iors. Avoiding “bad” or fattening foods gives them a
sense of power and control over their bodies, whereas
eating, binging, or purging leads to anxiety, depres-
sion, and feeling out of control. Clients with eating
disorders often seem sad, anxious, and worried. Those
with anorexia seldom smile, laugh, or enjoy any at-
tempts at humor; they are somber and serious most of
the time. In contrast, clients with bulimia are initially
pleasant and cheerful as though nothing is wrong.
The pleasant façade usually disappears when they
begin describing binge eating and purging; they may
express intense guilt, shame, and embarrassment.
It is important to ask clients with eating disorders
about thoughts of self-harm or suicide. It is not un-
common for these clients to engage in self-mutilating
behaviors such as cutting. Concern about self-harm
and suicidal behavior should increase when clients
have a history of sexual abuse (see Chaps. 11 and 15).
THOUGHT PROCESSES AND CONTENT
Clients with eating disorders spend most of the time
thinking about dieting, food, and food-related behav-
ior. They are preoccupied with their attempts to avoid
eating or eating “bad” or “wrong” foods. Clients can-
not think about themselves without thinking about
weight and food. The body image disturbance can be
almost delusional; even if clients are severely under-
weight, they can point to areas on their buttocks or
thighs that are “still fat,” thereby, fueling their need
to continue dieting. Clients with anorexia who are
severely underweight may have paranoid ideas about
their family and health care professionals, believ-
ing that they are their “enemies” who are trying to
make them fat by forcing them to eat.
SENSORIUM AND
INTELLECTUAL PROCESSES
Generally clients with eating disorders are alert and
oriented; their intellectual functions are intact. The
exception is clients with anorexia who are severely
malnourished and showing signs of starvation such
as mild confusion, slowed mental processes, and dif-
ficulty with concentration and attention.
JUDGMENT AND INSIGHT
Clients with anorexia have very limited insight and
poor judgment about their health status. They do
not believe that they have a problem; rather they
think that others are trying to interfere with their
ability to lose weight and to achieve the desired body
image. Facts about failing health status are not
enough to convince these clients of their true prob-
lems. Clients with anorexia continue to restrict food
intake or to engage in purging despite the negative
effect on health.
In contrast, clients with bulimia are ashamed of
the binge eating and purging. They recognize these
behaviors as abnormal and go to great lengths to
hide them. They feel out of control and unable to
change even though they recognize their behaviors
as pathologic.SELF-CONCEPT
Low self-esteem is prominent in clients with eating
disorders. They see themselves only in terms of their
ability to control their food intake and weight. They
tend to judge themselves harshly and see themselves
as “bad” if they eat certain foods or fail to lose weight.
They overlook or ignore other personal characteris-
tics or achievements as less important than thinness.
Clients often perceive themselves as helpless, power-
less, and ineffective. This feeling of lack of control over
themselves and their environment only strengthens
their desire to control their weight.ROLES AND RELATIONSHIPS
Eating disorders interfere with the ability to fulfill
roles and to have satisfying relationships. Clients
with anorexia may begin to fail at school, which is in
sharp contrast to previously successful academic per-
formance. They withdraw from peers and pay little
attention to friendships. They believe that others will
not understand or fear that they will begin out-of-
control eating with others.
Clients with bulimia feel great shame about their
binge eating and purging behaviors. As a result, they
tend to lead secret lives that include sneaking behind
the backs of friends and family to binge and purge in
privacy. The time spent buying and eating food then
purging can interfere with role performance both at
home and at work.PHYSIOLOGIC AND SELF-CARE
CONSIDERATIONS
The health status of clients with eating disorders re-
lates directly to the severity of self-starvation, purg-
ing behaviors, or both (see Table 18-1). In addition,
clients may exercise excessively, almost to the point
of exhaustion, in an effort to control weight. Many
clients have sleep disturbances such as insomnia, re-
duced sleep time, and early-morning wakening. Those
who frequently vomit have many dental problems
such as loss of tooth enamel, chipped and ragged teeth,
and dental caries. Frequent vomiting also may result
in sores in the mouth. Complete medical and dental
examinations are essential.18 EATINGDISORDERS 445