anorexia nervosa case study quizlet

• Find Flashcards
• Why It Works
• Tutors & resellers
• Content partnerships
• Teachers & professors
• Employee training

Brainscape's Knowledge Genome TM

Entrance exams, professional certifications.

• Foreign Languages
• Medical & Nursing

Humanities & Social Studies

Mathematics, health & fitness, business & finance, technology & engineering, food & beverage, random knowledge, see full index.

mental health > NCLEX Eating Disorders: Anorexia Nervosa & Bulimia Nervosa > Flashcards

NCLEX Eating Disorders: Anorexia Nervosa & Bulimia Nervosa Flashcards

The mother of a teen with an eating disorder expresses a concern that the family is responsible for the problem. Which question will best help the nurse identify another influence that is likely to have played a role in the teenager’s eating disorder?

a. “Does she have an after-school job?” b. “Does she have access to nutritious foods?” c. “Is there a family history of underweight adults?” d. “Is your daughter interested in clothes and fashion?”

ANS: D Women in this culture are bombarded by the fashion industry and media messages equating beauty with thinness. Although it is true that eating disorders are less common in countries where food is not abundant, in this culture persons with eating disorders tend not to choose nutritious foods. Workplace competition with men would be of greater significance than this broad statement. The biologic tendency to be overweight may influence some persons.

Long-term prognosis for eating disorders is improved dramatically when treatment includes long-term cognitive-behavioral therapy. What statement provides the best explanation to the patient for this component to the treatment plan?

a. “This will help you identify a healthy, weight restoration diet.” b. “Medication alone will not help you from relapsing back to your old habits.” c. “In order to manage your disorder, you have to understand the root problems.” d. “Prognosis has been proven to be much better with both medication and therapy.”

ANS: C Individuals need to resolve the core problems related to their eating behavior as well as the underlying psychological issues. Outcome literature indicates that long-term cognitive-behavioral, family, or interpersonal therapy, often in combination with antidepressant medication, results in the most sustained improvement. Long-term outcome studies show a more promising prognosis for those patients who continue treatment. Weight restoration is necessary but not sufficient for recovery. The options that discuss the components of treatment do not sufficiently explain the reasoning behind cognitive and behavior therapy.

The nurse is identifying outcomes for a teenager diagnosed with anorexia nervosa. Which outcome has the greatest impact on long-term prognosis?

a. Verbalize underlying psychological issues. b. Demonstrate effective coping skills related to conflict management. c. Demonstrate improvement in body imagine reflecting a realistic viewpoint. d. Consume adequate calories appropriate for age, height, and metabolic needs.

ANS: B Long-term prognosis is dependent on the patient’s ability to cope with the stressors that are at the root of the emotional problems such as conflict with family. Verbalization of underlying stressors is not a guarantee that there will be progress towards managing them. Acceptance of one’s body and adequate calorie intake is possible only after coping skills are learned and used.

Which statement is the basis for the cross-cultural assessment practices of eating disorders?

a. Mediterranean cultures are more likely to exhibit symptoms. b. Male-dominated cultures are more likely to accept this disorder. c. Westernized cultures tend to have similar numbers of diagnosed cases. d. Access to food is the primary factor in determining incidence of the disorder.

ANS: C The incidence and prevalence of eating disorders around the world are similar among European countries, the United States, Canada, Mexico, Japan, Australia, and other Westernized countries. Access to food is not necessarily a cultural factor

The nurse observes a distorted thinking pattern in a teenage patient diagnosed with an eating disorder. Which statement characterizes personalization by the patient?

a. “I’ve got to be thin to get a good job.” b. “There is no such thing as a healthy carbohydrate.” c. “My mother and dad fight all the time because I’m fat.” d. “My whole family will be disgraced if I don’t get into a good college.”

ANS: C The basis of personalization of thinking is that an individual compare themselves endlessly with others and perceive others’ behavior as a direct reaction to them. Believing the problems the parents are experiencing is a direct result of the patient’s weight is an example of such thinking. The thought that a job depends solely on weight or that all carbohydrates are bad are examples of dichotomous thinking. Feeling responsible for the family’s reputation is a reflection of control fallacy thinking.

A 16-year-old patient has anorexia nervosa. Which term used to describe the menstrual history is characteristic of this disorder?

a. Amenorrhea b. Dysmenorrhea c. Premenstrual syndrome d. Heavy menstrual flow

ANS: A Amenorrhea is common in patients with eating disorders, possibly due to altered hypothalamic function. The remaining options are not usually related to changes resulting from an eating disorder.

A 14-year-old patient newly admitted to the eating disorders unit refuses to eat meals and angrily shouts at the nurse, “You can’t make me eat! I’ll do whatever I want to do.” Which nursing intervention demonstrates an understanding of the priority safety issue for this anorexic patient?

a. Placing the patient’s favorite low calorie beverages in open view b. Assigning a staff member to one-on-one observation of the patient c. Unlocking the patient’s bathroom only at specific times during the day d. Explaining to the patient that they will be required to keep an eating journal

ANS: B The patient, especially when stressed, is capable of self-mutilation and needs to be protected from doing so. The issues of hydration, purging, and therapy work do not have the priority that physical safety has.

A nursing intervention that will be planned to occur early in the nurse-patient relationship with a patient with an eating disorder is:

a. Using confrontation to attack denial b. Placing the patient in a therapeutic group c. Formulating a therapeutic nurse-patient alliance d. Attacking enmeshment by separating patient and family

ANS: C An alliance is formulated early to give the patient an opportunity to participate in treatment and increase the patient’s sense of control, thus eliminating power struggles. Confrontation is rarely used early in the relationship. Placement in a group and anti-enmeshment techniques would normally take place after the contract has been agreed on

A patient is being assessed for a binge-eating–associated eating disorder. Which assessment question is directed towards collecting data on the most commonly abused substance among this patient population?

a. “How much alcohol do you drink on a weekly basis?” b. “Do you use amphetamines to help control your weight?” c. “Do you rely on laxatives to control your bowel movements?” d. “How many packs of cigarettes do you smoke on a daily basis?”

ANS: A Eating disorder symptoms predict the type of drug use, with bingeing associated more with alcohol and tranquilizer abuse, purging associated more with the abuse of multiple drugs, and restricting associated more with amphetamine.

The nurse is caring for a patient who is being treated for comorbid eating and affective disorders. For which medication would the nurse expect to prepare a patient teaching plan?

a. Fluoxetine (Prozac) b. Diazepam (Valium) c. Lorazepam (Ativan) d. Lithium

ANS: A SSRIs are effective in treatment of depression and have been found to be useful in treatment of eating disorders. Benzodiazepines like Valium and Ativan are used for anxiety reduction. Lithium is used for bipolar disorder.

A patient who is hospitalized with anorexia nervosa states during a one-to-one session with the nurse, “I’m freaking out. I’m losing it.”” Which nurse response would be most therapeutic at this time?

a. “Would you feel better if I called your parents?” b. “Just sit here and relax that will help you regain control.” c. “May I sit with you while you think about what is happening?” d. “Please tell me what thoughts are going through your head right now.”

ANS: D Helping the patient identify thoughts will facilitate the learning of effective coping mechanisms to deal with the stress. The patient needs to learn to bear and deal effectively with her own discomfort. The nurse is taking control without allowing the patient the opportunity to deal with her own issues. The nurse should encourage the patient to deal with her feelings and issues, rather than sit passively with her.

Accomplishment of which expectation should be considered most critical prior to discharging a patient with anorexia nervosa?

a. Attainment of minimum normal weight b. Resumption of normal menstrual cycle c. Reduction of periods of active exercise to three times daily d. Knowledge of nutritional value of foods required for a balanced diet

ANS: A Attaining the desired weight is the priority discharge goal because it best indicates patient compliance with the treatment plan. Resumption of the menstrual period may take an extended time. Having knowledge of nutrition does not ensure that the patient will apply it. Exercising three times aday is considered excessive.

Which patient statement demonstrates the expected emotional response to bingeing?

a. “I know it’s bad but I can’t help bingeing.” b. “Everyone indulges in bingeing some times.” c. “After I binge I feel happy for a little while.” d. “Bingeing isn’t bad if I do it only when I’m stressed.”

ANS: C Serotonin levels and mood both improve with bingeing. This affect on serotonin would not result in rationalization, denial, or a sense of guilt and hopelessness.

Which intervention best monitors the health status of a patient newly admitted for a diagnosis of bulimia nervosa?

a. Scheduling a bone mineral density screening b. Performing a portable electrocardiogram (ECG) c. Obtaining a urine sample for a urine analysis d. Arranging for a serum potassium level to be drawn

ANS: D Patients with bulimia nervosa require initial assessment for acute fluid and electrolyte imbalances (particularly serum potassium) for the presence of life-threatening imbalances. Bone mineral density screening for osteopenia and osteoporosis and assessment is appropriate but it does not have priority over of the blood work to identify an acute life-threatening condition. The remaining options are not diagnostic tests that are generally required of this diagnosis.

In an art therapy session, a patient with anorexia nervosa was asked to draw a picture of herself. Which drawing would likely depict the patient’s view of herself?

a. A tall, slim girl with obvious muscle definition b. A shapely figure of a model who she really admires c. A malnourished teenager with thin, lanky extremities d. A grossly obese figure lacking feminine characteristics

ANS: D Patients with eating disorders have alexithymia (i.e., difficulty naming their feelings) and they often have difficulty finding the words needed for talk therapy. Therefore, the use of expressive arts therapy allows for nonverbal self-disclosure and the experiential exploration of the inner experience. It also bypasses intellectual defenses and helps the patient to be more present in his or her bodily experience. The patient would be able to draw what she is unable to verbally describe. The other options do not reflect the anorexic patient’s self-view of their body.

A teenager admitted to the eating disorders unit has begun displaying behaviors that reflect possible secondary gains related to the hospitalization. What is the basis for this behavioral change?

a. The patient has moved into the guilt phase of the recovery process. b. The attention has reinforced the initial food-focusing behaviors. c. The medication therapy has not yet brought about the expected results. d. The increase of calories had help clarify the patient’s thought processes.

ANS: B Unfortunately, secondary gains, such as the attention generated from the hospitalization, reinforce the behavior associated with the eating disorder. There is no phase of the recovery identified with the expression of guilt. Clarity of one’s thinking nor the expected effects of medication therapy would contribute to secondary gains.

How does the mortality rate among patients diagnosed with eating disorders compare to those with other psychiatric diagnoses?

a. More deaths are attributed to substance abuse than to eating disorders. b. This disorder is associated with the highest death rate among all other disorders. c. This disorder has fewer associated deaths that any other impulse control disorder. d. More related deaths are recorded compared to those associated with schizophrenia.

ANS: B The mortality rate with eating disorders is higher than that seen with any other psychiatric diagnoses, and it has been reported at 4% to 20% of death among this population.

A patient being treated for an eating disorder is prescribed refeeding. Which outcome is the primary reason a patient receiving this treatment is closely monitored by the nursing staff?

a. Complies with treatment commendation made by treatment team b. Regularly consumes and tolerates between 3000 to 4000 kcal/day c. No physical signs or symptoms of an electrolyte imbalance are observable d. Discharge depends on patient’s ability to demonstrate a gain of 3 pounds per week

ANS: C Although all options are outcomes requiring nursing assessment and monitoring, the acute and serious nature of electrolyte imbalances has priority over the remaining options.

The interdisciplinary care team has suggested family-based therapy as a part of the care plan of a teenager diagnosed with an eating disorder. Which statement is the basis for this recommendation?

a. This approach encourages family involvement in the patient’s recovery. b. The family is often dysfunctional, enmeshed, and in need of counseling. c. This approach has shown a significant impact on successful long-term prognosis. d. The family implements the behavioral contract as established by the plan of care.

ANS: C Outcome studies of this approach to anorexia show a 90% improvement rate as compared with an 18% improvement rate for those receiving individual therapy. Five-year follow-up studies show that 70% of patients remained in recovery with this type of treatment. The remaining options are all correct but they do not directly address the impact on long-term prognosis.

A parent of a teenager being treated for anorexia nervosa asks the nurse what, “Being an enmeshed family” means. Which question provides the best response to the question?

a. “What do you think that statement means?” b. “Who told you your family was enmeshed?” c. “Are the members of your family expected to be independent and self-reliant?” d. “Does your family place importance on being successful and accepted by others?”

ANS: D An enmeshed family often puts a lot of importance on body image, social acceptance, and achievement. Expecting independence and self-reliance is not compatible with enmeshed family dynamics. The remaining options do not address the parent’s question

A patient with severe weight loss as a result of anorexia nervosa has refused meal trays and supplemental feedings for 3 days since being admitted to the hospital and so refeeding has been ordered. Which intervention will initiate this treatment?

a. Scheduling a nutrition consult with the hospital dietitian b. Tube feedings until the patient eats 90% of all meals for 1 day c. IV infusions beginning immediately and continuing for 48 hours d. Placing the patient on suicide precautions and one-to-one observation

ANS: B The priority is to begin refeeding, a procedure that involves tube feedings that are continued until the patient is voluntarily eating sufficient quantities. Refeeding takes place using foods and fluids via the GI tract, rather than by the parenteral route. Although refeeding is very threatening to the patient, since they have no control over the weight gain that will occur, suicide precautions are not indicated at this point, but careful assessments will continue. A nutritional consult is not useful at this point in the treatment since the patient is not making choices regarding eating.

A patient’s plan of care is being managed by an interdisciplinary team familiar with the etiology of eating disorders. Which team principle is most important to the successful treatment of this patient population?

a. The team must preserve the patient’s sense of autonomy. b. The patient must be an active member of the care planning team. c. The patient’s family must be included in the decision-making process. d. The plan of care must demonstrate collaboration and consistency by the team.

ANS: D In order to best assure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. Although the remaining options are goals to be strived for, they do not have the importance that collaborative and consistent care planning has for successful treatment.

Which concern has the greatest priority for a patient admitted with a diagnosis of bulimia nervosa?

a. Social isolation b. Imbalanced fluid volume c. Compromised family coping d. Disturbed perception of body image

The physical harm that can result for a fluid imbalance has priority over any of the psychological options presented.

A patient diagnosed with bulimia nervosa is hospitalized for treatment of electrolyte imbalance. Which response by the nurse to the patient’s request to use the bathroom immediately after eating lunch is most therapeutic?

a. “No one is allowed to leave the dining room during meals.” b. “Okay, but as you know I will accompany you to the bathroom.” c. “We’ve discussed that there are other options than to induce vomiting.” d. “I think I understand your plan, and I cannot permit you to carry it out.”

ANS: B To best ensure a good prognosis, the plan of care has to include consistent and collaborative efforts by all members of the interdisciplinary team. The patient is most likely attempting to purge to manage weight gain and the nurse must attempt to prevent that behavior. Refusing to allow the request does not account for the fact that the patient might actually need to void or defecate. Assuming the patient’s motivation in this manner is confrontational and nontherapeutic, suggesting that other options are available is not addressing the immediate request.

After ignoring a unit rule regarding being weighed, a patient receiving treatment for an eating disorder tells the nurse, “I can’t get weighed this morning, because I drank a glass of juice a few minutes before breakfast.” Which statement by the nurse is consistent with treatment principles?

a. “I’m pleased that you took in some calories.” b. “This is weight day. Please step on the scale.” c. “We need to discuss why you chose to ignore the rules about being weighed.” d. “The rule is ‘weigh before eating’; now we have to put it off until tomorrow.”

ANS: B The nurse needs to create a structured and supportive environment with clear, consistent, and firm limits. This helps to establish a predictable routine and promotes internal control that the patient currently lacks. This response is calm, matter-of-fact, and firm. The nurse is not permitting the patient to be manipulative, nor is she setting up a situation in which a power struggle is likely to arise. The patient should not be praised for behavior that broke the rules. Although the issue needs to be discussed, this is not the time to address it. The remaining option suggests that the patient will not be weighed according to schedule.

A patient is being assessed for possible anorexia nervosa. Which behaviors are supportive of such a diagnosis? Select all that apply.

a. Eats only red apples and green grapes b. Exercises 3 times a day every day c. Has lost 25 pounds but wears only pre-loss clothing d. Becomes extremely agitated whenever expected to eat e. Reports fantasies about being able to eat without gaining weight

ANS: A, B, C, D

The characteristic of anorexia nervosa do not include fantasies about eating.

Which reports describe behaviors that meets the criteria for a diagnosis of binge eating? Select all that apply.

a. Sister reports, “She is so sad after she finishes.” b. Claims, “I can’t control myself when I get that way.” c. The patient reports, “making myself vomit” at least twice a week. d. Mother reports seeing the patient, “eat entire loaf of bread for lunch.” e. Maintains that, “I look okay now but I do this so I don’t gain any weight.”

ANS: A, B, C, D All described behaviors are characteristic of binge eating except for the belief that body image is currently acceptable.

Which assessment findings support a diagnosis of bulimia nervosa? Select all that apply.

a. Loose watery stool b. Red rash on extremities c. Blood pressure of 88/58 d. A potassium level of 2.8 mEq/L e. Reports of mild muscle cramping

ANS: A, C, D, E

A red rash on the extremities is not a characteristic of bulimia. All other options can be related to the disorder.

The mother of a teenager is concerned that the child may be anorexic. Which report of the teenager’s behavior is support of such a diagnosis?

a. Insists she likes “really baggy clothes” b. Will eat only lean protein, fruits, and vegetables c. Has had one menstrual period in the last 2 years d. Although she has grown 3 inches, she has gained no weight e. Regularly claims that she will “eat later” but seldom does

ANS: A, C, D, E A willingness to eat lean meats, fruits, and vegetables would not be characteristic of a patient exhibiting anorexia. The remaining options could be seen in such a patient.

mental health (42 decks)

• Psychiatric Nursing: Theory, Principles, and Trends
• NCLEX Questions for psychiatric nursing: theory, principles and trends
• Nursing Practice in Clinical Setting
• NCLEX Questions for nursing practice in clinical setting
• Therapies: Theory and Clinical Practice
• NCLEX questions for Therapies: Theory and Clinical Practice
• The Nursing Process and Standards of Practice
• NCLEX questions for Nursing Process and Standards of Practice
• Therapeutic Commmunication: Interviews and Interventions
• NCLEX questions for Therapeutic Communication
• Adaptation to Stress
• NCLEX Questions for adaptation to stress
• Culture, Ethnicity and Spirituality
• NCLEX Questions for culture, ethnicity and spirituality
• Legal and Ethical Aspects in Clinical Practice
• NCLEX questions for legal and ethical aspects in clinical practice
• Exam 1 NCLEX
• Neurobiology in Mental Health and Mental Disorder
• NCLEX Questions Neurobiology
• Anxiety and Anxiety Disorders
• NCLEX Anxiety
• Substance-Related Disorders and Addictive Behaviors
• NCLEX Substance-Related Disorders
• Psychopharmacology
• NCLEX Psychopharmacology
• NCLEX for Mood Disorders, Bipolar & Adjustment Disorders
• NCLEX Personality Disorders
• NCLEX Disorders of Infancy, Childhood & Adolescence
• NCLEX Eating Disorders: Anorexia Nervosa & Bulimia Nervosa
• NCLEX Crisis: Theory & Intervention
• NCLEX Suicide Preventions & Interventions
• NCLEX Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders
• NCLEX Sexual Disorders: Sexual Dysfunctions and Paraphilias
• NCLEX Mental and Emotional Responses to Medical Illness
• NCLEX Sleep Disorders: Dyssomnias and Parasomnias
• NCLEX Violence: Anger, Abuse, and Aggression
• NCLEX Grief: In Loss and Death
• NCLEX Schizophrenia & Other Similar Disorders
• NCLEX Community Mental Health
• Corporate Training
• Teachers & Schools
• Android App
• Help Center
• Law Education
• All Subjects A-Z
• All Certified Classes
• Earn Money!

