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• To increase your knowledge of the physical and psychological effects of anorexia nervosa
• To recognise the challenges of providing care to patients with anorexia nervosa in acute hospital settings
• To enhance your ability to deliver psychologically informed care to patients with anorexia nervosa
Anorexia nervosa is a challenging and highly distressing illness associated with significant and often debilitating symptoms that affect the person’s physical and mental well-being, as well as their wider social networks. Although some patients can make important steps in their recovery in the community, many will become significantly unwell and require medical stabilisation and refeeding in an acute medical ward as a result of significant weight loss. This article describes some of the challenges experienced by adult nurses when caring for patients with anorexia nervosa on acute medical wards and explores how the patient’s distress may manifest and complicate the recovery process. The article also discusses the principles of psychologically informed care and therapeutic interactions that nurses can use to promote recovery and ensure optimal practice.
Nursing Standard. doi: 10.7748/ns.2023.e12199
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Purvis F, Snowden J (2023) Psychologically informed care of patients with anorexia nervosa on an acute medical ward. doi: 10.7748/ns.2023.e12199
Published online: 28 December 2023
Eating disorders are distressing and challenging illnesses that can affect people of all ages and backgrounds, although they are much more common in women than in men (Galmiche et al 2019). They often have profound effects on individuals and families, disrupting their social, psychological, physical and occupational functioning. The most common eating disorders are anorexia nervosa, bulimia nervosa and binge eating disorder (Hay et al 2017).
It is challenging to determine the number of people with an eating disorder accurately due to the likelihood of underreporting. However, a meta-analysis by Galmiche et al (2019) identified that the lifetime prevalence rates for eating disorders worldwide were 8.4% for women and 2.2% for men. For anorexia nervosa, prevalence was around 1.4% in women and 0.2% in men, with a significant increase over the past two decades (Galmiche et al 2019). However, the 2019 Health Survey for England (NHS Digital 2020) identified that 16% of adults surveyed screened positive for a possible eating disorder, revealing the potential scale of the issue. The prevalence of eating disorders has also likely increased as a result of the coronavirus disease 2019 (COVID-19) pandemic (Taquet et al 2022), due to factors such as social isolation and changes to people’s routine and structure (Touyz et al 2020, Brown et al 2021).
Eating disorders often start in adolescence, with one study suggesting that onset began before the age of 22 years in 75% of cases (Volpe et al 2016). Of the 24,300 hospital admissions in England in 2020-23 due to eating disorders, almost half (11,700) were young people under the age of 25 years (Children’s Commissioner 2023). Eating disorders are also associated with a high mortality rate, with a nine times greater risk of death at five years among those with anorexia nervosa compared with their peers without the condition (Auger et al 2021), emphasising the need to optimise treatment outcomes for those affected.
• People with anorexia nervosa may require admission to an acute medical ward in the event of significant deterioration to prevent loss of life
• The priority in acute medical wards is safe refeeding and weight restoration, but nurses also have an important role in supporting patients’ day-to-day care
• Nurses should be aware of the psychological symptoms patients may present with and how these can affect their response to treatment
• Nurses can take several approaches to providing effective psychologically informed care to patients with anorexia nervosa in the acute medical ward
Anorexia nervosa is characterised by a person’s drive to restrict their energy intake relative to their body’s physical requirements, leading to a significantly low body weight in the context of their age, sex, developmental trajectory and physical health (American Psychiatric Association 2022). The individual will also likely present with a strong preoccupation with their weight and body shape, typically an overvaluation of these which is likely to cause them significant distress (Fairburn et al 2008, Mitchison et al 2017).
Alongside the drive for thinness, the individual may often find it challenging to recognise how unwell they have become. This is often coupled with demonstrating significant body image distortion and dissatisfaction, which perpetuates the cycle of disordered eating and weight loss through the negative mood states it generates (Mitchison et al 2017). Many individuals who experience menstruation will notice that this will cease (amenorrhea). Although this symptom is no longer diagnostic, it suggests significant physical health risks and impairment in functioning when combined with low body weight (Lopes et al 2022).
Symptoms such as binge eating and compensatory behaviours, for example purging and laxative use, are often evident in eating disorders such as bulimia nervosa and binge eating disorder. In anorexia nervosa, these symptoms may or may not be present alongside low weight. For many people who initially had a restrictive form of anorexia, bingeing and purging symptoms can become apparent over time (Serra et al 2022).
While multifactorial in its aetiology, the development of anorexia nervosa is likely related to a complex and interlinked series of biological, psychological and social risk factors. For many people, certain focuses and pressures in society have a significant role in the development of their eating disorder; for example, social comparisons and the ‘thin/fit ideal’ are prevalent on social media platforms, which may influence body image perceptions (Dane and Bhatia 2023).
