achieve the figure she wants. Her ballet in-
structor has expressed concern to Maggie’s parents
about her appearance and fatigue.CLINICALVIGNETTE: ANOREXIANERVOSA
Maggie’s family reports that she has gone from
being an A and B student to barely passing in school.
She spends much of her time isolated in her room and
is often exercising for long hours, even in the middle of
the night. Maggie seldom goes out with friends, and
they have stopped calling her. The nurse interviews
Maggie but gains little information as Maggie is reluc-
tant to discuss her eating. Maggie does say she is too fat
and has no interest in gaining weight. She does not un-
derstand why her parents are forcing her to come to
“this place where all they want to do is fatten you up and
keep you ugly.”