• Case report
• Open access
• Published: 15 February 2022

Terminal anorexia nervosa: three cases and proposed clinical characteristics

• Jennifer L. Gaudiani   ORCID: orcid.org/0000-0002-2035-9390 1 ,
• Alyssa Bogetz 2 &
• Joel Yager 2  

Journal of Eating Disorders volume  10 , Article number:  23 ( 2022 ) Cite this article

79k Accesses

30 Citations

454 Altmetric

Metrics details

Most individuals with eating disorders will either recover, settle into an unrecovered but self-defined acceptable quality of life, or continue to cycle from crisis to relative stability over time. However, a minority of those with severe and enduring eating disorders recognize after years of trying that recovery remains elusive, and further treatment seems both futile and harmful. No level of harm reduction proves achievable or adequately ameliorates their suffering. In this subgroup, many of those with anorexia nervosa will experience the medical consequences of malnutrition as their future cause of death. Whereas anyone who wishes to keep striving for recovery despite exhaustion and depletion should wholeheartedly be supported in doing so, some patients simply cannot continue to fight. They recognize that death from anorexia nervosa, while perhaps not welcome, will be inevitable. Unfortunately, these patients and their carers often receive minimal support from eating disorders health professionals who are conflicted about terminal care, and who are hampered and limited by the paucity of literature on end-of-life care for those with anorexia nervosa.

• Case presentation

Three case studies elucidate this condition. One patient was so passionate about this topic that she asked to be a posthumous co-author of this paper.

Conclusions

Consistent with literature on managing terminal illness, this article proposes clinical characteristics of patients who may be considered to have a terminal eating disorder: diagnosis of anorexia nervosa, older age (e.g. age over 30), previous participation in high quality care, and clear and consistent determination by a patient who possesses decision-making capacity that additional treatment would be futile, knowing their actions will result in death. By proposing the clinical characteristics of terminal anorexia nervosa, we hope to educate, inspire compassion, and help providers properly assess these patients and provide appropriate care. We hope that this proposal stimulates further expert consensus definitions and clinical guidelines for management of this population. In our view, these patients deserve the same attendant care and rights as all other patients with terminal illness, up to and including medical aid in dying in jurisdictions where such care is legal.

As a patient with severe and enduring anorexia nervosa advocating for my legal right to MAID (medical aid in dying), I confronted numerous obstacles and challenges from the medical profession, related not just to the question of whether I should have access to MAID generally, but more so, how my anorexia, a psychiatric condition frequently misunderstood by the medical community, interacted with my decision making capacity and desire to pursue MAID as one potential option knowing that my illness was indeed terminal. –Alyssa

The vast majority of potentially terminal illnesses carry with them thoughtfully considered and evidence-based staging criteria. These criteria allow patients and clinicians to distinguish mild and likely curable presentations of the disease from irreversible, pre-terminal and terminal stages. Medical specialties treating cancer, organ failure, or various infectious diseases have dedicated considerable attention and resources to delineating levels of severity. While preliminary suggestions for labeling severe and enduring anorexia nervosa (SE-AN) [ 1 ] and for staging the disorder have been proposed [ 2 ], generally accepted staging criteria for anorexia nervosa (AN) have not yet been developed. Remarkably, the same diagnostic label (“AN”) and treatment criteria that apply to teenagers only a few months into their disorder are also used for patients who are decades older, who have lived through innumerable admissions to inpatient and residential care facilities, and whose quality of life has been irrevocably damaged by persistent, severe mental and physical illness. The field acknowledges SE-AN as a somewhat distinct clinical condition, but despite thoughtful clinical and research efforts [ 3 , 4 ] the designation has not been formalized as a diagnosis, and consensus regarding criteria for SE-AN remains elusive [ 5 ].

AN carries the second highest mortality rate in the DSM-5 after opioid use disorder, with a death rate estimated at 5–16 times that of the general population. [ 6 , 7 ] Several important recent studies confirm and expand upon these data. A specialized medical inpatient unit in France for those with severe anorexia nervosa evaluated 384 patients admitted over 17 years, with a mean age at admission of 29.4 years old. The standardized mortality ratio (SMR) was 15.9 for women and 22.4 for men, where older age was determined to be a major predictor of mortality. The mean age at death was 41.3 (± 15.3) years, on average two years after hospital admission. The SMR was maximally increased for patients whose first admission to the unit took place while they were between 25 and 35 years old. Specifically, those admitted between 30–34 years old had the highest SMR of 26. Somatic (medical) causes accounted for 43% of deaths, while 11.5% of deaths were caused by suicide. [ 6 ] In a registry-based observational epidemiological study encompassing the entire population of Denmark over 44 years, the SMR for all-cause mortality reached a maximum of about 6 in the age group 20–34 years, and the SMR for suicide in those with AN was 11. Natural causes accounted for two-thirds of death in those with AN. [ 8 ] Finally, a retrospective cohort study evaluated 19,041 individuals with an eating disorder in Ontario, Canada, using administrative healthcare data. The entire cohort, not comprised only of those with AN, had an SMR of 5; they found that potential years of life lost were 6 times higher than expected compared with the Ontario population. Similar to the other studies, peak values for SMRs were observed among adults between 30 and 44 years old, and again the SMRs observed in males were almost two-fold higher than in females. [ 9 ] Importantly, the profound suffering inherent in AN drives the high suicide rate noted in multiple studies, where up to 20% of patients who die prematurely do so by suicide [ 10 ]. Compared with gender- and age-matched groups, patients with AN are 18 times more likely to die by suicide [ 11 ].

Based on these data, AN can unquestionably prove fatal. Despite this fact, the field lacks clinical roadmaps for compassionate, appropriate care for those who will not be able to survive. This does great disservice to patients and their families. By comparison, we do not expect individuals with metastatic lung cancer who have disease progression despite past treatments, which often come with negative sequelae, to keep presenting for those same ineffective treatments. Rather, they are more likely to receive the psychological preparation, connection, and medical and emotional support offered to patients with terminal conditions. Although current laboratory measures and imaging studies by themselves are unable to help us stage patients with AN, based primarily on clinical histories and patients’ narratives we can better understand the clinical course of this illness and the subset of patients with AN who may seek palliative care [ 12 , 13 , 14 ].

There is growing recognition that palliative care may be appropriate for some patients, but the clinical characteristics for terminal anorexia nervosa have not been proposed. Delineating and validating this stage would greatly assist patients, families, and clinicians across disciplines, especially those in palliative and hospice care. Designating terminal AN may more readily enable patients to receive palliative care, hospice care, and emotional and practical resources for loved ones, as well as access to medical aid in dying (MAID) where legal. Therapeutic goals in these situations are to ameliorate suffering and honor the life lived. Of note, MAID is offered to individuals whose death is inevitable within six months from an underlying disease process; it provides patients a choice in how they die, not whether they die. It is not a means of suicide.

In this paper, we describe three cases of exceptional people whose AN was terminal, and who died peacefully with family around them. All three were patients of a private practice outpatient medical clinic specializing in eating disorders in Denver, Colorado. One patient, who had been a medical researcher herself, was so passionate about the topic that she asked to join as a posthumous author on this paper so her voice could be heard. The other two patients’ parents consented to share their son’s/daughter’s stories and reviewed, and all three families edited the relevant story prior to manuscript submission. All families agreed that first names should be used instead of a pseudonym or initials in order to emphasize the truly personal, real-life origin of these stories. Based on these experiences and others [ 12 , 14 ], we conclude by proposing a set of clinical characteristics of those who can be identified as having terminal AN.

Case presentations

Case 1: aaron.

Aaron was a 33-year-old man with a long history of restrictive AN, severe obsessive compulsive disorder (OCD), recurrent major depression, and chronic suicidality. He had been a sensitive child with low self-esteem and perfectionism from a young age. His parents noticed OCD traits from early childhood, but he did not receive this formal diagnosis until years later.

During his freshman year in high school, a health class warned about the risks of “eating junk food.” Aaron began to run regularly and played hours of basketball daily. One by one, he eliminated dietary fats and created food rules. His parents thought this was just a stage, an assessment they came to understand very differently over time, but they eventually recognized his serious problems and established a treatment team. Later in high school, Aaron was hospitalized several times for AN, participated in family therapy, and required his mother’s presence, even at school, to complete meals. Despite graduating as valedictorian of his high school class, he was initially too ill to start college. Later, his attempt to begin college was thwarted by his need for constant supervision of food intake. Aaron’s perfectionism and self-criticism ultimately ended his college career.

Over the next two decades, Aaron spent countless months in medical hospitals and in inpatient and residential eating disorder settings. He repeatedly gained the weight required for discharge so that he could return home, only to inevitably relapse. He felt mortified and guilty about the amount of money his family spent on his treatment, and he was acutely aware of life passing him by.

In his early 30 s, following a long and serious downward spiral during which he refused a higher level of care, his family finally threatened to call 911 if he did not enter treatment. Consequently, he was admitted to an inpatient eating disorder program. After first spending time in a hospital setting for stabilization where he refused to eat, a feeding tube was placed. A court mandate to ensure ongoing treatment was requested and granted on grounds of grave disability from his mental illness, and he spent the next 10 months against his will in inpatient and residential eating disorder care. He cut off communication with his parents but allowed the treatment team to talk with them. Eventually his therapist convinced him to have family sessions over the phone; it was the only time his parents could talk to him.

Aaron’s persistent resistance to treatment throughout his stay at the eating disorder program caused difficulty in maintaining his nutritional stability. He underwent in-depth exposure and response prevention therapy around food as he continued to be tube fed, and he was finally able to sustain his weight with oral food. At that time, he only agreed to eat to avoid the prospect of being administered olanzapine against his will, as he feared this medication would cause him to gain weight.

After Aaron had been fully weight restored for several months, he was stepped down to a partial hospital program (PHP). He immediately restricted intake and proceeded to lose nearly a pound a day, resulting in readmission to residential treatment where, after intensive efforts, he once again achieved his target weight. Aaron struggled with basic activities of daily living due to his OCD. For instance, he resisted using lotion or lip balm as he feared they might be absorbed into his skin as calories. He completed a course of intranasal ketamine in hopes of alleviating his OCD, depression, and suicidality, but ketamine treatments had no meaningful impact.

Author JG (hereafter referred to as “Dr. G”) first met Aaron for an outpatient medical consultation after he had completed this most recent residential treatment and was once again about to step down to PHP. This consultation constituted one component of an organized, comprehensive future discharge plan. In this initial medical visit, after a year of residential treatment, Aaron was medically stable. He desperately missed his eating disorder behaviors, fantasized about eating less and losing weight, and wished his AN would have already taken his life. Aaron mused that his all-or-nothing, perfectionistic temperament made the unknown terrifying, but he felt proud of how rigidly he had previously adhered to his eating disorder rituals, as he believed that few others could achieve a similar degree of calorie restriction. Despite his long history of treatments, including his year of suffering through the long court-mandated treatment, Aaron had never meaningfully changed his eating related attitudes, thoughts, or behaviors. He had absolutely no motivation for recovery.

During the initial consultation, Dr. G informed both Aaron and his emotionally supportive and highly invested parents that she could offer ongoing outpatient medical care along one of two pathways. In one, Aaron would complete PHP, be discharged to home (where he lived with his parents), see a therapist and dietitian regularly, and work on whatever degree of recovery he could bear, aiming toward a quality of life that he called “living productively.” Should he decide that he required a higher level of care, the team would promptly support that choice. On the second pathway, if Aaron relapsed and declined readmission, the outpatient team would no longer battle with him to seek a higher level of care, given the futility of his most recent, autonomy-depriving treatment course. Rather, the family and team would support and comfort him until such time as he required home palliative care and eventually hospice support. Aaron initially felt that these two choices were needlessly stark and binary, and he settled back into PHP.

Two months after the initial consultation, Aaron continued to endure PHP, primarily to honor his commitment to his residential treatment team that he would see through his course of treatment. But he felt no better. He received a course of intravenous ketamine to supplement the intranasal ketamine treatment initiated in the residential program, but he experienced no improvements in mood, hopelessness, or OCD. Just before discharge to his parents’ home, he still hadn’t decided which treatment pathway to choose. He would not accept psychiatric medications, and a team consisting of a physician, therapist, and dietitian was established to care for him at home.

However, starting on the day of his discharge from PHP, Aaron stopped eating altogether, a course of behavior that is rare even in those with severe AN. He drank only water, stating, “I don’t want to die, but my eating disorder is in charge.” A week later, he met with his longstanding outpatient therapist. She was very apprehensive about his ability to remain in the community, and she felt ambivalent concerning what her role might be if he insisted on remaining at home. Aaron told her, “I wish I could eat, but I won't eat; I don't want to die, but I feel hopeless that there's any other pathway.” The therapist worried that she would be forced to have Aaron detained against his will in his home state. A formal decision-making evaluation was performed by a local psychiatrist, and Aaron was found to possess decisional capacity. Consulting with his home therapist, Dr. G proposed that Aaron’s refusal to eat was less about “wanting to die” than simply accepting that he could not live—he was not “attracted to life” [ 17 ]. Dr. G suggested that the proper course at this point would be to proceed with a home palliative care consultation and shift treatment goals to supporting comfort and dignity, as Aaron clearly declined a return to treatment.

During a telemedicine meeting with Dr. G a week later, Aaron asserted, “I don't want to do this for anybody else anymore. It's time to do things only if I want them.” At about this time, Aaron also sought comfort from his therapist and his religious leader, as the prospect of death frightened him, and he was unsure what dying would mean. But he described that being given the choice of what would happen next was empowering – “different, scary, relieving, and right” – in great contrast to repeatedly feeling powerless and demeaned by his many prior chaotic relapses followed by intense pressures to return to treatment. Aaron signed a Do Not Resuscitate (DNR) order and within the next few days was referred to a home palliative and hospice care organization. Dr. G spoke with the organization’s medical director to explain why this brilliant 33-year-old man who was refusing to eat was being referred for palliative care. Aaron hoped that the home palliative care service would help him and his family “process this sorrow and fear.”

Two weeks later, after more than a month of eating nothing and drinking only water, Aaron’s OCD and insomnia were heightened; he worried that by simply smelling his mother’s cooking he might be ingesting those calories. He believed that he might absorb calories from the grocery cart of the person ahead of him at the store. Always reluctant to take medications, he began to consider accepting anxiolytics from the hospice staff, whom he thought were extremely kind.

Aaron noted that by spending no energy forcing himself to eat, he was able to direct energy toward engaging in his faith. His siblings came to visit, and as they talked and laughed, he realized it had been years since they had connected positively. Throughout the course of his eating disorder, every family connection had felt fraught. He summarized his collective family’s response to this pre-terminal phase as, “They were very supportive. They recognize the gravity of this situation. They aren't angry, sad but not fearful.” As he chose to spend his days talking with his parents and sleeping, he noted that he was thinking about others "rather than being so self-absorbed." Imagining his parents’ distress made him sad, and he wanted his parents to keep getting support after his death. "This is one of the hardest things they've had to deal with in their lives."

Even as he rapidly lost weight, Aaron’s body distortions grew worse, and he kept wishing his weight would fall even faster. After almost six weeks without food, Aaron began accepting anxiolytics and antiemetics. He obsessed that someone might have injected his water bottles with calories. When Dr. G asked if he had any words to share for posterity, he expressed words of warning for those who might find themselves in his situation: “OCD will amplify,” “Be prepared for an annoying obsessive brain that might drive you crazy,” and “Just because you aren’t eating doesn’t mean it’s all good now.” He expressed how vital it was to “have people in your life [doctor, parents, family, close friends] whom you trust and can seek reassurance from, who love you unconditionally,” whose comforting words can be “life-saving in terms of giving you peace.” He connected deeply with a feeling that peace comes from God.

After about eight and a half weeks without any food, Aaron was spontaneously vomiting daily and feeling much weaker. Beautifully cared for by home hospice, he began to take low dose morphine for pain and distress. When Aaron’s parents wondered what his death certificate would say about cause of death, Dr. G reassured them that the cause would be anorexia nervosa and malnutrition, not suicide. Often speaking through tears, Aaron’s parents described how they were enjoying a deep loving sweetness with their son that they hadn’t experienced in years, and how they would miss him when he died. They felt compassion for those who lose a loved one abruptly without having time for love, connection, and closure. Often, they saw glimpses of the boy they hadn’t seen in years, as when he looked at photos that made him laugh.

Two weeks later, Aaron passed away with his family surrounding him. Even as they were exhausted and grieving deeply, his parents expressed enormous gratitude for the care he received and for the way they had been able to reconnect with him.

Case 2: Jessica

Jessica was a 36-year-old woman with a history of OCD and AN, purging subtype (laxatives) that began during her junior year of high school, when she tried to lose weight prior to a vacation. This started a pattern of restricting, binge eating, and then overexercising that persisted into college. When her weight, which had remained normal for some time, did eventually drop, she left college for intensive outpatient eating disorder treatment. It was such a difficult experience that from this time on, she mistrusted eating disorders providers. She lamented that she lost most of the fun of college to her eating disorder.

Due to progressive constipation, Jessica began using laxatives, which led to laxative abuse. She soon found that every time she stopped taking laxatives, her weight skyrocketed (due to rehydration and rebound edema). Ultimately, her AN caused her to drop out of nursing school. Jessica experienced her first hip fracture from severe osteoporosis when she was critically emaciated at age 27, requiring her to move home with her parents; the following month she incurred a stress fracture of her shoulder from using crutches. Her parents pursued guardianship as Jessica was refusing a higher level of care, but her medical team refused to release records to the family’s attorney due to HIPAA. Without the option to pursue guardianship with mandated longer-term residential treatment, her parents came to believe this was the critical juncture where recovery might have been possible, but instead her disease became more entrenched. Over the next 7 months, working with her outpatient primary care provider, dietitian, and therapist, she slowly gained a meaningful amount of weight, although she remained very underweight. Following this, she got an excellent job and once again lived independently from her parents, working productively for three years. However, at age 29, her increased anxiety, the side effects of laxative abuse, and the shame of her anorexia caused her to separate herself from her family and to work from home, increasing her isolation. She checked herself into an expert inpatient medical center to stop using laxatives and then spent a week in inpatient eating disorder treatment before leaving against medical advice. Jessica did manage to stay off laxatives for a year but was plagued by edema. Repeatedly, restriction and overexercise would recur, usually accompanied by laxative abuse, which at its worst consisted of taking 100 tablets a day.

During her initial consultation with Dr. G, Jessica memorably stated, “The eating disorder keeps me out of integrity with my values. It doesn't feel good. You believe something but aren't living it. This is the biggest motivation for wanting to change. I really want to live in alignment with my values, honoring my body, feeling things, stopping being unkind to my body.” Although very kind and compassionate towards others, she struggled to show herself the same grace.

Jessica met criteria for immediate admission back to the inpatient medical service, but given her prior negative experiences with treatment, she wanted to attempt to keep working and live near her parents. She agreed to outpatient care with a multidisciplinary team, focusing on harm-reduction goals. Initially, Jessica was able to follow medical and nutritional recommendations faithfully. Then, within three months of initiating outpatient medical care she fell and sustained a pelvic fracture. This was frightening, disabling, and prevented her from taking her calming (and to her, calorie-burning) nature walks. Overcome by managing the challenges of a rapidly changing body on her own and worried about her fracture and bone health, Jessica readmitted herself to specialized inpatient medical care for medical stabilization. Following stabilization, she agreed to transfer to residential care to attempt a full course of eating disorder treatment. However, after two weeks in the residential care program she left against clinical advice, unable to follow the meal plan consistently and feeling extremely distressed by her bodily changes (even though her weight had barely changed).

