begin to resolve these issues and improvecommuni-
cation. Family therapy also is useful to help members
to be effective participants in the client’s treatment.
Studies have shown that dysfunctional families may
take as long as 2 years to demonstrate improved func-
tioning (Gowers & North, 1999).
Individual therapy for clients with anorexia ner-
vosa may be indicated in some circumstances such as
if the family cannot participate in family therapy, if
the client is older or separated from the nuclear fam-
ily, or if the client has individual issues requiring
psychotherapy. McIntosh, Bulik, McKenzie, Luty &
Jordan (2000) reported that in therapy focusing on
grief and interpersonal disputes and deficits, role tran-
sitions can improve interpersonal functioning and
decrease symptoms.
Bulimia Nervosa
Most clients with bulimia are treated on an out-
patient basis. Hospital admission is indicated if bing-
ing and purging behaviors are out of control and the
client’s medical status is compromised. Most clients
with bulimia have near-normal weight, which reduces
the concern about severe malnutrition—a factor in
clients with anorexia nervosa.
COGNITIVE-BEHAVIORAL THERAPY
Cognitive-behavioral therapy has been found to be
the most effective treatment for bulimia. This out-
patient approach often requires a detailed manual to
guide treatment. Strategies designed to change the
client’s thinking (cognition) and actions (behavior)
about food focus on interrupting the cycle of diet-
ing, binging, and purging, and altering dysfunctional
thoughts and beliefs about food, weight, body image,
and overall self-concept (Halmi, 2000).
PSYCHOPHARMACOLOGY
Since the 1980s, several controlled studies have been
conducted to evaluate the effectiveness of antidepres-
sants to treat bulimia. Drugs such as desipramine
(Norpramin), imipramine (Tofranil), amitriptyline
(Elavil), nortriptyline (Pamelor), phenelzine (Nardil),
and fluoxetine (Prozac) were prescribed in the same
dosages used to treat depression (see Chap. 2). In all
the studies, the antidepressants were more effective
than were the placebos in reducing binge eating. They
also improved mood and reduced preoccupation with
shape and weight. Most of the positive results, how-
ever, were short-term with only 22% to 25% of
clients maintaining complete abstinence from binge
eating and purging by the end of treatment (Zhu &
Walsh, 2002).
APPLICATION OF THE
NURSING PROCESS
Although anorexia and bulimia have several differ-
ences, many similarities are found in assessing, plan-
ning, implementing, and evaluating nursing care for
clients with these disorders. Thus this section ad-
dresses both eating disorders and highlights differ-
ences where they exist.Assessment
Several specialized tests have been developed for eat-
ing disorders. An assessment tool such as the Eating
Attitudes Test often is used in studies of anorexia and
bulimia. This test also can be used at the end of treat-
ment to evaluate outcomes because it is sensitive to
clinical changes.HISTORY
Family members often describe clients with anorexia
nervosa as perfectionists with above-average intelli-
gence, achievement-oriented, dependable, eager to
please, and seeking approval before their condition
began.Parents describe clients as being “good, causing
us no trouble” until the onset of anorexia. Likewise,
clients with bulimia often are focused on pleasing
others and avoiding conflict. Clients with bulimia,
however, often have a history of impulsive behavior
such as substance abuse and shoplifting as well as anx-
iety, depression, and personality disorders (Schultz
& Videbeck, 2002).GENERAL APPEARANCE AND
MOTOR BEHAVIOR
Clients with anorexia appear slow, lethargic, and fa-
tigued; they may be emaciated, depending on the
amount of weight loss. They may be slow to respond
to questions and have difficulty deciding what to say.
They are often reluctant to answer questions fully be-
cause they do not wanting to acknowledge any prob-
lem. They often wear loose-fitting clothes in layers,
regardless of the weather both to hide weight loss
and to keep warm (clients with anorexia are gener-
ally cold). Eye contact may be limited. Clients may
turn away from the nurse, indicating their unwill-
ingness to discuss problems or to enter treatment.
Clients with bulimia may be underweight or over-
weight but are generally close to expected body weight
for age and size. General appearance is not unusual,
and they appear open and willing to talk.MOOD AND AFFECT
Clients with eating disorders have labile moods that
usually correspond to their eating or dieting behav-18 EATINGDISORDERS 443