The course of anorexia nervosa can be highly variable, with recovery possible at any stage; however, the risk of relapse and enduring illness often remains high for many people (National Institute for Health and Care Excellence (NICE) 2019). When diagnosed at an early stage, recovery outcomes are more favourable (Treasure et al 2015), however recovery rates remain modest, estimated at between 13-50% after 1-2 years (Wonderlich et al 2020). Recovery is likely to be complicated by the effects of social stigma, as there are many misconceptions about the presentation and causes of eating disorders (Schaumberg et al 2017); such stigma has led some individuals to delay seeking help for their symptoms (Ali et al 2017).
Outpatient psychological therapy is the preferred first-line treatment for anorexia nervosa; however, many people are unable to access this in a timely manner since the process of seeking help for onward referral and accessing a specialist service can take several years (Austin et al 2021). This delay may contribute to deterioration of the person’s symptoms (Vall and Wade 2015). A lack of training for GPs in the core knowledge about eating disorders may also act as a barrier to timely identification of the early signs of these illnesses and to individuals accessing treatment (Beat 2023).
Many people with anorexia nervosa will need more intensive treatment, such as day patient care, admission to a specialist eating disorder unit or admission to an acute medical ward in the event of significant deterioration to prevent loss of life (Treasure et al 2021). In accordance with NICE (2020) guidelines, this should be to an age-appropriate setting and in a hospital as close to the person’s home as possible. In a specialist eating disorder unit, treatments are likely to combine weight restoration and psychological therapies and support, whereas medical stabilisation, safe refeeding and weight restoration will be prioritised in an acute medical ward.
Given the rise in admissions and physical complications associated with anorexia nervosa (NHS Digital 2022), attention has focused on the safe care and management of patients presenting with an urgent need for refeeding in acute medical hospitals. In some cases, the care of patients with anorexia nervosa has been found to be suboptimal, often due to the complex nature of the illness and concerns about refeeding complications, which can be fatal (Staab et al 2022).
Failings in the care of patients with eating disorders were highlighted in the Parliamentary and Health Service Ombudsman (2017) report on the case of Averil Hart, a patient with anorexia nervosa who died in 2012 of hypoglycaemia in what was considered a preventable death. The report identified serious shortcomings in communication and coordination between services and emphasised the importance of appropriate training for healthcare professionals.
These concerns have been addressed in the Managing Medical Emergencies in Eating Disorders guidance (Royal College of Psychiatrists 2023), which seeks to support safe practice by outlining clearer physical parameters indicating severity of medical risk. The guidance includes a risk assessment framework and accessible checklists to ensure that acute medical risk is identified early and acted on.
While the patient should always be considered an active participant in their recovery, at this stage in their treatment it is possible that high levels of ambivalence may preclude their ability to make the behaviour changes that would be expected in most psychological therapies (Gulliksen et al 2015). Although the priority must be safe refeeding and weight restoration in acute medical wards (Attia and Walsh 2023), nurses have an important role in supporting day-to-day care while patients recover enough physically to access specialist mental health interventions.
The acute medical ward environment is fast-paced and often not designed optimally to monitor patients with eating disorders whose physical health is severely compromised (Royal College of Psychiatrists 2023). Due to the nature of the ward environment, patients who engage in compensatory behaviours can often do so successfully, which can lead to significant deterioration if they avoid weight restoration. This deterioration and potential risk of death is preventable; however, in this environment it is highly challenging for healthcare staff to constantly monitor these patients’ mealtimes, periods off the ward and visits to the bathroom (Royal College of Psychiatrists 2023).
Patients with anorexia nervosa who are admitted to an acute medical ward need to be weighed frequently and assessed on this. However, due to the busy environment, it can be challenging for nurses to provide adequate psychological support during this emotive task. As a result, patients may feel distressed because of the continual emphasis on their appearance while neglecting their internal emotions (Eiring et al 2021).
In addition, there is a significant link between eating disorders and neurodiversity (Westwood et al 2017, Kerr-Gaffney et al 2021). Research has demonstrated a higher prevalence of autism in individuals receiving treatment for anorexia nervosa and many autistic women experience prolonged eating disorder symptoms (Saure et al 2020). Furthermore, inpatient settings can present challenges for autistic women due to the high-stimulus environment and the need to adapt to new routines as part of their care (Babb et al 2021). An awareness of the needs of this group is important to support implementation of tailored treatments that could improve recovery outcomes (Tchanturia et al 2019).
Despite clearer guidance on the care of patients with eating disorders in medical emergencies (Royal College of Psychiatrists 2023), there remain many challenges for nurses in caring for patients with anorexia nervosa on acute medical wards. A particular challenge is how to support the recovery process in patients experiencing an insidious and challenging illness that often seeks to undermine the life-saving care plans implemented by the multidisciplinary team (Fixsen et al 2023).
From a psychological perspective, an intense anxiety related to weight gain likely underlies a patient’s presentation, but this can present in different ways. For example, in the authors’ clinical experience, many individuals will demonstrate a high level of treatment adherence but will be internally terrified at the prospect of change and weight gain and may turn their distress and turmoil inwards, perhaps resulting in self-harm behaviours. Evidence shows that up to 72% of people with eating disorders also engage in self-harm behaviours, particularly those with a binge-purge element to their illness (Kostro et al 2014, Sagiv and Gvion 2020).