At home, Jessica again tried hard to follow treatment recommendations at a harm-reduction level (no laxatives, low caloric intake, gentle movement in the outdoors), but once more the distress of bodily changes was too much for her to bear. About a month after leaving the residential program, Jessica first talked about the possibility of palliative care and began talking with her mom about suicidal thoughts. Most nights she would say she hoped she didn’t wake up the next morning. In order to help Jessica resist the laxatives that gave her such severe abdominal pain and nausea, and still hoping to support her in finding an acceptable degree of harm reduction, Dr. G worked with Jessica to use diuretics to manage fluid weight changes. (Notably, this approach would rarely if ever be offered in a more typical eating disorders treatment plan.) Jessica operated within these guidelines and constraints for the next five months, at times thinking she might be able to persist, but more often lamenting that this strategy was still too difficult and painful. By this point, she had been granted indefinite leave from work and moved in with her parents.

About nine months after initial consultation, Jessica acknowledged that it was time for a palliative approach, confessing, “I’m just ready. It's been a long fight. I'm eating so little, and I'm back on the laxatives every couple of days.” She declined intranasal or intravenous ketamine which might have ameliorated her depression, OCD symptoms, and hopelessness. As she felt progressively miserable physically and psychologically, her suicidality increased. She purchased a gun, and one night she drove to a bridge with thoughts of jumping off, but then decided to return home. She had difficulty finding a therapist who understood terminal AN and who could accept her treatment trajectory, but she found and worked with a kind naturopathic doctor who specialized in mental health, and she did experience some benefit from psychiatric medications.

At this point, fearful of suffering a long, drawn-out death from starvation and unwilling to put her parents through the agony of witnessing this decline, Jessica requested referral to a palliative care specialist who assessed patients for medical aid in dying (MAID). Dr. G spoke with Jessica’s parents repeatedly, assuring them that guardianship and forced treatment were likely now to be futile. The parents had done everything possible to help their daughter find an acceptable quality of life. Jessica signed a DNR order. After speaking with the palliative care physician by phone to discuss the case and advocate for Jessica, Dr. G completed the MAID forms as consulting physician, given that Jessica’s prognosis was presumed to be 6 months or less. The palliative care physician prescribed the MAID medications.

About a year after the initial consultation, and about three months after the MAID consultation, Dr. G saw Jessica for the last time via telemedicine. Jessica wrote to Dr. G in an e-mail, “I’ve been back in a place the last several weeks where the emotional pain and the physical and emotional exhaustion of living like this are just too much for me. I’m trying to make it to the end of May, maybe through June to meet my brother’s upcoming baby before I go.” Jessica described her life as filled with unbearable pain and anxiety. Watching people walking around the neighborhood making future plans felt devastating, because she’d “give anything to be in anybody else’s shoes.” Yet when she thought about stopping diuretics, eating enough food, and gaining weight so she could physically live that life, she said, “it feels impossible.”

Jessica waited several weeks to fill the MAID prescription. She then set multiple dates to use it over a couple of months and changed her mind as that date got closer. A month before her death, she started to receive home hospice services. During this time period, she had long conversations with her parents, brother, and friends, noting that she had many happy memories over her life, apologizing for what she had put them all through over the years, and stating that she hated her eating disorder. She told them she realized that, while her eating disorder behaviors made it seem like she hadn’t loved or trusted them at times, she loved them all very much. She repeatedly told her family that she didn’t want to die, that she didn’t want to miss out on future time with her family, friends, and niece and nephew, but she just couldn’t continue to exist this way. The emotional pain and anxiety were unbearable. She couldn’t live a normal life, and she felt her body was too destroyed to recover. Her parents believe that in her last month she was trying to die naturally by barely eating, reducing her fluid intake, and walking for hours daily, even when she had to sit down often to catch her breath. She stopped driving and carried identification in case she collapsed on a walk. She fainted at home several times in the week before her death, including the night before she died. On the day she took the MAID prescription, she stayed in bed, was at peace, and spent time talking with each parent and her brother. Together as a family, they reminisced, laughed, cried, had their “hug circle” as they had called it since her childhood, and felt surrounded by love. Her parents each held a hand, and her brother sat right next to her. During the three doses of the medicine taken over an hour, she was comfortable and conscious. Within ten minutes of taking the final dose, Jessica closed her eyes, and her breathing slowed.

Jessica didn’t choose to live with anorexia. For all the years she endured living within its prison and myriad complications, her parents ultimately felt strongly that she deserved to choose the time, place, and way of her release. They felt that an unexpected blessing of MAID was that it allowed Jessica to live several months longer than she otherwise would have. Knowing she didn’t have to die a violent death by suicide, that she would have a peaceful way out when the pain and anxiety became unbearable, and that she would be able to die with dignity surrounded by loving family, allowed her to hold on longer. As a dying wish to her mother, she shared, “Mom, I'd like you to do something that will help others not go through what I went through."

Case 3: Alyssa

Alyssa, the posthumous author on this paper, was a 36-year-old woman with OCD, depression, and restrictive AN who described herself as having “a type A, neurotic personality: a sensitive, compassionate, loving person who's incredibly self-critical and has wanted to do things 0% or 110% with no gray area.” She first felt suicidal at age 13, when she realized that her body was too large to fit into standard dress sizes for her upcoming Bat Mitzvah. She started therapy at that time and was continually in therapy thereafter. After going through high school at a higher weight, the summer before college she vowed to change her body and began exercising in earnest. In college it was easy to restrict. By the time she returned home for Thanksgiving she had lost a substantial amount of weight. Everyone praised her, and she experienced “a deluge of external validation that was irresistible,” firmly establishing her eating disorder by age 18. Alyssa wrestled with AN throughout the rest of her education and career. A brilliant academic, she became the only non-physician Assistant Director of a major academic medical center residency department, mentoring residents and students, doing research, and publishing in major journals.

After struggling with AN for 15 years, during which she received intermittent outpatient support, Alyssa moved in with her parents and reduced her workload. She was extremely helpful in her mother’s struggle with a cancer diagnosis and often underplayed the significance of her own illness. At age 33, to correct severe hypercalcemia she was admitted to the teaching hospital in which she had previously worked. The family felt that her AN was hardly addressed during that hospitalization, in part due to the fact that institutional expertise for AN was confined to a pediatric program. To them, this felt like a vital missed opportunity to attempt changing her disease trajectory, in particular as the only recommendation on discharge was to seek residential eating disorder care.

Alyssa worked for 7 months to obtain insurance authorization for care in a residential eating disorders program, and to gain enough weight to meet their admission criteria. However, upon admission to that program she was deemed still too underweight (by one pound) and was referred to a specialized inpatient medical program. Being rejected for care after so much work also felt like a missed therapeutic opportunity. After a delay, Alyssa spent several weeks in the specialized hospital program and met the minimal criteria for discharge, departing with the understanding that she would immediately enroll in another residential program. However, after discharge from the hospital she refused to do so and could never accept going to an eating disorders program thereafter.

In the years prior to initial consultation with Dr. G, Alyssa’s outpatient treatment team included a local primary care physician with whom she was very close, a therapist she had been seeing regularly in recent years, and an expert eating disorders therapist who had worked with her and the family over the years. Over a period of three years, Alyssa had intermittently thought about and even phoned Dr. G’s outpatient medical clinic, but she never booked an appointment, indicating that she felt very ambivalent about recovery and was considering a palliative care approach. When she finally presented for an initial consultation, Alyssa identified her goals as follows: “I really want a life, to use my Masters in Social Work degree to help others heal, to find a partner, and to experience pleasure, laughter, joy, and freedom, including from my own brain.” As her main barrier she cited the chronic, longstanding shame and body disgust that persistently kept her from meeting her own needs.

At the time of initial consultation, Alyssa met criteria for inpatient medical hospitalization, although she experienced remarkably few physical symptoms, which reinforced her view that she must be “fine.” She declined a higher level of care. Nonetheless, she saw herself as shamefully thin, more keenly felt given her extended family’s experience of the Holocaust. She wanted to be able to walk down the street without turning heads due to being so emaciated, but concurrently struggled to balance this desire against her strong resistance to gaining weight.

Alyssa agreed to ongoing care with the clinic and accepted referral to an expert registered dietitian. She committed to at least attempt a harm reduction approach in which she would slowly restore weight to a point where she could be more physically, mentally, and professionally functional, and where she could resume her yoga practice. However, she stipulated that she would halt weight restoration if and when her AN thinking could no longer bear it. Over the course of the next year or so, she valiantly succeeded in increasing her caloric intake considerably above her previous severely restrictive baseline. But due to the hypermetabolic state often seen in malnourished patients who increase their caloric intake, she experienced no meaningful weight gain.

Nine months after initial consultation, Alyssa emphatically reflected that her goals had not changed, but she had grave doubts about her ability to achieve them. She described feeling “utterly exhausted” and could no longer muster the strength to keep fighting. She vividly described her daily internal battles, struggling every minute of the day to eat enough of her meal plan and constantly fighting against the extreme headwinds of her AN’s resistance. Once she had eaten, she would bitterly berate and punish herself for having done so. At this point she was not certain that her AN was terminal, but she was moving strongly in that direction and wanted to understand her options.

Dr. G clarified that at any time, Alyssa could choose to pursue full recovery and a higher level of care, could continue fighting as she was, or could consider two options that did not focus on recovery. The first option would be choosing palliative care. This would acknowledge that she would likely not survive and also allow her to consider a "bucket list" of experiences for the time she had left. Palliative care would mean that she could eat what appealed to her, with no pressure applied by the team. The treatment focus would be on finding joy and comfort as much as possible. Dr. G emphasized the value of signing a DNR document to protect Alyssa from the mandates of the healthcare system in the event that she experienced an abrupt decline and/or cardiac arrest. Alyssa was also advised that a home palliative care/hospice evaluation would be useful to oversee her treatment as desired during this stage, for emotional and practical support if needed and to protect her parents from any potential legal repercussions should she pass away at home as an emaciated adult. Dr. G noted that for some patients, this stage can last a long time, and that some can “reset” when pressures to gain weight and threats of mandated treatment are removed. In some cases, this state of reduced external pressure might even lead to renewed ability to engage in meaningful harm reduction and even recovery work.

The second option would be to seek hospice care. Hospice care would be suitable if the torments of her AN and the extraordinary difficulties of moving about the world in a skeletal body were beyond being helped by a palliative care approach. Given her faster metabolism, if Alyssa abandoned her attempts to consume a higher meal plan, she would clearly have a less than six-month prognosis and qualify for hospice care. With this option, Dr. G would refer Alyssa to a home hospice service, anticipating that she would become increasingly frail. The home hospice staff would establish warm relationships with Alyssa and her parents, make sure that anxiety, insomnia, nausea, and/or pain were managed, and provide them all access to psychological and spiritual support as desired. During this time, Alyssa could live her life as she chose. As she became less independent, hospice would provide assistive aids such as a shower chair, bedside commode, and hospital bed. The overall goals would be to maximize Alyssa’s comfort, dignity, and time to connect with family.

During this conversation, Dr. G also noted that Alyssa lived in a location where MAID was legal. If she chose the hospice route—and had interest—a referral for the option of MAID was also possible. Alyssa was informed that she herself would have to administer the MAID medications if she chose to use them; no one else could administer them to her. After completing the required regulatory processes and filling the prescription, MAID medications could be used or not as desired. But, as the human body can be exceptionally resilient even with terminal malnutrition, having the medications at hand would give Alyssa the opportunity, while still having an intact brain, to choose not to suffer through additional weeks of extreme physical discomfort and weakness.

A week after these options were reviewed, Alyssa wrote Dr. G:

After deep reflection and discussion with my parents, I’ve decided it makes sense to initiate the Hospice process (Ie evaluation, etc.) now so my family and I are prepared for what may come. I would value your guidance and help with this….I do not know if they have ever worked with patients like myself… I would love for you to be the PCP overseeing this process regardless of the Hospice we select if, and only if, you are comfortable with this. I want to be clear that my priority is to obtain access to the medications that would support my legal right to die should I wind up choosing this path in the future. I feel strongly that based on our thorough discussion, I am aware of my options and their risks and benefits in light of the trajectory of my illness. Please do let me know what I can do to help facilitate initiation of this process. I am available and happy to help.

In a family meeting the following week, Alyssa’s father, a physician, tearfully shared the principles he and Alyssa’s mother had come to accept during intense conversations with their daughter: She had the right to choose care or no care after having been ill for 18 years. There would be no ultimatums. This disease would probably be the reason that "we lose you." They knew how much she had suffered and continued to suffer, and they understood that at some point the psychological anguish would become unbearable for her. They respected that this could be as bad as physical pain. They accepted that when the anguish became unbearable, Alyssa would have the right to end her life by taking medical aid in dying medications. They agreed that financial planning and end of life planning were worthy tasks. To Dr. G and to Alyssa, these words conveyed deeply reassuring love, compassion, and support.

Alyssa’s parents asked whether any treatments remained that might yet change the outcome of her course, specifically noting that Alyssa had not completed a full residential eating disorder program, never fully restored weight, never tried newer psychedelic options such as ketamine, psilocybin, or MDMA, and hadn’t had a feeding tube. Dr. G acknowledged that all but the feeding tube might ordinarily be undertaken prior to someone’s seeking end of life care for AN. Yet, she had been suffering for so long, and despite many conversations about all these treatment possibilities, Alyssa would not consent to any of them. Therefore, given her clarity of understanding around these issues and her sense that she could not fight anymore, everyone had to accept that they weren’t meaningful options. With regards to a surgical feeding tube in the context of AN rather than due an anatomical impediment, Dr. G noted that if someone restricts the “tube God gave them,” i.e. their esophagus, they would also be very likely to restrict through a surgical feeding tube, so that would not be a long term solution.

An excellent home hospice agency agreed to work with Alyssa and her family, and Dr. G placed a referral for a MAID consultation. The palliative care physician met with Alyssa about MAID. Since the idea of requesting MAID for a patient with AN was so foreign and unnerving to him, he asked Alyssa to be assessed formally for decision-making capacity. After a local psychiatrist confirmed that Alyssa clearly possessed decision-making capacity, the palliative care doctor fully accepted Alyssa’s right to enter home hospice care and could understand the rationale for MAID provision. However, even as he and his team provided empathetic support, he ultimately felt personally unable to write the MAID medication prescription due to his discomfort with the unique presentation. Clarification with the state’s Medical Board and other regulatory entities determined that Dr. G, licensed in this state although based in another state, could serve as prescribing physician, and that Alyssa’s longstanding primary care physician could serve as consulting physician. Dr. G prescribed the MAID medications about six weeks after Alyssa entered hospice care. Four days before her death, eager to contribute to this article, Alyssa sent Dr. G the following (unedited) notes about her thoughts on this complicated topic:

Below I share the considerations I made as I weighed the potential benefits and risks of pursing MAID. I share my experience in hopes of offering a first-hand perspective that may help other patients and physicians as they consider and weigh the option of utilizing MAID, rather than offering a prescriptive decision-making tool or recommending that all patients with terminal SEAN have access to such medication.

Personal considerations:

MAID not pursued in isolation, but rather in the context of being in Hospice care following a terminal dx of anorexia (i.e., estimated 6 months or left to live). I would not have qualified for Hospice care unless my illness was terminal (i.e., not reversible for me in light of physical, mental, emotional damage to my body).

In my individual case, death was inevitable. I clearly understood my prognosis and accepted this. I saw MAID as an opportunity to select a specified time and circumstances for my death. Death itself is fraught with fear, ambiguity, a sense of powerlessness and tremendous anguish, not just for the patient who is dying, but for that patient’s family. Upon deep reflection, I came to see MAID as an opportunity to relieve my suffering and minimize at least some of my family’s suffering related to my death by choosing the when and how of my death, rather than “wait” for sudden death from cardiac arrest or other outcome of my illness or experience a slow and protracted death as my family and I watch my body and mind degrade over days and maybe even weeks of time

I had to ask important questions about my quality of life and whether for me, the quality of my life was more important than the quantity of days I remained alive. I was experiencing extreme physical pain, was unable to walk, could not sit without discomfort, I couldn’t swallow my food, my breath was labored, and I had frequent chest pain. I was not living. I felt like “dead girl barely walking.” For me personally, a longer life spent in bed feeling ill and suffering and dependent on others to provide most of my care was not how I wanted to live. My concerns about this suffering trumped any fear of selecting the route of my death (again, knowing that death was inevitable). Knowing that I could utilize MAID if the suffering became so severe offered me a sense of ease and peace of mind in my final stage of life that I would not have had otherwise

One question that I needed to answer for myself honestly was whether I understood the impact use of MAID would have on my family. I had to confront that my use of MAID would be difficult for them, not just the idea of my using it but how their presence at the end of my death, watching me administer my own medications to die, would be ingrained in their memories of me as their daughter and their sister, and how this story of my passing would affect my family throughout the generations to come (i.e., what stories would they tell about my life and death, how could this be traumatizing or perhaps seen as healing?). Such questions could only be answered through ongoing involvement and discussion with my family members, which we had with my physicians and amongst ourselves

Another important question I asked was how would I want a family member to die if I knew their illness was terminal and death was imminent. Would I see their use of MAID as a compassionate act towards themselves? How would I tell their story? Would I extend the compassion I was asking for from them to them if the situation were reversed? I also asked them individually how they would want to die if they could have the option of choosing?

All in all, a voluntary decision, not made in haste, thoughtful, careful, meticulous. Decision made as arrangements were made for my passing including burial arrangements, financial and family orders.

Decision also heavily considered with spiritual advisors (chaplain, Rabbi, etc.)

Challenges faced:

MAID in general is highly controversial and its use is RARE – even for patients who do receive it, many do not end up using it. Only a handful of physicians who support using it. Makes it unknown and scary for physicians and patients alike; limited research

Makes acceptance of its use more difficult for family members, too

Prescribing MAID (for some physicians) may feel counter to physician identity as healer & fixer; may spark deep internal/ethical/moral debate for individual physicians as they weigh the option of whether to prescribe

Do they see this as an act of compassion for patients who wish to relieve their suffering?

Do they see this as prescribing a means of suicide?

Anorexia specific – for me, a big issue that caused most ethical debate was whether my case of anorexia nervosa was “reversible.” Many physicians misunderstand SEAN (not even an official DSM diagnosis) and that while anorexia nervosa is a psychiatric illness, it comes with severe medical complications that ultimately are the reason for death. Some of the physicians I worked with could not believe my illness was indeed terminal, but rather felt that there would be something that could be done to reverse the physical damage done to my body that would somehow lengthen my life (even if not for very long – i.e., 1 year).

Yes, perhaps I could stay alive for a few months while in the hospital, but I would have to live in the hospital (MDs might see the benefit of this, but could I? NO! This is where my own reflection around quality of life came in)

My personal belief that this is what makes having such an extreme form of AN so agonizing – mental and emotional suffering is compounded by painful physical complications

Gross misunderstanding about anorexia nervosa in general.

Just over a day before she died, Alyssa wrote to Dr. G, “Thank you with all of my heart for helping to make this possible. I view it as a tremendous act of love.” With family and spiritual support surrounding her, Alyssa became unresponsive in the natural course of her malnutrition. Shortly thereafter, she passed away peacefully. She never actually ingested the MAID medication she had at her disposal.

By presenting these three cases, we have intended to convey some of the emotional, moral, and ethical challenges and dilemmas that patients with SE-AN, their families, and their professional caregivers may face at the end of life. Suffering from unrelenting and irredeemable disorders, these patients made difficult choices, ultimately deciding “enough is enough” [ 18 ]. The anguish endured by these patients and their families resulted in part from lack of professional understanding and consensus regarding terminal care for patients with AN. Neither the fields of palliative and hospice care nor eating disorders have provided definitions or guidance regarding what constitutes a terminal condition in AN or proper ways to address patients and their families grappling with this condition.

Accordingly, we present the following proposed clinical characteristics of those with terminal AN for consideration by both fields (Table 1 ). As illustrated by our cases, no set of criteria will apply perfectly to every patient who identifies with having a terminal case of AN. However, based on prior literature on criteria for clinical terminality [ 15 ], high SMR in those who have previously received inpatient care, are older, and have a history of more severely medically compromised presentations [ 6 , 7 , 8 , 9 , 10 , 11 ], and clinical expertise, the authors propose these clinical characteristics. Some deviation within the second and third characteristics is to be expected and must be individualized to the patient situation. However, the first and fourth must be met in full.

Proposed clinical characteristics of patients with terminal anorexia nervosa

A diagnosis of anorexia nervosa . Anorexia nervosa is the only eating disorder that carries a guaranteed medical cause of death from malnutrition should weight loss continue unabated. As a result, consistent with literature on duration of life during hunger strikes resulting in death [ 16 ], a prognosis of less than 6 months can fairly be established when the patient acknowledges further treatment to be futile and stops engaging in active recovery work. A less than six-month prognosis is congruent with current practice around determination of terminal diagnoses. We fully recognize that patients with SE-AN are likely to have other psychiatric conditions as well.

Age of 30 or older . This criterion accommodates for what is clinically seen as a potential “late maturation phase” in which even those who have been sick for a long time may discover a shift in values and desires that motivates recovery as they enter their late 20 s. Every effort should be made to promote full recovery and continuation of life in those younger than 30. However, the SMR data of multiple recent studies showing the highest death rates in those with a history of inpatient admissions, longer duration of AN, and age over 30 years old [ 6 , 7 , 8 , 9 ], taken alongside what functionally has often been a decade or two of exhaustive, ultimately unsuccessful eating disorder treatment, indicates that the age of around 30 as a minimum for terminal AN is reasonable.

Prior persistent engagement in high-quality, multidisciplinary eating disorder care. Worldwide access to expert eating disorder care varies widely, as does the availability of access to expert inpatient, residential, and full day treatment programs for those with eating disorders. Thus, the definition of care identified here must remain somewhat broad. Before someone can decide they cannot recover, they must have participated in high-quality, expert care to the maximum extent that this is available. This provision should motivate policies that allow for transfers of patients out of designated “networks” that lack expertise, with funding coverage provided at a center of excellence. Ideally, at least some of this treatment will have been undertaken at a sufficiently high level of care to provide extensive structure and support, preferably to the point of full weight restoration at least once in the relatively recent past. Congruent with receipt of such care, qualified health care professionals on the team must support the patient in their decision to stop fighting. We acknowledge that many factors may impact patients’ ability to participate in such care, including lack of access to eating disorders expertise, limitations of the healthcare system, and a personal sense—often based on prior treatment experiences—that admission to certain care settings would cause more harm than good.

Consistent, clear expression by an individual who possesses decision-making capacity that they understand further treatment to be futile, they choose to stop trying to prolong their lives, and they accept that death will be the natural outcome. Careful determination of decisional capacity is required in each case [ 19 ]. An individual who wavers in their conviction or expresses different goals to different people is not yet ready to receive the appellation of terminal AN.

Most eating disorders providers have cared for patients with AN who, despite suffering for decades, continue to show extraordinary determination and resilience. These patients still want help, at least with a harm-avoidance strategy if not with outright full recovery. In these cases, every effort must be made to support the patient’s wishes and provide appropriate resources for recovery. There must be no “giving up” on those who still seek to get better. Indeed, the drive to live and ability to find aspects of life worth fighting for can be seen vividly in the majority of those with AN, even in the face of years or decades of illness and suffering. The psychological imperatives of AN that often lead patients to resist or refuse clinically appropriate care, hazarding medical and psychological risk and deterioration, may seem to conflict with a stated desire to keep trying for recovery. However, in honoring patient autonomy, responsive care must always be offered as long as an individual states that this is their wish.

Patients in their earlier and younger years of AN may say they would rather die than gain weight or nourish themselves properly, a characteristic indicating that AN may present as an ego-syntonic mental illness. Nonetheless, the majority of patients with AN ultimately recover, and such expressions of anguish can be met with compassion and appropriate multidisciplinary care. We would not condone accepting a terminal diagnosis in younger patients. Of note, there are no explicit physiologic markers or measurables (weight, degree of weight loss, presence of or degree of organ failure, vital signs) which delineate someone with terminal AN. Even individuals with extreme medical malnutrition may recover fully if they so choose and have access to expert care. By contrast, if all criteria for terminal AN are met, as in the case of Aaron, individuals should not be obliged to demonstrate extreme medical instability before having the right to choose to stop fighting. Furthermore, while the obsessional ruminations of individuals with AN can be perplexing, clinicians should not regard the presence of body distortions and food fears as proof that these patients are unable to understand personal options and make reasoned health care decisions.

How can we determine that patients with severe anorexia nervosa possess the clinical decision-making capacity necessary to permit them to withdraw from treatment? With respect to decision-making capacity, four traditional criteria are usually applied: understanding, appreciation, ability to reason, and communication of decision [ 20 ]. In Dr. G’s estimation, confirmed in the two cases where formal independent assessment by a psychiatrist was performed, each of the patients met these criteria and was therefore capable of deciding to withdraw from conventional treatment. Alyssa’s clear, incisive writing just days before her death beautifully illustrates the insight and cognitive capacity that many patients with AN possess right up to the end of their life.

Clinical, legal, and ethical commentators in the field concur that withdrawal from treatment may be appropriate when further treatment, whether voluntary of involuntary, will provide only brief improvement, and is unlikely to offer sustained quality of life [ 21 , 22 ]. A formal assessment of decision-making capacity may help ameliorate family member fears that such an important decision is being made in an appropriate and ethical manner, especially when AN fears and distortions can seem so irrational. In addition, a formal bioethics evaluation might be valuable, but consideration of this must be balanced against most bioethicists’ lack of experience with patients who have AN, with the risk that their own innate and misguided reaction that “this patient just has to eat” could undermine a qualified patient’s decisions that are supported by their longstanding care team and family. Even medical ethicists must be wary about how their own cognitive and affective biases might influence their recommendations. [ 23 ]

Family members and carers play an immensely important role in the lives of those with AN. They bear witness to the suffering and challenges experienced by those with AN and are usually directly involved in the recovery process in multiple ways (financial/material support/behavioral support/engagement in the therapeutic work, among others). Many dread the day their child legally becomes an adult and can choose to exclude them from the details of recovery work, such that they become the financial supporters of care they are no longer privy to. The exhaustion, fear, love, and hope experienced by family members cannot be overstated. In any case where a patient meets the criteria for terminal AN, it is always preferable to include family members in the discussions and ideally come to a consensus. There may be dissent within a family about whether their loved one should be allowed to make the decision to stop fighting. These three cases illustrated how each family was meaningfully involved in the clinical discussions in the months before each patient’s death. Each family’s ultimate acceptance (through deep grief) of their son or daughter’s prognosis and choice contributed to a heightened sense of connection and love prior to death.

Acknowledging the considerable controversies surrounding MAID for patients with mental disorders [ 24 , 25 , 26 ], we also submit that patients with terminal AN who are severely physiologically compromised, and whose end-of life suffering results from both psychological and physical pain, should be afforded access to medical aid in dying in locations where such assistance has been legalized—just like other patients with terminal conditions.

AN confers an exceptionally high death rate. The lack of acceptance of terminality in AN and the absence of professionally condoned protocols and standard procedures for supporting patients and families through these phases further complicates end-of-life stages for the adults with AN who cannot keep fighting. These represent a small fraction even of the population of those with SE-AN. Per our proposed clinical characteristics, patients must not only decline further recovery-oriented treatment (which is not uncommon at times for those with AN), but also must explicitly and consistently choose to stop trying to prolong their lives, accepting that death will be the natural outcome. When a patient begins talking about the possibility of not being able to survive, every effort should be made to validate such a serious perspective and to offer an individualized and thoughtful series of harm reduction strategies and treatment options that might make life bearable. However, the process of seeking alternatives to death must not be so exhaustive as to disrespect limits the patient sets; while a family might be desperate for their loved one to try an experimental treatment or “just try going to treatment one more time,” they must ultimately accept the patient’s lack of consent for these.

Our proposed clinical characteristics of patients with terminal AN have no bearing on those who wish to keep fighting despite very long-standing and severe disease, even when their eating disorder behaviors seem incongruent with survival. Very specifically, to move toward a designation of terminal AN, an individual must express consistently that they can no longer live with their disease and will no longer maintain a minimum nutritional intake needed to support life. To be clear, each patient is unique and requires careful individual assessment and consideration as to the best approach going forward. Consistent with calls from others regarding the need for better definition and agreement regarding labeling and staging for SE-AN in general [1,2,3,4 5], the authors hope that these cases and characteristics of those with terminal AN will provide a starting point for identification, care, and further discussion. We would strongly encourage the development of expert consensus criteria and clinical guidelines endorsed by both the fields of palliative and hospice care and eating disorders. These brave, suffering individuals deserve no less.

Availability of data and materials

All narrative data and record of e-mails exchanged with patients and families throughout and after their care with the clinic are available.

Abbreviations

• Anorexia nervosa

Dr. Jennifer Gaudiani

Medical Aid in Dying

Obsessive Compulsive Disorder

• Severe and enduring anorexia nervosa

Broomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring anorexia nervosa: a systematic review and critical analysis. Int J Eat Disord. 2017;50(6):611–23.

Article   Google Scholar  

Treasure J, Stein D, Maguire S. Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence. Early Interv Psychiatry. 2015;9(3):173–84.

Touyz S, Hay P. Severe and enduring anorexia nervosa (SE-AN): in search of a new paradigm. J Eat Disord. 2015;3:26.

Wonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: Update and observations about the current clinical reality. Int J Eat Disord. 2020;53(8):1303–12.

Broomfield C, Noetel M, Stedal K, Hay P, Touyz S. Establishing consensus for labeling and defining the later stage of anorexia nervosa: A Delphi study. Int J Eat Disord. 2021. https://doi.org/10.1002/eat.23600 .

Article   PubMed   Google Scholar  

Guinhut M, Godart N, Benadjaoud MA, Melchior JC, Hanachi M. Five-year mortality of severely malnourished patients with chronic anorexia nervosa admitted to a medical unit. Acta Psychiatr Scand. 2021;143(2):130–40. https://doi.org/10.1111/acps.13261 ( PMID: 33247947 ).

van Eeden AE, van Hoeken D, Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and bulimia nervosa. Curr Opin Psychiatry. 2021;34(6):515–24. https://doi.org/10.1097/YCO.0000000000000739 .

Article   PubMed   PubMed Central   Google Scholar  

Nielsen S, Vilmar JW. What can we learn about eating disorder mortality from eating disorder diagnoses at initial assessment? A Danish nationwide register follow-up study using record linkage, encompassing 45 years (1970–2014). Psychiatry Res. 2021;303: 114091. https://doi.org/10.1016/j.psychres.2021.114091 .

Iwajomo T, Bondy SJ, de Oliveira C, Colton P, Trottier K, Kurdyak P. Excess mortality associated with eating disorders: population-based cohort study. Br J Psychiatry. 2021;219(3):487–93. https://doi.org/10.1192/bjp.2020.197 .

Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry. 2011;68(7):724–31.

Smith AR, Zuromski KL, Dodd DR. Eating disorders and suicidality: what we know, what we don’t know, and suggestions for future research. Curr Opin Psychol. 2017;12(22):63–7.

Google Scholar  

Lopez A, Yager J, Feinstein RE. Medical futility and psychiatry: palliative care and hospice care as a last resort in the treatment of refractory anorexia nervosa. Int J Eat Disord. 2010;43(4):372–7.

PubMed   Google Scholar  

Westermair AL, Buchman DZ, Levitt S, Trachsel M. Palliative Psychiatry for severe and enduring anorexia nervosa includes but goes beyond harm reduction. Am J Bioeth. 2021;21(7):60–2.

Westmoreland P, Mehler PS. Caring for patients with severe and enduring eating disorders (SEED): certification, harm reduction, palliative care, and the question of futility. J Psychiatr Pract. 2016;22(4):313–20.

Bachar E, Latzer Y, Canetti L, Gur E, Berry EM, Bonne O. Rejection of life in anorexic and bulimic patients. Int J Eat Disord. 2002;31(1):43–8.

Yager J. Managing patients with severe and enduring anorexia nervosa: when is enough, enough? J Nerv Ment Dis. 2020;208(4):277–82.

Hui D, Nooruddin Z, Didwaniya N, Dev R, De La Cruz M, Kim SH, Kwon JH, Hutchins R, Liem C, Bruera E. Concepts and definitions for “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care”: a systematic review. J Pain Symptom Manag. 2014;47(1):77–89.

Altun G, Akansu B, Altun BU, Azmak D, Yilmaz A. Deaths due to hunger strike: post-mortem findings. Forensic Sci Int. 2004;146(1):35–8. https://doi.org/10.1016/j.forsciint.2004.03.022 .

Yager J, Ganzini L, Nguyen DH, Rapp EK. Working with decisionally capable patients who are determined to end their own lives. J Clin Psychiatry. 2018;79(4):17r11767.

Appelbaum PS. Intuition, self-reflection, and individual choice: considerations for proposed changes to criteria for decisional capacity. Philos Psychiatry Psychol. 2017;24(4):325–8.

Rebecca Dresser (March 1984/April, 1984) Article and Commentary on Anorexia Nervosa: Feeding The Hunger Artists: Legal Issues In Treating Anorexia Nervosa. Wisconsin Law Review, 1984, 297. https://advance-lexis-com.proxy.hsl.ucdenver.edu/api/document?collection=analytical-materials&id=urn:contentItem:3S41-1KG0-00CW-H0MM-00000-00&context=1516831 .

Hébert PC, Weingarten MA. The ethics of forced feeding in anorexia nervosa. CMAJ. 1991;144(2):141–4.

PubMed   PubMed Central   Google Scholar  

Rhodes R, Strain JJ. Affective forecasting and its implications for medical ethics. Camb Q Healthc Ethics. 2008;17(1):54–65.

Freeland A, Godkin D, Dembo J, Chan P, Knoops F, Lachmann M, Morissette L, Smith DH, Stewart DE, Trew M, Wong MR, Charbonneau M. Medical assistance in dying (MAiD) for persons whose sole underlying medical condition is a mental disorder: challenges and considerations. Can J Psychiatry. 2021;31:7067437211043315.

Sheehan K, Gaind KS, Downar J. Medical assistance in dying: special issues for patients with mental illness. Curr Opin Psychiatry. 2017;30(1):26–30.

Rooney W, Schuklenk U, van de Vathorst S. Are concerns about irremediableness, vulnerability, or competence sufficient to justify excluding all psychiatric patients from medical aid in dying? Health Care Anal. 2018;26(4):326–43.

Download references

Acknowledgements

Dr. Gaudiani would like to acknowledge the Gaudiani Clinic’s nurse, Abby Brockman, RN, for her excellent clinical care of these patients and their families.

There was no funding received for this paper.

Author information

Authors and affiliations.

CEDS-S, FAED, Gaudiani Clinic, Denver, CO, USA

Jennifer L. Gaudiani

Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA

Alyssa Bogetz & Joel Yager

You can also search for this author in PubMed   Google Scholar

Contributions

Dr. Gaudiani was the internist for the three patients, drafted the article, and reviewed and approved revisions. Ms. Bogetz (deceased patient) contributed to the text and proposed criteria. Dr. Yager consulted with Alyssa and her family, contributed to the text, and provided extensive editing.

Corresponding author

Correspondence to Jennifer L. Gaudiani .

Ethics declarations

Ethical approval and consent to participate.

Consent for publication of these cases was provided by all of the deceased patients’ families and by Alyssa prior to her death, and all families asked that patients’ first names be used in lieu of initials. This case report did not require further ethical approval.

Consent for publication

All three authors consented to publish this article. Ms. Bogetz (posthumous author) consented prior to her death, both verbally and in writing. Written informed consent for publication of their clinical details was obtained from the parents of the other two patients. A copy of the consent forms is available for review by the Editor of this journal as an additional file.

Competing interests

The authors have no competing interests to declare with regards to any of the material in this paper.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Alyssa Bogetz: 1985–2021, former patient

^Alyssa Bogetz: deceased

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Gaudiani, J.L., Bogetz, A. & Yager, J. Terminal anorexia nervosa: three cases and proposed clinical characteristics. J Eat Disord 10 , 23 (2022). https://doi.org/10.1186/s40337-022-00548-3

Download citation

Received : 19 October 2021

Accepted : 01 February 2022

Published : 15 February 2022

DOI : https://doi.org/10.1186/s40337-022-00548-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Medical aid in dying
• Obsessive compulsive disorder

Journal of Eating Disorders

ISSN: 2050-2974

• General enquiries: [email protected]

• Patient Care & Health Information
• Diseases & Conditions
• Anorexia nervosa

If your doctor suspects that you have anorexia nervosa, he or she will typically do several tests and exams to help pinpoint a diagnosis, rule out medical causes for the weight loss, and check for any related complications.

These exams and tests generally include:

• Physical exam. This may include measuring your height and weight; checking your vital signs, such as heart rate, blood pressure and temperature; checking your skin and nails for problems; listening to your heart and lungs; and examining your abdomen.
• Lab tests. These may include a complete blood count (CBC) and more-specialized blood tests to check electrolytes and protein as well as functioning of your liver, kidney and thyroid. A urinalysis also may be done.
• Psychological evaluation. A doctor or mental health professional will likely ask about your thoughts, feelings and eating habits. You may also be asked to complete psychological self-assessment questionnaires.
• Other studies. X-rays may be taken to check your bone density, check for stress fractures or broken bones, or check for pneumonia or heart problems. Electrocardiograms may be done to look for heart irregularities.

Your mental health professional also may use the diagnostic criteria for anorexia in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

More Information

• Bone density test
• Complete blood count (CBC)
• Electrocardiogram (ECG or EKG)
• Liver function tests

Treatment for anorexia is generally done using a team approach, which includes doctors, mental health professionals and dietitians, all with experience in eating disorders. Ongoing therapy and nutrition education are highly important to continued recovery.

Here's a look at what's commonly involved in treating people with anorexia.

Hospitalization and other programs

If your life is in immediate danger, you may need treatment in a hospital emergency room for such issues as a heart rhythm disturbance, dehydration, electrolyte imbalances or a psychiatric emergency. Hospitalization may be required for medical complications, severe psychiatric problems, severe malnutrition or continued refusal to eat.

Some clinics specialize in treating people with eating disorders. They may offer day programs or residential programs rather than full hospitalization. Specialized eating disorder programs may offer more-intensive treatment over longer periods of time.

Medical care

Because of the host of complications anorexia causes, you may need frequent monitoring of vital signs, hydration level and electrolytes, as well as related physical conditions. In severe cases, people with anorexia may initially require feeding through a tube that's placed in their nose and goes to the stomach (nasogastric tube).

Care is usually coordinated by a primary care doctor or a mental health professional, with other professionals involved.

Restoring a healthy weight

The first goal of treatment is getting back to a healthy weight. You can't recover from anorexia without returning to a healthy weight and learning proper nutrition. Those involved in this process may include:

• Your primary care doctor, who can provide medical care and supervise your calorie needs and weight gain
• A psychologist or other mental health professional, who can work with you to develop behavioral strategies to help you return to a healthy weight
• A dietitian, who can offer guidance getting back to regular patterns of eating, including providing specific meal plans and calorie requirements that help you meet your weight goals
• Your family, who will likely be involved in helping you maintain normal eating habits
• Psychotherapy

These types of therapy may be beneficial for anorexia:

• Family-based therapy. This is the only evidence-based treatment for teenagers with anorexia. Because the teenager with anorexia is unable to make good choices about eating and health while in the grips of this serious condition, this therapy mobilizes parents to help their child with re-feeding and weight restoration until the child can make good choices about health.
• Individual therapy. For adults, cognitive behavioral therapy — specifically enhanced cognitive behavioral therapy — has been shown to help. The main goal is to normalize eating patterns and behaviors to support weight gain. The second goal is to help change distorted beliefs and thoughts that maintain restrictive eating.

Medications

No medications are approved to treat anorexia because none has been found to work very well. However, antidepressants or other psychiatric medications can help treat other mental health disorders you may also have, such as depression or anxiety.

Treatment challenges in anorexia

One of the biggest challenges in treating anorexia is that people may not want treatment. Barriers to treatment may include:

• Thinking you don't need treatment
• Fearing weight gain
• Not seeing anorexia as an illness but rather a lifestyle choice

People with anorexia can recover. However, they're at increased risk of relapse during periods of high stress or during triggering situations. Ongoing therapy or periodic appointments during times of stress may help you stay healthy.

• Acupuncture

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

When you have anorexia, it can be difficult to take care of yourself properly. In addition to professional treatment, follow these steps:

• Stick to your treatment plan. Don't skip therapy sessions and try not to stray from meal plans, even if they make you uncomfortable.
• Talk to your doctor about appropriate vitamin and mineral supplements. If you're not eating well, chances are your body isn't getting all of the nutrients it needs, such as Vitamin D or iron. However, getting most of your vitamins and minerals from food is typically recommended.
• Don't isolate yourself from caring family members and friends who want to see you get healthy. Understand that they have your best interests at heart.
• Resist urges to weigh yourself or check yourself in the mirror frequently. These may do nothing but fuel your drive to maintain unhealthy habits.

Alternative medicine

Dietary supplements and herbal products designed to suppress the appetite or aid in weight loss may be abused by people with anorexia. Weight-loss supplements or herbs can have serious side effects and dangerously interact with other medications. These products do not go through a rigorous review process and may have ingredients that are not posted on the bottle.

Keep in mind that natural doesn't always mean safe. If you use dietary supplements or herbs, discuss the potential risks with your doctor.

Anxiety-reducing approaches that complement anorexia treatment may increase the sense of well-being and promote relaxation. Examples of these approaches include massage, yoga and meditation.

Coping and support

You may find it difficult to cope with anorexia when you're hit with mixed messages by the media, culture, and perhaps your own family or friends. You may even have heard people joke that they wish they could have anorexia for a while so that they could lose weight.

Whether you have anorexia or your loved one has anorexia, ask your doctor or mental health professional for advice on coping strategies and emotional support. Learning effective coping strategies and getting the support you need from family and friends are vital to successful treatment.

Preparing for your appointment

Here's some information to help you get ready for your appointment and know what to expect from your doctor or mental health professional.

You may want to ask a family member or friend to go with you. Someone who accompanies you may remember something that you missed or forgot. A family member may also be able to give your doctor a fuller picture of your home life.

What you can do

Before your appointment, make a list of:

• Any symptoms you're experiencing, including any that may seem unrelated to the reason for the appointment. Try to recall when your symptoms began.
• Key personal information, including any major stresses or recent life changes.
• All medications, vitamins, herbal products, over-the-counter medications and other supplements that you're taking, and their dosages.
• Questions to ask your doctor so that you'll remember to cover everything you wanted to.

Some questions you might want to ask your doctor or mental health professional include:

• What kinds of tests do I need? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Is there a generic alternative to the medicine you're prescribing?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor or mental health professional is likely to ask you a number of questions, including:

• How long have you been worried about your weight?
• Do you exercise? How often?
• What ways have you used to lose weight?
• Are you having any physical symptoms?
• Have you ever vomited because you were uncomfortably full?
• Have others expressed concern that you're too thin?
• Do you think about food often?
• Do you ever eat in secret?
• Have any of your family members ever had symptoms of an eating disorder or been diagnosed with an eating disorder?

Be ready to answer these questions to reserve time to go over any points you want to focus on.

• Sim LA (expert opinion). Mayo Clinic, Rochester, Minn. Jan. 31, 2018.
• Anorexia nervosa. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed Nov. 13, 2017.
• Hales RE, et al. Anorexia nervosa. In: The American Psychiatric Publishing Textbook of Psychiatry. 6th ed. Washington, D.C.: American Psychiatric Publishing; 2014. http://psychiatryonline.org. Accessed Nov. 13, 2017.
• Klein D, et al. Anorexia nervosa in adults: Clinical features, course of illness, assessment, and diagnosis. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Mehler P. Anorexia nervosa in adults and adolescents: Medical complications and their management. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Mehler P. Anorexia nervosa in adults: Evaluation for medical complications and criteria for hospitalization to manage these complications. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Pike K. Anorexia nervosa in adults: Cognitive behavioral therapy (CBT). https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Walsh BT. Anorexia nervosa in adults: Pharmacotherapy. https://www.uptodate.com/contents/search. Accessed Nov. 13, 2017.
• Anorexia nervosa. Merck Manual Professional Version. http://www.merckmanuals.com/professional/psychiatric-disorders/eating-disorders/anorexia-nervosa. Accessed Nov. 13, 2017.
• Harrington BC, et al. Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician. 2015;91:46.
• Brockmeyer T, et al. Advances in the treatment of anorexia nervosa: A review of established and emerging interventions. Psychological Medicine. In press. Accessed Nov. 13, 2017.
• Davis H, et al. Pharmacotherapy of eating disorders. Current Opinion in Psychiatry. 2017;30:452.
• Herpertz-Dahlmann B. Treatment of eating disorders in child and adolescent psychiatry. Current Opinion in Psychiatry. 2017;30:438.
• Fogarty S, et al. The role of complementary and alternative medicine in the treatment of eating disorders: A systematic review. Eating Behaviors. 2016;21:179.
• Eating disorders. National Alliance on Mental Illness. https://www.nami.org/Learn-More/Mental-Health-Conditions/Eating-Disorders/Overview. Accessed Nov. 13, 2017.
• Lebow J, et al. Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa? Eating Disorders. In press. Accessed Dec. 4, 2017.
• Lebow J, et al. The effect of atypical antipsychotic medications in individuals with anorexia nervosa: A systematic review and meta-analysis. International Journal of Eating Disorders. 2013;46:332.
• Five things to know about safety of dietary supplements for children and teens. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/tips/child-supplements. Accessed Feb. 9, 2018.

Associated Procedures

Products & services.

• A Book: Mayo Clinic Family Health Book
• Newsletter: Mayo Clinic Health Letter — Digital Edition

Mayo Clinic in Rochester, Minnesota, has been recognized as one of the top Psychiatry hospitals in the nation for 2023-2024 by U.S. News & World Report.

• Symptoms & causes
• Diagnosis & treatment
• Doctors & departments

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

• Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

• Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
• The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
• Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
• FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
• Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

Your gift holds great power – donate today!

Make your tax-deductible gift and be part of the cutting-edge research and care that's changing medicine.

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Anorexia nervosa in adolescents

An overview.

Peterson, Kathleen PhD, RN, PCPNP-BC; Fuller, Rebecca RN-BC

Kathleen Peterson is a professor of nursing at The College at Brockport, State University of New York. Rebecca Fuller is a level III clinical nurse at Golisano Children's Hospital, University of Rochester in N.Y.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Anorexia nervosa (AN) is an eating disorder that is difficult to treat, and relapse is common. This article addresses management strategies and nursing interventions for adolescents diagnosed with AN.

Anorexia nervosa (AN) is an eating disorder that is difficult to treat, and relapse is common. Here, explore management strategies and nursing interventions for adolescents diagnosed with AN.

DX, 16, WAS ADMITTED with anorexia nervosa (AN) after unsuccessful outpatient treatment. She had intentionally lost 30 lb over 6 months by restricting her nutritional intake and counting calories. DX met the inclusion criteria for hospital admission following evaluation of her vital signs, height, weight, body mass index (BMI), serum electrolytes, and nutritional status.

AN is a potentially life-threatening eating disorder in which patients experience extreme fears of gaining weight and altered perceptions of their body. 1,2 First recognized in France in 1874, AN describes the symptoms associated with self-starvation and a preoccupation with weight. 1 According to a national representative survey of adolescents ages 13 to 18, the incidence of AN in both males and females was 0.3% and the median age at onset was 12.3 years. 3 AN has the highest mortality of all mental health disorders, typically resulting from complications of starvation or suicide. 4

Using a case history, this article focuses on AN in adolescents and discusses current treatment approaches and appropriate nursing interventions.

Three key features

According to The Diagnostic and Statistical Manual of Mental Health Disorders , 5th edition (DSM-5), an AN diagnosis requires each of the following three key features: 5

• persistent self-restriction of energy intake, leading to significant weight loss
• an intense fear of gaining weight, or persistent behavior that interferes with weight gain
• a disturbance in self-perceived weight or shape.

Determining a BMI percentage according to patient age is important in assessing adolescents for AN. The CDC offers a BMI calculator and instructions (see Resources ). Patients under the 5% margin for BMI with age are considered underweight. 6 One study suggested a BMI below the 10th percentile may result in the malnourishment associated with AN. 7

Healthcare providers must also follow trends specific to the individual patient's weight. For instance, a petite adolescent who has parents with a similar frame may fall into a low percentile without an AN diagnosis. Similarly, clinicians must assess deviations from individual growth trajectories, even if the patient's weight has not fallen to dangerous levels; for example, an adolescent patient whose weight has dropped from the 75th percentile to the 25th percentile for his or her age, presenting with other essential signs and symptoms of AN.

The DSM-5 describes two subtypes of AN: the restricting type and the binge-eating or purging type. 5 Both are characterized by a 3-month time frame.

• In restricting type, patients achieve weight loss primarily through dieting, fasting, and/or excessive exercise. 8
• Patients diagnosed with binge-eating or purging type have engaged in recurrent episodes of self-induced vomiting or the misuse of laxatives, diuretics, or enemas. 8

Risk factors

Why do some adolescents develop AN and other eating disorders while others do not? Eating disorders such as AN are caused by combinations of behavioral, biological, genetic, psychological, and environmental or cultural influences. 1 The following factors may put individuals at increased risk for developing an eating disorder. 1,5,9,10

Biological factors include:

• female gender
• a family member diagnosed with an eating disorder and/or mental health disorder
• a history of dieting.

Psychological factors include:

• obsessive-compulsive disorder (OCD) and behavioral inflexibility
• perfectionism
• body image dissatisfaction
• anxiety and/or depression.

Environmental or cultural factors include:

• immersion in a culture that values thinness
• participation in modeling, ballet, wrestling, gymnastics, or other activities that encourage thinness
• teasing and bullying
• a limited social network.

Studies of twins have demonstrated an estimated AN heritability between 33% and 84%. 11 Research is ongoing regarding whether specific chromosomes have a role in the development of AN. 11

Pathophysiology

Adolescents with AN often present with significant weight loss and a preoccupation with food and weight. They may restrict certain foods or calories and develop food rituals. These individuals may refuse foods they once enjoyed, refuse to eat socially with family and friends, and overexercise to extremes.

The excessive restriction of calories may impede growth and stop menstruation in female adolescents. Combined with an emphasis on exercise, these restrictions lead to malnourishment, causing protein deficiencies and disrupting the cardiovascular, renal, gastrointestinal, endocrine, integumentary, hematologic, and reproductive systems. 11 Studies have demonstrated that malnutrition associated with AN also affects neuropsychological functioning by reducing brain tissue. 11

Signs and symptoms

Nurses can identify physical signs and symptoms, such as amenorrhea, headaches, irritability, constipation, syncope, dizziness, loss of muscle mass, dry skin, and hair loss. Healthcare providers conducting a physical exam of patients with suspected AN should monitor vital signs for hypotension, bradycardia, hypothermia, and orthostatic changes greater than a 20 mm Hg decrease in systolic BP or a 10 mm Hg decrease in diastolic BP within 3 minutes of standing from a supine position. 12

Other notable findings include hypercarotenemia, acrocyanosis, lanugo, dependent edema, breast atrophy, scaphoid abdomen, and parotid swelling. 11 Additionally, patients with binging or purging type AN may have a calloused dorsum on their dominant hand and eroded tooth enamel. 11,13 Individuals with AN may dress in baggy clothing or layers and complain of feeling cold. 1

Psychiatric comorbidities

Patients with AN often present with mental health issues, including depression, obsessive tendencies, social anxiety, separation anxiety, and phobias such as the fear of swallowing or gaining weight. 1 Other common psychiatric disorders associated with AN include personality disorders and self-injurious behaviors. 11 Some patients with restricting type AN may present with OCD as well. Additionally, patients with binge-eating or purging type AN may have alcohol use disorder and other substance use disorders. 5

Complications

Some complications of the weight loss and malnutrition associated with AN will resolve with improved weight, but others may be chronic. These issues can affect every organ system and occur at any weight. 11 Endocrine abnormalities may include the delayed onset of puberty, amenorrhea, and permanent adversely affected fertility, often leading to greater reductions and delays in reproduction across the patient's lifespan. 14-16 The most common endocrine change related to AN is reversion to a prepubertal state. 15 Levels of cortisol and other hormones may be elevated, and hypoglycemia may occur. 15

After just 1 year, patients may experience decreased bone density , leading to osteoporosis and fragility fractures. 15 Malnourishment may permanently change neurocognitive functioning due to atrophy of the gray and white matter. 14 Cardiac complications include left ventricular atrophy and subsequent annular changes, leading to mitral valve prolapse. Prolonged QT intervals may increase the risk for cardiac dysrhythmias and sudden death. 14,15

The gastrointestinal system is affected as well, including possible dysphagia from weakened and uncoordinated pharyngeal muscles, slowed gastric emptying, and chronic constipation. 15 Additionally, AN affects the respiratory system , including abnormalities in pulmonary function and potentially spontaneous pneumothorax. 15 Similarly, the renal system may be affected, with patients possibly developing dehydration and renal insufficiency related to self-imposed fluid restriction. Other renal abnormalities may include pyuria, proteinuria, and hematuria. 11

Hematologic complications, such as anemia, leukopenia, and thrombocytopenia, may occur as a result of changes in the bone marrow. 11 AN may also cause abnormalities in a patient's sense of taste , or dysgeusia, as well as a reduced ability to determine sweetness and an overperception of fat in foods. 8 Additionally, patients with AN may experience complications related to the dermatologic system, including: 8,15

• xerosis, or skin that is dry and scaly
• lanugo-like body hair, which is described as dark hair that is fine and downy
• telogen effluvium, or hair loss
• carotenoderma, or yellowing skin
• hyperpigmentation
• seborrheic dermatitis, which is characterized by erythema and greasy scales
• acrocyanosis, in which a patient's hands and feet are cold, blue, and sometimes sweaty
• perniosis, or painful or pruritic erythema
• livedo reticularis, which is characterized by circular patches that are reddish or cyanotic in color
• paronychia, or inflammation or infection of the skin around the nail
• striae distensae, which is characterized by erythematous or hypopigmented patches
• delayed wound healing.

Many of these complications can be appropriately addressed with in-patient hospitalization to safely manage weight restoration. Conducted too rapidly, weight restoration may lead to refeeding syndrome, a metabolic derangement characterized by severe fluid and electrolyte imbalances that can lead to cardiac dysrhythmias and sudden death. 2 A large-scale study demonstrated that a 2 kg per week weight gain with appropriate medical monitoring was safe for many patients. 2

One 2015 practice parameter provides an evidence-based approach to evaluate and treat eating disorders in adolescents. 1 Many short, validated, and reliable tools are available to screen younger patients for eating disorders, such as the eating disorder examination questionnaire, the eating disorder inventory, and the eating attitudes test. 1

Though preferred, outpatient therapy is not always possible. Criteria established by the Society for Adolescent Health and Medicine will assist clinicians to decide whether hospitalization is necessary (see Indications for hospitalization ). 17

The Practice Guideline for the Treatment of Patients with Eating Disorders provides empirical evidence for inpatient treatment of eating disorders in adolescents. 18 Critical aspects of care include restoring fluid and electrolyte balance, improving nutritional status, monitoring and enforcing any prescribed physical activity, monitoring vital signs and weight, and monitoring intake of food and fluid and output of urine and bowel movements. The guideline lists additional goals for treating AN, including: 18

• restoring patients to a healthy weight
• treating any physical complications
• enhancing patient motivation to cooperate and participate in treatment to restore healthy eating patterns
• providing education regarding nutrition and healthy eating habits
• helping patients reassess and change core dysfunctional cognitions, attitudes, motives, conflicts, and feelings
• treating any associated psychiatric comorbidities, including deficits in mood, impulse regulation, self-esteem, and behavioral issues
• enlisting family support and providing appropriate counseling and therapy
• preventing relapse.

Many healthcare facilities that treat adolescents with eating disorders have institutional guidelines for consistency in patient care. For example, the goals for in-patient hospitalization at Boston Children's Hospital include weight gain and nutritional stabilization, vital signs and electrolyte stabilization, psychiatric consultation, and parental education. Nursing flowsheets and protocols provide clear guidelines and ensure consistency of nursing care. 14

Nursing considerations

Nurses play a key role in evaluating and treating adolescents with eating disorders such as AN and should take a nonjudgmental approach to patient care. In school health settings or in primary care, nurses should determine the appropriate height and weight as estimated in the growth chart and refer patients given evidence of growth failure or extreme weight loss. 1

Part of a comprehensive evaluation is a physical and psychiatric evaluation. Nurses assess patient eating patterns and body satisfaction, evaluating food intake, weight fluctuations, body image, and exercise. The SCOFF questionnaire uses a series of five questions to gauge patient risk for eating disorders such as AN: 11,19

• Do you make yourself sick because you feel uncomfortably full?
• Do you worry you have lost control over how much you eat?
• Have you lost more than 13 to 14 lb ( one stone) in a 3-month period?
• Do you believe yourself to be fat when others say you are too thin?
• Would you say that food dominates your life?

Lab testing requirements include a complete blood cell count; a comprehensive metabolic panel; and kidney, liver, and thyroid function studies. If applicable, nurses should also assess menstrual history, and hormonal studies can help identify amenorrhea. Additionally, dual-energy X-ray absorptiometry for bone density may be beneficial for female patients with amenorrhea lasting longer than 6 months and all male patients with significant weight loss. 1

Severe malnourishment leads to a variety of complications as already described. Nurses are vital in the emergency management of clinically unstable dysrhythmias, as well as cardiac arrest, hypothermia, and fluid and electrolyte disturbances. 1

Psychiatric evaluation

Adolescents with AN are often resistant to treatment and think that their weight is normal. Psychological recovery for patients with AN includes improving self-esteem, developing better interpersonal relationships, and returning to a healthy lifestyle. 11

Outpatient psychosocial interventions may be effective for this patient population, including family-based treatment. This consists of 10 to 20 family therapy sessions over a 6- to 12-month period and empowers parents to take charge of their adolescent's weight restoration. Cognitive behavioral therapy may also be helpful. 1

Psychiatric hospitalization programs, partial hospitalization, and residential programs may be considered if outpatient interventions are unsuccessful or unavailable. Developmental awareness and sensitivity are essential in providing skilled care for adolescents with eating disorders. Healthcare facilities should utilize a multidisciplinary approach, including a team of nurses, along with a psychotherapist, a pediatrician, and a dietitian. Medications should be reserved for comorbidities and patients who do not improve with psychosocial interventions. 1

Case study continued

DX, the patient introduced at the beginning of this article, expressed anxiety over nutrition and had limited her intake to 800 calories a day. Specifically, she voiced concerns about “getting fat” and “not being able to finish meals.” Her psychosocial assessment and unsuccessful outpatient treatment plan were also considered. Further assessment revealed that she excelled academically and ran cross-country at a suburban high school.

DX entered a 17-day eating disorder treatment program according to facility protocols, which outlined nursing interventions, utilized a multidisciplinary approach to stabilization, and coordinated follow-up outpatient care. The day of admission was counted as day 0.

Upon admission, DX weighed 40.9 kg (89.98 lb) and measured 164.5 cm (5 ft 4 in), with a BMI of 15.4. Adolescent females of her age and height should be eating about 2,200 calories daily with a BMI between 18.5 and 24.5. 20

Before she was weighed, DX completed a measured void, removed all clothing, and donned a hospital gown. Her weight and orthostatic BP were monitored daily until discharge. A neurologic evaluation revealed that DX was alert and oriented with coherent thought processes. Although she was experiencing anxiety and depression, she had no suicidal ideation. The nursing staff obtained results of her ECG and serum electrolytes upon admission, as well as an abdominal X-ray that revealed constipation requiring laxatives. Her ECG and electrolyte values were within normal limits, but her systolic BP decreased 40 mm Hg from a supine to a standing position. Her resting heart rate was 50 bpm.

She received consultations from child life, music therapy, social work, nutrition, and psychology. Per protocol, DX's bathroom door remained locked and no garbage receptacles were kept in the room to prevent purging. Liquid nutrition was initially prescribed at 1,000 calories and increased by 500 calories daily until a caloric intake of 3,500 was reached.

DX consumed oral liquid nutrition without requiring enteral nutrition. All meals were eaten in a dining room designed to build rapport and support therapeutic communication for those with eating disorders. This therapeutic milieu encourages patients to express feelings while consuming nourishment. Per facility protocol, meals were ingested in a 30-minute time frame, during which the patient was monitored by the nursing staff. Hydroxyzine was prescribed before each meal due to visible patient anxiety.

During her first 3 days, DX's weight increased to 41.2 kg (90.64 lb) and her orthostatic hypotension and lab results remained stable. On day 3, DX began eating solid nutrition equivalent to 2,000 calories/day. She was able to meet small goals with assistance from the nursing staff.

DX followed the eating disorder treatment plan as prescribed over the course of the next 10 days. Her weight increased to 43.1 kg (94.82 lb), and her orthostatic BP changes decreased to less than 10 mm Hg. She developed relationships with the nursing staff and participated in music therapy and other therapeutic groups conducted by child life specialists. DX worked with a dietitian to develop healthy eating habits and received passes to leave the hospital for short periods with her family, which allowed them to encourage her prescribed nutrition outside of the hospital setting.

During the remainder of her hospitalization, DX achieved a healthy weight of 48.7 kg (107.14 lb). Her insight and motivation toward recovery improved, and she worked to restore healthy eating patterns and family relationships. Her discharge involved planning and coordinating outpatient care, including referral to a psychologist and enrollment in family therapy and an eating disorders partial hospitalization program. These outpatient services are essential in preventing relapse and achieving a full recovery.

AN may result in a variety of complications due to malnutrition associated with weight loss that affects almost every organ system. 15 Nutrition rehabilitation, cognitive-behavioral psychotherapy, and family therapy are necessary in the treatment of AN, but studies have demonstrated that these may be more beneficial in the weight maintenance phase. 15 Nurses play a critical role in identifying at-risk adolescents and encouraging early treatment.

Academy for Eating Disorders: Resources

www.aedweb.org/resources/resources/fast-facts

Centers for Disease Control and Prevention: BMI percentile calculator for child and teen

www.cdc.gov/healthyweight/bmi/calculator.html

Children's Hospital of Orange County: Eating disorders (medical stabilization) care guideline

www.choc.org/wp/wp-content/uploads/careguidelines/EatingDisordersCareGuideline.pdf

Toledo Center for Eating Disorders: Eating Disorder Inventory-3 (EDI-3) scale descriptions. Psychological Assessment Resources (PAR)1

http://toledocenter.com/wp-content/uploads/2015/10/EDI-3-Scale.pdf

Mayo Clinic: Teen eating disorders: tips to protect your teen

www.mayoclinic.org/healthy-lifestyle/tween-and-teen-health/in-depth/teen-eating-disorders/art-20044635

National Association of Anorexia Nervosa and Associated Disorders

https://anad.org

National Eating Disorders Association

www.nationaleatingdisorders.org

The Center for Eating Disorders at Sheppard Pratt: A collection of supportive and informative books, websites, blogs and helpful organizations

www.eatingdisorder.org/eating-disorder-information/resources

Indications for hospitalization 17

One or more of the following justify hospitalization for adolescents with eating disorders, including AN:

• 75% median BMI for age and gender
• dehydration
• electrolyte disturbances, such as hypokalemia, hyponatremia, and hypophosphatemia
• ECG abnormalities, such as a prolonged QT interval or severe bradycardia
• physiologic instability, such as significant hypotension, severe bradycardia, or hypothermia
• arrested growth and development
• unsuccessful outpatient treatment
• acute food refusal
• uncontrollable binge-eating and purging
• acute medical complications of malnutrition, including syncope, seizures, heart failure, and pancreatitis
• psychiatric or physical comorbidities that prohibit or limit appropriate outpatient treatment, such as severe depression, suicidal ideation, OCD, and type 1 diabetes mellitus

Reproduced with permission from the Journal of Adolescent Health, 56, Society for Adolescent Health and Medicine, Golden NH, Katzman DK, et al., Position paper of the Society for Adolescent Health and Medicine: medical management of restrictive eating disorders in adolescents and young adults, Pages No. 121-125, 2015, with permission from Elsevier.

adolescents; AN; anorexia nervosa; binge-eating; BMI; body mass index; eating disorders; purging

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Increasing cultural competence with lgbtq patients, the hazards and benefits of social media use in adolescents, assessing mental health in vulnerable adolescents, mental health in nursing: a student's perspective, mental health problems among youth experiencing sex trafficking.

Change Password

Your password must have 6 characters or more:.

• a lower case character, 
• an upper case character, 
• a special character 

Password Changed Successfully

Your password has been changed

Create your account

Forget yout password.

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password

Forgot your Username?

Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

• July 01, 2024 | VOL. 181, NO. 7 CURRENT ISSUE pp.565-686
• June 01, 2024 | VOL. 181, NO. 6 pp.461-564
• May 01, 2024 | VOL. 181, NO. 5 pp.347-460
• April 01, 2024 | VOL. 181, NO. 4 pp.255-346
• March 01, 2024 | VOL. 181, NO. 3 pp.171-254
• February 01, 2024 | VOL. 181, NO. 2 pp.83-170
• January 01, 2024 | VOL. 181, NO. 1 pp.1-82

The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use , including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

Anorexia Nervosa

• Evelyn Attia M.D.
• B. Timothy Walsh M.D.

Search for more papers by this author

At the suggestion of her pediatrician, “Rachel,” a 19-year-old college freshman at a competitive liberal arts college, was brought by her parents for psychiatric evaluation during spring break. According to her parents, Rachel had lost 16 lb since her precollege physical the previous August, falling to a weight of 104 lb at a height of 5 feet, 5 inches. Rachel’s chief complaint was that “everyone thinks I have an eating disorder.” She explained that she had been a successful student and field hockey player in high school. Having decided not to play field hockey in college, she began running several mornings each week during the summer and “cut out junk food” to protect herself from gaining “that freshman 10.” Rachel lost a few pounds that summer and received compliments from friends and family for looking so “fit.” She reported feeling more confident and ready for college than she had expected as the summer drew to a close. Once she began school, Rachel increased her running to daily, often skipped breakfast in order to get to class on time, and selected from the salad bar for her lunch and dinner. She worked hard in school, made the dean’s list the first semester, and announced to her family that she had decided to pursue a premed program. When Rachel returned home for Christmas vacation, her family noticed that she looked thin and tired. Despite encouragement to catch up on rest, she awoke early each morning to maintain her running schedule. She displayed a newfound interest in cooking and spent much of the day planning, shopping, and preparing dinner for her family. Rachel returned to school in January and thought she might be developing depression. Courses seemed less interesting, and she wondered whether the college she attended was right for her after all. She was sleeping less well and felt cold much of the day. Rachel’s parents asked her to step on the bathroom scale the night she returned home for spring break. Rachel was surprised to learn that her weight had fallen to 104 lb, and she agreed to a visit to her pediatrician, who found no evidence of a general medical illness and recommended a psychiatric consultation. Does Rachel have anorexia nervosa? If so, how should she be treated?

Anorexia nervosa is a serious mental illness characterized by the maintenance of an inappropriately low body weight, a relentless pursuit of thinness, and distorted cognitions about body shape and weight. Anorexia nervosa commonly begins during middle to late adolescence, although onsets in both prepubertal children and older adults have been described. Anorexia nervosa has a mortality rate as high as that seen in any psychiatric illness (1) and is associated with physiological alterations in virtually every organ system, although routine laboratory test results are often normal and physical examination may reveal only marked thinness.

Current Definition

DSM-IV (2) lists four criteria for the diagnosis of anorexia nervosa:

1. Refusal to maintain body weight at or above a minimally normal weight for age and height

2. Intense fear of gaining weight or becoming fat, even though underweight

3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight

4. In postmenarchal females, amenorrhea (i.e., the absence of at least three consecutive menstrual cycles)

DSM-IV describes two subtypes of anorexia nervosa—the restricting subtype, consisting of those individuals whose eating behavior is characterized by restriction of type and quantity of food without binge eating or purging behaviors, and the binge-purge subtype, consisting of those who also exhibit binge eating and/or purging behaviors, such as vomiting or misuse of laxatives.

Diagnostic Challenges

The DSM-IV criteria are most easily applied when patients are both sufficiently ill to fulfill all four diagnostic criteria and able to describe their ideation and behavior accurately. However, because ambivalence and denial frequently lead those with anorexia nervosa to minimize their symptoms, the clinician must make inferences about mental state and behavior.

An additional problem in diagnosis is that many individuals meet some but not all of the formal diagnostic criteria. For example, some women who meet all other criteria for anorexia nervosa continue to report some spontaneous menstrual activity. In a community-based sample of 84 female patients with full- or partial-syndrome anorexia nervosa, those with amenorrhea were not statistically different from those without across a number of clinical variables (3) , which raises questions about the utility of this diagnostic criterion (4 , 5) .

Differential Diagnosis

Proper diagnosis of any condition that includes low weight and restrictive eating must include consideration of other psychiatric and medical conditions that include these problems. Psychotic disorders, including schizophrenia and schizoaffective and delusional disorders, as well as anxiety disorders, such as obsessive-compulsive disorder, can include symptoms of food avoidance and distorted beliefs about one’s body. Medical conditions, including endocrine disturbances (such as thyroid disease and diabetes mellitus), gastrointestinal disturbances (such as inflammatory bowel and celiac disease), infections (such as hepatitis), and neoplastic processes may present with weight loss and should be considered when evaluating a patient for a possible eating disorder.

Anorexia nervosa has been recognized for centuries. Sir William Gull coined the term anorexia nervosa in 1873, but Richard Morton likely offered the first medical description of the condition in 1689 (6 , 7) . Despite its long-standing recognition, remarkably little is known about the etiology of, and effective treatment for, anorexia nervosa. A 2002 review in the American Journal of Psychiatry concluded that little progress was made during the second half of the 20th century in understanding the etiology, prognosis, or treatment of the disorder (8) .

Epidemiology

Prevalence rates for anorexia nervosa are generally described as ranging from 0.5% to 1.0% among females (9 , 10) , with males being affected about one-tenth as frequently (10 , 11) . A recent study describing a large population-based cohort of Swedish twins born between 1935 and 1958 found the overall prevalence of anorexia nervosa among the 31,406 study participants to be 1.20% and 0.29% for females and males, respectively; the prevalence of anorexia nervosa in both sexes was greater among those born after 1945 (12) .

Risk Factors

The identification of risk factors for anorexia nervosa is challenging because the low incidence of the disorder makes the conduct of prospective studies of sufficient size very difficult. A variety of possible risk factors have been identified, including early feeding difficulties, symptoms of anxiety, perfectionistic traits, and parenting style, but none can be considered to have been conclusively demonstrated (13 , 14) . Similarly, cultural factors undoubtedly play some role in the development of anorexia nervosa, although the disorder’s long history and its presence in regions around the globe (15 – 18) suggest that factors other than culture provide central contributions to the development of the disorder. In fact, one review that considers historical reports of eating disorders, data regarding changing incidence rates of eating disorders over time, and the prevalence of eating disorders in non-Western cultures concludes that anorexia nervosa is not a culture-bound syndrome (19) . Genetic factors are increasingly accepted as important contributors to the risk of anorexia nervosa. Twin studies of eating disorders have consistently found that a significant fraction of the variability in the occurrence of anorexia nervosa can be attributed to genetic factors, with heritability estimates ranging from 33% to 84% (20) .

Course of Illness

The course of anorexia nervosa is highly variable, with individual outcomes ranging from full recovery to a chronic and severe psychosocial disability accompanied by physical complications and death. Intervention early in the course of illness and full weight restoration appear to be associated with the best outcomes. Adolescent patients have a better prognosis than do adults. One-year relapse rates after initial weight restoration approach 50% (21) . Intermediate and long-term follow-up studies examining clinical samples find that while a significant fraction of patients achieve full psychological and physical recovery, at least 20% continue to meet full criteria for anorexia nervosa on follow-up assessment, with many others reporting significant residual eating disorder symptoms, even if they do not meet full criteria for anorexia nervosa (22) .

Physiological Disturbances

A multitude of biological disturbances may occur in underweight patients, but most appear to be normal physiological responses to starvation. Clinically significant abnormalities may develop in the cardiovascular, gastrointestinal, reproductive, and fluid and electrolyte systems (23) . These abnormalities usually do not require specific treatment beyond refeeding, and they return to normal on weight restoration. A worrisome possible exception is reduced bone density; since peak bone density is normally achieved during young adulthood, a prolonged episode of anorexia nervosa during this development stage may have a long-term impact on the risk of osteoporosis.

Neurobiological Hypotheses

The striking physical and behavioral characteristics of anorexia nervosa have prompted the development of a variety of neurobiological hypotheses over the years. Recently, results of several investigations have suggested that abnormalities in CNS serotonin function may play a role in the development and persistence of the disorder (24 , 25) . Notably, studies of long-term weight-recovered patients have described indications of increased serotonin activity, such as elevated levels of the serotonin metabolite 5-hydroxyindoleacetic acid in the CSF (26) and reduced binding potential of 5-HT 2A receptors, suggestive of higher levels of circulating CNS serotonin, in several brain regions (27) .

Kaye and colleagues (28) hypothesize that individuals with anorexia nervosa may have a trait disturbance characterized by high levels of CNS serotoninergic activity leading to symptoms of anxiety that are relieved by dieting, which leads to a reduction in serotonin production. However, this provocative hypothesis is based on assessments conducted after the onset of illness, which therefore cannot distinguish a predisposing trait from a long-lasting consequence of anorexia nervosa.

Another recent line of inquiry into the biological underpinnings of anorexia nervosa focuses on the perfectionistic and rigid behavioral style, including repetitive and stereotyped behaviors, characteristic of the syndrome. Investigators have hypothesized that these behaviors may result from a propensity to extreme fear conditioning and resistance to fear extinction (29) , suggesting that abnormalities may be present in limbic structures known to be involved in the acquisition of conditioned fear behavior. Other investigators have proposed that difficulties of individuals with anorexia nervosa in changing maladaptive behavior may relate to problems with set shifting, a function mediated by corticostriatothalamocortical neural circuits (30 , 31) .

Engaging a patient with anorexia nervosa to participate fully in the psychiatric evaluation may present a greater challenge than would be the case for patients with other disorders, including other eating disorders such as bulimia nervosa or binge eating disorder. Patients with anorexia nervosa often present for evaluation not because of their own interest in symptom relief but because of the concerns of family, friends, or health care providers. It may be necessary to obtain additional information from family members or others who know the patient well.

In addition, during the evaluation, it may be helpful to identify symptoms of the illness that are most likely to be ego-dystonic for the particular patient. Patients commonly minimize their concerns about low weight, but they may be more concerned, and therefore more likely to participate in the evaluation, if they recognize poor concentration, increased irritability, low bone density, hair loss, or feeling cold as developments associated with their restrictive eating pattern.

Medical issues should be reviewed, including weight and menstrual history. A complete review of systems is indicated, as anorexia nervosa can manifest a multitude of disturbances, including cardiovascular symptoms (e.g., bradycardia and other arrhythmias, including QTc prolongation, and hypotension), gastrointestinal symptoms (e.g., slow motility, esophageal inflammation associated with purging), endocrinologic symptoms (low estrogen in females, low testosterone in males, osteopenia, and osteoporosis), and dermatologic changes, such as the development of a layer of fine hair (lanugo) on the face and extremities.

The evaluation should include specific questions about eating behaviors, including the number and content of all meals and snacks on a recent day. The clinician should inquire about 1) restricting behaviors, including limiting permissible foods, as well as decreasing caloric amounts; 2) binge eating; 3) purging behaviors, including vomiting and misuse of laxatives and diuretics; and 4) exercise and hyperactive behaviors, including preferential walking and standing.

Given patients’ reluctance to endorse all of the diagnostic symptoms of anorexia nervosa on first meeting, the clinician may do well to identify the problem as “low weight” and explain that the treatment needs to include weight restoration, whether or not the patient meets full criteria for anorexia nervosa. Patients and their families are generally very interested in data from the World War II Minnesota study of semistarvation that documented the association between starvation and the development of psychological symptoms frequently identified with anorexia nervosa, such as depression, anxiety, obsessionality about food, and rigidity about eating behaviors (32) . The clinician may have better results engaging the patient with the identification of symptoms that are commonly associated with the state of starvation and that the patient has likely found troubling (such as thinking constantly about food) and therefore worth resolving.

Treatment Guidelines

All current treatment guidelines for anorexia nervosa emphasize weight restoration. There is no clearly defined algorithm for how to accomplish this goal, although common practice includes the selection of the least restrictive treatment setting that is likely to be effective. The APA practice guideline on treatment of eating disorders suggests that highly structured treatments are often needed to achieve weight gain for patients at weights <85% ideal body weight (33) . Hospital-based treatments may be used when weight is significantly low (e.g., <75% of ideal body weight) or when there has been rapid weight loss or medical signs of malnutrition, including significant bradycardia, hypotension, hypothermia, and so on.

Generally, outpatient treatments rely on a team of professionals. Medical monitoring, including weight and laboratory assessment, may be provided by an internist or pediatrician; psychological support is offered by a psychiatrist or other therapist; and nutritional counseling from a dietitian or nutritionist is often included. The team is generally led by the medical or psychiatric clinician—typically the one with the greatest expertise in the management of eating disorders.

Effective treatments generally assess outcome by weight and behavioral change. Nonspecific support needs to be paired with expectation of progress in measurable medical, behavioral, and psychological symptoms. Weight restoration is generally associated with improvement in a variety of psychological areas, including mood and anxiety symptoms (34 , 35) . In contrast, psychological improvement without accompanying changes in weight and eating behavior is of limited value. Patients and families should be informed about the physiology of weight gain, including the substantial number of calories required daily.

A family-based outpatient treatment for anorexia nervosa, also called the “Maudsley method,” may be helpful for younger patients (36) . This approach empowers the parents of a patient with anorexia nervosa to refeed their child, renegotiate the relationship between child and parents to involve issues other than food, and help their child resume normal adolescent development without an eating disorder. Several preliminary studies have shown promising results for family therapy with adolescent patients (37 , 38) .

For patients with anorexia nervosa who do not respond to outpatient treatments or those who do not have specialized outpatient treatments available in their vicinity, more structured treatments such as inpatient or partial hospital (day treatment) programs may be necessary. Structured treatments generally include observation during and after meals together with a consistently applied behavioral program that reinforces weight gain and normal eating behaviors. In recent years, the length of hospital stay for anorexia nervosa has decreased substantially because of economic limitations imposed by third-party payers; nonetheless, hospital programs can achieve a rate of weight gain of 2–4 pounds per week during active treatment (39) .

Controlled Treatment Trials

While structured settings have been used successfully for weight restoration treatments, there is little empirical support for a specific level of care or a particular psychosocial treatment for anorexia nervosa. As mentioned, a family-based approach appears promising for children and adolescents with anorexia nervosa; family therapy has been reported to be superior to individual therapy in two randomized controlled trials for adolescents with anorexia nervosa (40 , 41) . For adults with anorexia nervosa, a small study by Pike and colleagues (42) found cognitive behavior therapy superior to nutritional counseling in preventing relapse after hospital-based weight restoration. A recent study by McIntosh et al. (43) provocatively suggested that a patient-centered nonspecific supportive therapy may have been more helpful than cognitive behavior therapy or interpersonal therapy, as measured by a global rating of anorexia nervosa symptoms, in a sample of 56 underweight women with anorexia nervosa receiving treatment over a minimum of 20 weeks; unfortunately, the amount of weight gain was modest and not significantly different among the three study treatments.

Randomized controlled trials of medications for patients with anorexia nervosa have consistently reported disappointing results. Several psychopharmacologic agents have been studied, without identification of clear benefit, although studies have been limited by small sample sizes and the fact that most of the trials have been conducted in hospital settings where other treatment interventions are offered in addition to study medication (44) . While it has been suggested that psychotropic medications are rendered ineffective in underweight patients by the biological impact of starvation, a recent study comparing fluoxetine and placebo in weight-restored patients notably found no significant benefit to medication during the year following nutritional rehabilitation (45) .

Summary and Recommendations

Although recognized for centuries, anorexia nervosa remains enigmatic, often difficult to treat, and potentially lethal. The current approach to treatment includes careful medical assessment, ongoing medical and weight monitoring, and behaviorally oriented treatment aimed at normalizing weight and eating behaviors. Family-based treatment appears promising for younger patients.

With Rachel, the patient in the vignette, her typical presentation, her low weight (corresponding to a body mass index of 17.3), and her reluctance to restore her weight to its previously healthy level led the evaluating psychiatrist to conclude that Rachel indeed had anorexia nervosa. The psychiatrist recommended that Rachel attempt outpatient treatment but explained to her and her family that many patients require more structured settings for successful weight restoration. The psychiatrist recommended that Rachel see an eating disorder specialist knowledgeable about the characteristics of anorexia nervosa and experienced in dealing with the challenges of its treatment. The outpatient treatment plan included weekly psychotherapy sessions, along with regular visits with her pediatrician and a nutritionist. Although Rachel had complained of “depression,” the psychiatrist elected not to prescribe antidepressant medication, as there is no evidence of its utility in anorexia nervosa, and weight gain in this disorder is known to lead to improvement in mood. In the meetings with Rachel, the psychiatrist used cognitive behavior therapy techniques to help her in reevaluating her assumptions that low weight was somehow essential to her sense of self-worth. Treatment outcome was assessed by changes in weight and eating behavior. Rachel’s family participated by helping to supervise meals at the start of treatment and offering her more autonomy around eating as she made progress. Rachel was asked to gain weight at a rate of >1 lb per week and knew that failure to meet this goal would lead to transfer of treatment to a more structured setting. Rachel reached and maintained her premorbid weight and was able to return to school 6 months after initial presentation.

Received July 19, 2007; accepted Aug. 6, 2007 (doi: 10.1176/appi.ajp.2007.07071151). From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York; and the Eating Disorders Research Unit, New York State Psychiatric Institute, New York. Address correspondence and reprint requests to Dr. Attia, New York State Psychiatric Institute, 1051 Riverside Dr., Unit 98, New York, NY 10032; [email protected] (e-mail).

CME Disclosure: Dr. Attia has received research support from Pfizer and Eli Lilly. Dr. Walsh has received research support from Abbott Pharmaceuticals.

APA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by scientific literature and clinical experience.

1. Sullivan PF: Mortality in anorexia nervosa. Am J Psychiatry 1995; 152:1073–1074 Google Scholar

2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994 Google Scholar

3. Garfinkel PE, Lin E, Goering P, Spegg C, Goldbloom D, Kennedy S, Kaplan AS, Woodside DB: Should amenorrhea be necessary for the diagnosis of anorexia nervosa? evidence from a Canadian community sample. Br J Psychiatry 1996; 168:500–506 Google Scholar

4. Cachelin F, Maher B: Is amenorrhea a critical criterion for anorexia nervosa? J Psychosom Res 1998;44:435–440 Google Scholar

5. Watson T, Andersen A: A critical examination of the amenorrhea and weight criteria for diagnosing anorexia nervosa. Acta Psychiatr Scand 2003;108:175–182 Google Scholar

6. Pearce JM: Richard Morton: origins of anorexia nervosa. Eur Neurol 2004; 52:191–192 Google Scholar

7. Silverman JA: Sir William Gull (1819–1890): limner of anorexia nervosa and myxoedema: an historical essay and encomium. Eat Weight Disord 1997; 2:111–116 Google Scholar

8. Steinhausen H-C: The outcome of anorexia nervosa in the 20th century. Am J Psychiatry 2002; 159:1284–1293 Google Scholar

9. Hoek HW, van Hoeken D: Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003; 34:383–396 Google Scholar

10. Hudson JI, Hiripi E, Pope HG Jr, Kessler RC: The prevalence and correlates of eating disorders in the National Comorbidity Survey replication. Biol Psychiatry 2007; 61:348–358 Google Scholar

11. Lucas AR, Beard CM, O’Fallon WM, Kurland LT: 50-year trends in the incidence of anorexia nervosa in Rochester, Minn: a population-based study. Am J Psychiatry 1991; 148:917–922 Google Scholar

12. Bulik CM, Sullivan PF, Tozzi F, Furberg H, Lichtenstein P, Pedersen NL: Prevalence, heritability, and prospective risk factors for anorexia nervosa. Arch Gen Psychiatry 2006; 63:305–312 Google Scholar

13. Jacobi C, Hayward C, de Zwaan M, Kraemer HC, Agras WC: Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy: Psychol Bull 2004; 130:19–65 Google Scholar

14. Striegel-Moore RH, Bulik CM: Risk factors for eating disorders. Am Psychologist 2007; 62:181–198 Google Scholar

15. Lee HY, Lee EL, Pathy P, Chan YH: Anorexia nervosa in Singapore: an eight-year retrospective study. Singapore Med J 2005; 46:275–281 Google Scholar

16. Njenga FG, Kangethe RN: Anorexia nervosa in Kenya. East Afr Med J 2004; 81:188–193 Google Scholar

17. Bennett D, Sharpe M, Freeman C, Carson A: Anorexia nervosa among female secondary school students in Ghana. Br J Psychiatry 2004; 185:312–317 Google Scholar

18. Hoek HW, van Harten PN, Hermans KME, Katzman MA, Matroos GE, Susser ES: The incidence of anorexia nervosa on Curaçao. Am J Psychiatry 2005; 162:748–752 Google Scholar

19. Keel PK, Klump KL: Are eating disorders culture-bound syndromes? implications for conceptualizing their etiology. Psychol Bull 2003; 129:747–769 Google Scholar

20. Bulik CM: Exploring the gene-environment nexus in eating disorders. J Psychiatry Neurosci 2005; 30:335–339 Google Scholar

21. Pike KM: Long-term course of anorexia nervosa: response, relapse, remission, and recovery. Clin Psychol Rev 1998; 18:447–475 Google Scholar

22. Fisher M: The course and outcome of eating disorders in adults and in adolescents: a review. Adolesc Med 2003; 14:149–158 Google Scholar

23. Walsh BT: Eating disorders, in Harrison’s Principles of Internal Medicine, 17th ed. Edited by Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL. New York, McGraw-Hill (in press) Google Scholar

24. Kaye WH, Frank GK, Bailer UF, Henry SE: Neurobiology of anorexia nervosa: clinical implications of alterations of the function of serotonin and other neuronal systems. Int J Eat Disord 2005; 37(suppl):S15–S19 Google Scholar

25. Attia E, Wolk S, Cooper T, Glasofer D, Walsh BT: Plasma tryptophan during weight restoration in patients with anorexia nervosa. Biol Psychiatry 2005; 57:674–678 Google Scholar

26. Kaye WH, Gwirtsman HE, George DT, Ebert MH: Altered serotonin activity in anorexia nervosa after long-term weight restoration: does elevated cerebrospinal fluid 5-hydroxyindoleacetic acid level correlate with rigid and obsessive behavior? Arch Gen Psychiatry 1991; 48:556–562 Google Scholar

27. Frank GK, Kaye WH, Meltzer CC, Price JC, Greer P, McConaha C, Skovira K: Reduced 5-HT 2A receptor binding after recovery from anorexia nervosa. Biol Psychiatry 2002; 52:896–906 Google Scholar

28. Kaye WH, Barbarich NC, Putnam K, Gendall KA, Fernstrom J, Fernstrom M, McConaha CW, Kishore A: Anxiolytic effects of acute tryptophan depletion in anorexia nervosa. Int J Eat Disord 2003; 33:257–267 Google Scholar

29. Strober M: Pathologic fear conditioning and anorexia nervosa: on the search for novel paradigms. Int J Eat Disord 2004; 35:504–508 Google Scholar

30. Holliday J, Tchanturia K, Landau S, Collier D, Treasure J: Is impaired set-shifting an endophenotype of anorexia nervosa? Am J Psychiatry 2005; 162:2269–2275 Google Scholar

31. Steinglass J, Walsh BT, Stern Y: Set shifting deficit in anorexia nervosa. J Int Neuropsychol Soc 2006; 12:431–435 Google Scholar

32. Schiele BC, Brozek J: “Experimental neurosis” resulting from semistarvation in man. Psychosom Med 1948; 10:31–50 Google Scholar

33. American Psychiatric Association: Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd ed. Am J Psychiatry 2006; 163(Jul suppl) Google Scholar

34. Meehan KG, Loeb KL, Roberto CA, Attia E: Mood change during weight restoration in patients with anorexia nervosa. Int J Eat Disord 2006; 39:587–589 Google Scholar

35. Attia E, Haiman C, Walsh BT, Flater SR: Does fluoxetine augment the inpatient treatment of anorexia nervosa? Am J Psychiatry 1998; 155:548–551 Google Scholar

36. Lock J, le Grange D, Agras WS, Dare C: Treatment Manual for Anorexia Nervosa: A Family Based Approach. New York, Guilford, 2001 Google Scholar

37. Lock J, le Grange D, Forsberg S, Hewell K: Is family therapy useful for treating children with anorexia nervosa? results of a case series. J Am Acad Child Adolesc Psychiatry 2006; 45:1323–1328 Google Scholar

38. Lock J, Agras WS, Bryson S, Kraemer HC: A comparison of short- and long-term family therapy for adolescent anorexia nervosa. J Am Acad Child Adolesc Psychiatry 2005; 44:632–639 Google Scholar

39. Guarda AS, Heinberg LJ: Inpatient and partial hospital approaches to the treatment of eating disorders, in Handbook of Eating Disorders and Obesity. Edited by Thompson JK. Hoboken, NJ, John Wiley & Sons, 2004, pp 297–322 Google Scholar

40. Russell GF, Szmukler GI, Dare C, Eisler I: An evaluation of family therapy in anorexia nervosa and bulimia nervosa. Arch Gen Psychiatry 1987; 44:1047–1056 Google Scholar

41. Robin AL, Siegel PT, Moye AW, Gilroy M, Dennis AB, Sikand A: A controlled comparison of family versus individual therapy for adolescents with anorexia nervosa. J Am Acad Child Adolesc Psychiatry 1999; 38:1482–1489 Google Scholar

42. Pike KM, Walsh BT, Vitousek K, Wilson GT, Bauer J: Cognitive behavior therapy in the posthospitalization treatment of anorexia nervosa. Am J Psychiatry 2003; 160:2046–2049 Google Scholar

43. McIntosh VVW, Jordan J, Carter FA, Luty SE, McKenzie JM, Bulik CM, Frampton CMA, Joyce PR: Three psychotherapies for anorexia nervosa: a randomized, controlled trial. Am J Psychiatry 2005; 162:741–747 Google Scholar

44. Attia E, Schroeder L: Pharmacologic treatment of anorexia nervosa: where do we go from here? Int J Eat Disord 2005; 37(suppl):S60–S63 Google Scholar

45. Walsh BT, Kaplan AS, Attia E, Olmsted M, Parides M, Carter JC, Pike KM, Devlin MJ, Woodside B, Roberto CA, Rockert W: Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. JAMA 2006; 295:2605–2612 Google Scholar

• Musicothérapie réceptive et anorexie mentale. Évaluation du dispositif DéPi-AM de détente psychomusicale dans l’accompagnement d’adolescentes hospitalisées : étude pilote auprès de 8 patientes Neuropsychiatrie de l'Enfance et de l'Adolescence, Vol. 72, No. 2
• Anorexie mentale et musicothérapie Soins, Vol. 68, No. 881
• L’anorexie mentale, une pathologie familière et complexe Soins, Vol. 68, No. 881
• Cognitive flexibility and the risk of anorexia nervosa: An investigation using self-report and neurocognitive assessments Journal of Psychiatric Research, Vol. 151
• Eating Disorders 18 June 2021
• Severe and Enduring Anorexia Nervosa: Enduring Wrong Assumptions? 15 February 2021 | Frontiers in Psychiatry, Vol. 11
• Characterization of Anorexia Nervosa on Social Media: Textual, Visual, Relational, Behavioral, and Demographical Analysis 20 July 2021 | Journal of Medical Internet Research, Vol. 23, No. 7
• Cognitive flexibility in acute anorexia nervosa and after recovery: A systematic review Clinical Psychology Review, Vol. 81
• Exploring the Eating Disorder Examination Questionnaire, Clinical Impairment Assessment, and Autism Quotient to Identify Eating Disorder Vulnerability: A Cluster Analysis 2 September 2020 | Machine Learning and Knowledge Extraction, Vol. 2, No. 3
• A systematic review of blood-based serotonergic biomarkers in Bulimia Nervosa Psychiatry Research, Vol. 279
• Eating Disorders 12 March 2019
• Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, Vol. 21, No. 2
• Anorexia Nervosa, Bulimia Nervosa, and Other Eating Disorders
• Impulse control in the dorsolateral prefrontal cortex counteracts post-diet weight regain in obesity NeuroImage, Vol. 109
• Anorexia Nervosa 23 January 2015
• Boletín Médico del Hospital Infantil de México, Vol. 72, No. 4
• The association between the development of weighing technology, possession and use of weighing scales, and self-reported severity of disordered eating 9 January 2014 | Irish Journal of Medical Science (1971 -), Vol. 183, No. 3
• Eating Disorders among Adolescents with a History of Obesity Pakistan Journal of Nutrition, Vol. 13, No. 8
• Risk Factors and Antecedent Life Events in the Development of Anorexia Nervosa: A Portuguese Case-Control Study 27 February 2014 | European Eating Disorders Review, Vol. 22, No. 4
• Anorexia nervosa in adolescents: challenges remain The Lancet, Vol. 383, No. 9924
• Family and Family Therapy, Vol. 22, No. 2
• Recognising anorexia nervosa: approaches to treatment British Journal of Mental Health Nursing, Vol. 2, No. 1
• Journal of Clinical Densitometry, Vol. 16, No. 4
• Open Journal of Preventive Medicine, Vol. 03, No. 02
• Food Restriction and Reward in Rats 24 August 2012
• Back to life: How to use positive psychology to beat anorexia? 25 January 2012 | International Journal of Research Studies in Psychology, Vol. 1, No. 2
• Osteopathic Family Physician, Vol. 4, No. 6
• Anorexie mentale par procuration : une présentation inhabituelle La Presse Médicale, Vol. 40, No. 5
• Recognising anorexia nervosa British Journal of Wellbeing, Vol. 1, No. 9
• Identification and Management of Eating Disorders in Children and Adolescents 1 December 2010 | Pediatrics, Vol. 126, No. 6
• Medical futility and psychiatry: Palliative care and hospice care as a last resort in the treatment of refractory anorexia nervosa 14 May 2009 | International Journal of Eating Disorders, Vol. 43, No. 4
• Neural processing of negative word stimuli concerning body image in patients with eating disorders: An fMRI study NeuroImage, Vol. 50, No. 3
• Anorexie mentale à l'adolescence EMC - Pédiatrie - Maladies infectieuses, Vol. 5, No. 1
• Journal de Pédiatrie et de Puériculture, Vol. 23, No. 1
• Scandinavian Journal of Caring Sciences, Vol. 24, No. 3
• Pro‐anorexia websites: What a clinician should know 29 November 2008 | International Journal of Eating Disorders, Vol. 42, No. 4
• Expert Opinion on Investigational Drugs, Vol. 18, No. 5

Search by category

Popular searches.

Eating disorder case study

Discover another eating disorder recovery story

"eating disorders tend to hide and they don't want to be seen, and if somebody else can see it ... it's a lot harder to hide".

Contact us to make an enquiry or for more information

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Anorexia nervosa: a case study

• PMID: 1052188
• DOI: 10.1159/000286995

D.R., a single 19-year-old female experiencing anorexia nervosa, was admitted to a mental health center inpatient unit weighing 64 lb, approximately 54 lb underweight, with liver, kidney, and pancreas damage. D.R. was hospitalized for 59 days. Treatment consisted of utilizing a hierarchy of reinforcements in the form of privileges mutually agreed upon between patient and therapist, psychodynamic and supportive psychotherapy, and involvement in the ward milieu therapeutic program. All privileges had to be earned. Access to food was controlled by the staff. For pounds gained privileges were granted, for pounds lost privileges were curtailed. Dynamically, D.R.'s eating behavior was viewed as an unconscious spite and revenge reaction toward her parents as well as an attempt to elicit attention. At the time of discharge D.R. weighed 104.5 lb. Prior to discharge D.R. agreed that if her weight dropped below 100 lb she would return for readmission. Five months later D.R.'s weight stabilized between 102 and 104 lb. Two years later, D.R.'s weight remains at that level. The study cautions against using solely a behavior modification approach in the treatment of anorexia nervosa.

PubMed Disclaimer

Similar articles

• Focal psychodynamic therapy, cognitive behaviour therapy, and optimised treatment as usual in outpatients with anorexia nervosa (ANTOP study): randomised controlled trial. Zipfel S, Wild B, Groß G, Friederich HC, Teufel M, Schellberg D, Giel KE, de Zwaan M, Dinkel A, Herpertz S, Burgmer M, Löwe B, Tagay S, von Wietersheim J, Zeeck A, Schade-Brittinger C, Schauenburg H, Herzog W; ANTOP study group. Zipfel S, et al. Lancet. 2014 Jan 11;383(9912):127-37. doi: 10.1016/S0140-6736(13)61746-8. Epub 2013 Oct 14. Lancet. 2014. PMID: 24131861 Clinical Trial.
• [Psychotherapy based on object relation with object and psychodynamic attitude to treatment of eating disorders]. Izydorczyk B. Izydorczyk B. Psychiatr Pol. 2010 Sep-Oct;44(5):677-91. Psychiatr Pol. 2010. PMID: 21452503 Review. Polish.
• Rate of weight gain of inpatients with anorexia nervosa under two behavioral contracts. Solanto MV, Jacobson MS, Heller L, Golden NH, Hertz S. Solanto MV, et al. Pediatrics. 1994 Jun;93(6 Pt 1):989-91. Pediatrics. 1994. PMID: 8190589
• New therapies for the eating disorders. Behavior modification of obesity and anorexia nervosa. Stunkard A. Stunkard A. Arch Gen Psychiatry. 1972 May;26(5):391-8. doi: 10.1001/archpsyc.1972.01750230001001. Arch Gen Psychiatry. 1972. PMID: 4553422 Review. No abstract available.
• Treatment of anorexia nervosa in a young adult patient with diabetes mellitus. Malone GL, Armstrong BK. Malone GL, et al. J Nerv Ment Dis. 1985 Aug;173(8):509-11. doi: 10.1097/00005053-198508000-00010. J Nerv Ment Dis. 1985. PMID: 4020370
• Food Restriction in Anorexia Nervosa in the Light of Modern Learning Theory: A Narrative Review. Garcia-Burgos D, Wilhelm P, Vögele C, Munsch S. Garcia-Burgos D, et al. Behav Sci (Basel). 2023 Jan 23;13(2):96. doi: 10.3390/bs13020096. Behav Sci (Basel). 2023. PMID: 36829325 Free PMC article. Review.

Publication types

• Search in MeSH

Related information

Linkout - more resources, full text sources.

• S. Karger AG, Basel, Switzerland

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Characteristics of Suicide Attempts in Anorexia and Bulimia Nervosa: A Case–Control Study

Sébastien guillaume.

1 Inserm, U1061, Montpellier, France

2 Université Montpellier I, Montpellier, France

3 CHU Montpellier, Hôpital Lapeyronie, Psychiatric Emergency and Post Emergency Department, Pole Urgence, Montpellier, France

4 King's College London, Institute of Psychiatry, London, United Kingdom

Isabelle Jaussent

Emilie olié, catherine genty, jacques bringer.

5 Endocrinology Department, CHU Montpellier, Montpellier, France

Philippe Courtet

Ulrike schmidt.

Conceived and designed the experiments: SG PC US. Performed the experiments: EO CG JB. Analyzed the data: IJ. Wrote the paper: SG US.

Compared to other eating disorders, anorexia nervosa (AN) has the highest rates of completed suicide whereas suicide attempt rates are similar or lower than in bulimia nervosa (BN). Attempted suicide is a key predictor of suicide, thus this mismatch is intriguing. We sought to explore whether the clinical characteristics of suicidal acts differ between suicide attempters with AN, BN or without an eating disorders (ED).

Case-control study in a cohort of suicide attempters (n = 1563). Forty-four patients with AN and 71 with BN were compared with 235 non-ED attempters matched for sex, age and education, using interview measures of suicidal intent and severity.

AN patients were more likely to have made a serious attempt (OR = 3.4, 95% CI 1.4–7.9), with a higher expectation of dying (OR = 3.7,95% CI 1.1–13.5), and an increased risk of severity (OR = 3.4,95% CI 1.2–9.6). BN patients did not differ from the control group. Clinical markers of the severity of ED were associated with the seriousness of the attempt.

There are distinct features of suicide attempts in AN. This may explain the higher suicide rates in AN. Higher completed suicide rates in AN may be partially explained by AN patients' higher desire to die and their more severe and lethal attempts.

Introduction

Eating disorders (ED) are biologically based serious mental disorders with high levels of mortality and disability, physical and psychological morbidity and impaired quality of life [1] . In anorexia nervosa (AN), this excess mortality is explained in part by the physical complications and in part by an increased rate of suicide. Across studies, approximately 20 to 40% of deaths in AN are thought to result from suicide [2] , [3] with SMRs for suicide of 31 in a recent meta analysis [4] and ranging from 13.6 to 56.9 [2] , [3] , [5] . In bulimia nervosa (BN), the same meta-analysis found a lower SMR of 7.5 [4] with some studies showing no excess mortality [6] and more recent data suggesting that suicide rates may be increased in this group [7] .

Rates of suicidal and self-harming behaviors in ED populations are also raised compared to healthy controls [8] , [9] and comparable or higher than in other psychiatric populations [9] , [10] . Studies comparing rates of suicidal behavior in AN and BN have had mixed results with some finding no difference between AN and BN [10] , [11] and others finding lower rates of suicide attempts (SA) in AN than BN [12] [for review see [13] ].

In general, attempted suicide is one of the most potent and reliable predictors of completed suicide [14] , thus the mismatch between attempted and completed suicide in different ED diagnoses and subtypes is intriguing. What explains this discrepancy? One possibility is that as people with AN are more physically compromised than those with BN, this may make them more likely to die from a suicide attempt. Another possibility is that people with AN may make more severe and lethal attempts than those with BN, perhaps as a result of differences in the motives for suicidal behavior due to underlying personality traits or axis I or II comorbidity. In line with this hypothesis, a case series of nine completed suicides in AN patients found that the majority of these deaths were caused by use of methods with low rescue potential and high likelihood of death (e.g. jumping in front of a train or hanging). Nevertheless, to date no study has compared eating-disordered suicide attempters with a comparison group of suicide attempters who do not have an ED with respect to the characteristics of their suicide attempt. This comparison potentially has important clinical implications.

Aims of the study

The aim was to determine whether in a prospectively gathered and well-characterized cohort of current suicide attempters the clinical characteristics of suicidal acts differ between suicide attempters with life-time or current AN or BN and suicide attempters without ED. We hypothesized that AN patients would show SA that are more severe than those in BN and other non-eating disordered attempters. We also hypothesized that suicide attempts by people with BN would be broadly similar to attempts in a general population of suicide attempters.

Participants and clinical assessment

Study participants were identified from a large cohort of suicide attempters (n = 1563), consecutively hospitalized and survivors of a current suicide attempt (SA) in a specialized unit of the Montpellier University Hospital. Patients included in the cohort had to be between 18 and 75 years old, French-speaking, and with all four biological grandparents originating from Western European countries (for genetic purposes). This cohort is part of a large ongoing multi-centre study of suicidal behavior, which has been approved by the local research ethics committee (Comité de protection des personnes “Sud-Méditerranée IV” Lapeyronie hospital, Montpellier France). After having received information on the study, potential participants completed and returned a consent form.

In total, 139 patients with a lifetime history of DSM-IV eating disorders were identified, constituting 11.2% of the total cohort. Of these, 44 patients satisfied the lifetime criteria for anorexia nervosa (of whom twenty-eight (63.6%) had a current ED at the time of their attempt), 64 fulfilled the lifetime criteria for bulimia nervosa (of whom fifty-two (73.2%) BN patients had a current ED at the time of their attempt), 7 met both the lifetime criteria for AN and BN and 24 for Eating Disorders Not Otherwise Specified (EDNOS). Patients were split into two groups, a lifetime AN (n = 44) and a BN group which included those with lifetime BN and both lifetime BN and AN (n = 71), as in these cases BN was the most recent diagnosis before the SA. Patients with EDNOS were excluded due to their low number and the heterogeneity of this group. A control group of 235 SA patients without an ED and matched for age (± one year), sex and education level was also selected from the larger cohort of suicide attempters. The selection procedure of participants for the present study is described in figure 1 .

Patients were evaluated after remission of a potential mood episode (i.e. a current Hamilton Depression Rating Scale score below 15). They were interviewed by trained psychiatrists or psychologists, using the Mini International Neuropsychiatric Interview (MINI) [15] . Current and lifetime DSM-IV diagnoses (including ED diagnoses) were assessed by the interviewer and then blindly rated by an independent psychiatrist according to medical case notes and MINI. Further information about ED history was obtained for each patient using their medical records and when available, information from relatives. The Diagnostic Interview for Genetic Studies and dimensional scales (see below) were used to obtain information regarding suicidal behavior.

Suicide attempts were defined as the occurrence of self-directed injurious acts with intent to end one's own life [16] . As previously described [17] , a serious attempt was defined as an attempt which was deemed to be violent (i.e. using method other than poisoning or wrist cutting such as hanging, drowning, using a firearm…) [18] or one that justified admission to an medical intensive care unit.

For participant with a history of multiple suicide attempts, only the most severe suicide attempt was considered for analysis (which was also the current SA for 34.2% of the sample). The most severe suicide attempt was defined as the attempt with the most severe medical consequences and thus the highest score on the risk section of the Risk Rescue Rating Scale (see below).

We characterized this most severe SA using the French versions of three observer-rated scales: (1) The Risk Rescue Rating Scale (RRRS) [19] : this is a 10-item scale, with 5 items evaluating the risk of the suicidal act (primarily the medical consequences) (RRRS risk scores range from 5 to 15; a high score denotes high risk) and 5 items evaluating the likelihood of rescue following an attempt (RRRS rescue scores range from 5 to 15; a high score denotes high rescue potential). (2) The Suicidal Intent Scale [20] : this is a 15-item scale designed to assess the severity of suicidal intention associated with a SA. This scale provides a total score consisting of two sub-scores, one assessing the objective circumstances of the attempt (SIS planning: scores range from 0 to 16; a high score denotes high planning), the other assessing the belief the person had about the severity of the attempt (SIS conception: score from 0 to 14; a high score denotes a higher expectation of dying). (3) The scale for suicide ideation (SSI) [21] : this is a 21-item rating scale that measures the intensity of person's suicidal ideation (scores range from 0 to 38; a high score denotes a high level of suicide ideation). This scale was retrospectively rated to assess the period just before the attempt.

Statistical analysis

The sample is described using percentages for categorical variables and medians and ranges for continuous variables (age at diagnosis, age at onset of first SA) as their distributions were tested with the Shapiro-Wilk statistic and were skewed. Clinical and social characteristics between cases and controls were compared using Chi-square tests (for categorical variables) or Mann-Whitney tests (for continuous variables).

Univariate comparisons between the cases and controls were performed using unconditional logistic regression models including stratification variables, i.e. gender, age and educational level. Finally, Spearman's rank-order correlations were used to measure the associations between two continues variables. Significance was set at p<0.05. Statistical analyses were carried out using SAS version 9.1 (SAS Institute, Inc. Cary, North Carolina).

Demographics and clinical characteristics

Table 1 shows the sociodemographic characteristics and comorbid DSM-IV lifetime axis I diagnoses of the whole ED sample and the control sample. No significant difference was found between the groups regarding lifetime comorbid axis-I disorders. Interestingly, among ED patients only one (an AN patient) was free of any comorbid diagnosis. Finally, there were no significant differences between the group in proportion of patient with a chronic medical comorbidity (i.e: diabetes mellitus, thyroid disorders or chronic neurologic disorders such as epilepsy).

Table 2 shows clinical characteristics and lifetime comorbid DSM-IV diagnoses for the whole ED sample and ED subgroups. The age of onset of ED in AN and BN patients did not differ. As expected in the ED sample, the lowest body mass index (BMI) since onset was lower in the AN sample than in the BN sample (p<0.0001). The proportion of patients with a previous hospitalization was higher in the AN sample than in BN sample (p<0.0001). No significant differences were found between the AN and BN groups in terms of comorbid axis-I disorders.

Characteristics of the Suicidal Behavior

Table 3 shows characteristics of suicidal behavior in non-ED controls, ED patients and sub-groups (AN, BN). Comparing controls and the whole ED sample, a higher proportion of ED patients had a lifetime history of a serious SA (OR 1.8; CI 1.1 to 3.0) and a higher proportion of ED patients had a history of recurrent SA (i.e. at least two SA) (OR = 1.9; CI 1 to 2.9).

Compared to controls, AN patients were significantly more likely to have made a serious SA (OR = 3.4; 95% CI 1.4 to 7.9). They also had a higher risk of having made a highly severe SA as assessed by the RRRS-risk scale (OR = 3.4; 95% CI 1.2 to 9.6) and their most severe SA was characterized by a higher expectation of dying on the SIS (OR = 3.7; 95% CI 1.1 to 13.5).

The BN group was not significantly different to the control group of non-ED suicide attempters for any of the above characteristics of their SA.

We also compared the characteristics of suicidal behavior between the BN and AN group. Serious suicide attempts tended to be occur more commonly in AN (OR = 2.2 95% CI = [1.0 to 5.0], p = 0.0585) and expectation of dying (SIS conception score) was associated with AN (OR = 3.2 95%CI = 1.1 to 9.5 for the last tercile, p = 0.0354).

Twenty-eight (63.6%) AN and fifty-two (73.2%) BN patients had a current eating disorder at the time of their attempt. We performed a sensitivity analysis in people with a current eating disorder only (i.e. excluding people with a remitted eating disorder) and the results remain the same. The only exception was the “expectation to die” (SIS conception score) which was not significantly different between current AN patients and controls (OR = 5.0; CI 0.9 to 27.7).

A history of hospitalization for an ED was associated with a higher lifetime history of a serious SA (OR = 4.0; CI 1.5 to 10.5) and during their most severe attempt a higher RRRS rescue score (OR = 6.4; CI 1.2 to 33.4) suggesting a higher likelihood of rescue during their most severe attempt. None of the other SA features were different. (Data not shown).

Finally, we compared patients with a lifetime binge-purging subtype (irrespective of the diagnosis of AN or BN) versus patients with a lifetime restrictive subtype only. 74% (n = 85) of the ED patients had a purging subtype and 26% (N = 30) a restrictive subtype. Patients with a purging subtype were younger when they made their first SA (median age of 21 vs 24.5 years; p = 0.03). There were no differences between purging and restricting sub-type patients for the other features of the SA.

Correlations between clinical variables

We performed correlations in the ED group only. The lowest BMI since ED onset was negatively correlated with the “expectation to die” (r = −0.29, p = 0.004) and with the intensity of suicidal ideation before the attempt (SSI total score) (r = −0.26, p = 0.013). There were no other significant correlations between clinical characteristics (lowest BMI, age of ED onset, time between onset of ED and first SA, time between onset of ED and most lethal SA and time between onset of ED and current SA) and suicidal scales.

The main aim of our study was to assess the clinical features of suicidal acts in people with AN or BN compared to suicide attempters without an ED, and compared to each other. Our study is the first to show conclusively that AN patients make more serious and severe SA and have a higher expectation that they will die from their attempt than other suicide attempters. In contrast, the features of SA in BN patients seem very similar to those of suicide attempters without ED.

Previous studies have suggested that AN patients who make a suicide attempt have high suicidal intent [10] , [22] , however, our study is the first to note the greater severity of SA in this group compared to non-ED groups. Earlier studies have suggested that comparative suicide rates in AN may be inflated due to reliance on AN in-patient samples [23] . In the present study, only a sub-group of AN had a history of hospitalization, thus countering this idea.

Although our study concerned suicide attempters and not patients with completed suicide, our findings could also help to explain the intriguing discrepancy between rates of SA and completed suicides in AN and BN. Higher completed suicide rates in AN in spite of equivalent or lower rates of SA compared to BN may at least partially be explained by AN patients' higher desire to die and their more severe attempts. Our findings are congruent with those from a case series of nine completed suicides in AN patients which found that the majority of these deaths were caused by use of methods with low rescue potential and high likelihood of death (e.g. jumping in front of a train or hanging) [24] . This suggests that deaths from suicide in AN are not usually the result simply of their greater physical frailty compared to other suicide attempters.

We can only speculate on the mechanisms underlying the greater seriousness of AN patients' suicide attempts. Recent theories of suicidal behavior such as the Interpersonal-Psychological theory of suicidal behavior [25] or the Stress-Diathesis model of suicidal behavior [16] may help to understand the higher lethality of SA in AN compared to other suicide attempters. Joiner's theory posits that in general suicide results when three factors combine: (a) a feeling of being alone and not belonging; (b) a sense of being a burden to others, and (c) an acquired ability to endure pain. AN is a chronic and often severe disorder with poor quality of life, social isolation, loneliness and burdensomeness to self and others [26] , [27] . Increased ability to endure pain arises through either extreme food restriction or regular exposure to behaviors such as vomiting, laxative abuse and self-injury [23] . The unique interplay between these predisposing social evaluative and physical factors in people with AN may explain the greater seriousness of SA in this group compared to other suicide attempters. In terms of Mann's stress diathesis model, previous studies in ED have shown that attempts are linked with factors known to increase diathesis to suicidal behavior in general [16] , such as impulsive [11] and anxious personality traits [10] , [28] , [29] or childhood trauma, such as sexual abuse [13] . Unique stressors triggering SA in AN may be starvation related increases in depressive symptomatology and associated cognitive impairments. Unfortunately, we did not assess patients' BMI patients at the time of their SA, but this latter suggestion is supported by the fact that in our sample lowest BMI since ED onset correlated with the belief that the SA would cause death and the intensity of suicidal ideation before the attempt. Moreover, we found that previous hospitalization, i.e. a marker of clinical severity of the ED was associated with severity of SA.

In this context, a particular finding was that whilst patients with a history of hospitalization for an ED had a higher lifetime history of a serious SA than those without hospitalization, they also had a higher likelihood of rescue during their most severe attempt. One potential explanation is that this reflects greater willingness to seek help amongst this subgroup.

Another important factor that might be at play is psychiatric comorbidity. Until now, most of the studies focusing on SA in ED have studied characteristics of ED with or without history of SA. One of the stronger correlates of SA usually found is psychiatric comorbidity (particularly mood disorders). The literature suggests that bipolar depressive patients have a much higher risk of completed suicide [30] and a higher rate of suicide attempts [31] than unipolar ones. Although the difference between major depressive disorder and bipolar disorder among our AN and BN patients is not significant, AN patients had higher rate of bipolar disorder and BN patients had higher rate of major depressive disorder. These differences in term of mood disorders comorbidity rates may also play a role in the greater seriousness of AN patients' suicide attempts.

Our study has considerable methodological strengths. The sample is reasonably large given the low prevalence of disorders like AN. The patients were carefully assessed using structured and well-validated instruments. The control group was matched in term of sex, age and education. Furthermore, to the best of our knowledge, this study is the first to assess SA characteristics in different ED among a sample of suicide attempters.

Limitations

Limitations include firstly, that we did not assess patients' BMI patients at the time of their SA. This prevents us from determining how BMI relates to risk of SA. We also cannot exclude the possibility that the higher lethality of the SA in the anorexic sample was a consequence of a poorer physical state. Against this is the fact that AN patient reported having a high expectation of dying before their attempt. The expectation that one will die as a result of the SA, might be a better index of the seriousness of a SA than medical severity [32] because attempters are often unaware of the potential lethality of a drugs or a method. Secondly, SA was assessed retrospectively. However, it is unlikely that ED and controls patients would differ in their degree of recall bias for the variables examined. Thirdly, we did not assess comorbid personality disorders. Lastly, we studied only those patients who were admitted to our unit (the only one dealing with suicide attempters in the area) after an initial assessment in one of several emergency rooms of the city. Thus, we did not include (and have no information) on patients who were discharged after initial assessment and treatment in the emergency room. Hence, our results are generalisable to patients admitted to a specialized unit following a suicide attempt.

Higher completed suicide rates in AN in spite of equivalent or lower rates of SA compared to BN may at least partially be explained by AN patients' higher desire to die and their more severe and lethal attempts. Clinicians need to be alert to the high risk of lethal SA among patients with current or past AN. A careful and repeated evaluation of suicidal risk in these patients could improve the early detection and treatment of suicidal behavior. Recent data suggest an elevated suicide rate in EDNOS patients [7] . Our study did not include people with EDNOS, but future studies should focus on this patient group. Future studies should also focus on developing a better understanding of the mechanisms which specifically increase the suicide risk in AN.

Competing Interests: The authors have declared that no competing interests exist.

Funding: This study received financial support from CHU Montpellier (PHRC UF 7653, Ph Courtet PI) and Agence Nationale de la Recherche (ANR NEURO 2007 “GENESIS”, Ph Courtet PI). S. Guillaume received a grant from l'Institut Servier. Ulrike Schmidt is supported by the NIHR Biomedical Research Centre for Mental Health, South London and Maudsley NHS Foundation Trust and Institute of Psychiatry, King's College London and by a National Institute of Health (NIHR) Programme Grant for Applied Research (Reference number RP-PG-0606-1043). The views expressed herein are not necessarily those of the NHS, the NIHR or Department of Health. All authors report no financial relationships with commercial interests. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.