Conversely, other patients with anorexia nervosa may be experiencing feelings of desperation and low motivation to recover and may perceive benefits of continuing to restrict their energy intake. As a result, they may become overtly distressed and even aggressive towards those treating them, seeking to undermine treatment – for example, by declining oral food and supplements or covertly tampering with or purging nasogastric feeds (Kells and Kelly-Weeder 2016). Individuals may also seek to influence others to inadvertently collude with their illness to interfere with their treatment plan, in an attempt to satisfy their drive for thinness and control (Kells and Kelly-Weeder 2016).
It is important that nurses are aware of the psychological symptoms that the patient may present with and understand how these symptoms could affect their response to treatment. For example, a distorted body image, compounded by the effects of starvation on the brain, might mean that the patient feels unable to agree to life-saving treatment, such as refeeding, and their anxiety associated with weight gain might manifest as panic attacks and episodes of high expressed emotions (Royal College of Psychiatrists 2023). The patient may also feel a sense of achievement when they lose more weight, despite already being gravely unwell.
Some patients who are undergoing refeeding may attempt to compensate for the increase in oral or nasogastric intake through potentially harmful means, such as taking laxatives, diuretics or diet pills they may have brought in from home. Furthermore, some patients may induce vomiting or exercise in a covert way in an attempt to lose calories (Royal College of Psychiatrists 2023).
The presentation of anorexia nervosa may be complicated further by the presence of mood disorders such as depression, which often originates from a combination of psychological and physical factors that may be pre-morbid and/or related to the eating disorder (Godart et al 2007). Anorexia nervosa may give rise to self-harm behaviours and suicidal ideation, as well as cognitive deficits such as memory issues and low concentration (Smith et al 2018). This can complicate the process of orienting a patient to their treatment plan or may mean they find it challenging to understand certain ward routines.
Caring for someone with anorexia nervosa can be challenging and highly stressful, even for experienced and specialised teams. Nurses strive to care compassionately and to collaborate with patients to achieve shared goals and outcomes. However, when the person does not agree with their care plan, or if this is being enforced in their best interests under the Mental Health Act 1983 (amended 2007), then significant challenges can arise, including fractures in the therapeutic relationship and the healthcare team.
There are several approaches nurses can take to provide effective psychologically informed care to patients with anorexia nervosa who have been admitted to an acute medical ward.
Arguably one of the most significant challenges for people with mental illness is the associated stigma. Some healthcare professionals hold stigmatising beliefs about eating disorders, for example attributing blame to the individual and feeling that they are at least partly responsible for their illness (McNicholas et al 2016). Such beliefs may be driven by healthcare professionals’ lack of knowledge and/or confidence in caring for this patient group due to limited experience or training, which may lead to fear or avoidance. Stigma may compound the shame and isolation that the individual feels due to their self-stigmatisation, thus reinforcing the negative symptoms of the illness and adversely affecting their longer-term recovery (Foran et al 2020).
To address stigma, it is important that nurses use a non-judgemental approach when supporting patients with an eating disorder and recognise and reflect on any pre-existing biases or judgements they might have about these illnesses. Supervision and oversight of the individual’s overall care from an adult community eating disorders service, in collaboration with the mental health liaison team, can also be beneficial.
Communication with patients can be challenging and might be intensified by a sense of mutual distrust between the nurse and the patient. Communication can be further complicated when the patient is subject to restrictions under the Mental Health Act 1983 (amended 2007) and nurses may be unsure about whether honesty and clarity in terms of divulging treatment plans is likely to be helpful or perceived as inflammatory. In the context of healthcare environments such as acute medical wards, which can be highly stressful and emotionally demanding for patients receiving treatment for anorexia nervosa, communication is likely to become increasingly fraught (Yorke et al 2018). Therefore, it is vital to recognise the likely effects of starvation on the patient’s cognitive function, understand their underlying emotions and acknowledge that they may currently feel ambivalent about change.
Even if the patient requires treatment under the Mental Health Act 1983 (amended 2007), it is essential that nurses work collaboratively with them and their family and are clear about treatment and recovery goals to ensure the patient feels they are being treated as an equal and active participant in their care (Sly et al 2014). Weight restoration is often a highly sensitive area, but keeping conversations out in the open can dissuade the secretive aspect of the illness and establish clear expectations and boundaries. The patient may feel relieved to have responsibility over the agonising decision to eat taken from them, and may find that a calm, clear and honest communication style assists in developing a trusting relationship (Salzmann-Erikson and Dahlén 2017). In the authors’ clinical experience, it is preferable to sidestep conversations about calories, specifics of weight gain and body image and to focus instead on the underlying emotion or more neutral topics.
While the nurse may wish to provide reassurance – for example, about the patient’s weight or appearance – the relief the patient may experience in response can be short lived, and the nurse may inadvertently collude with or reinforce eating disorder cognitions (Treasure et al 2011). Talking about interests outside of their eating disorder and engaging patients in meaningful activities while on the ward is likely to have a greater therapeutic effect (Snowden and Gelling 2022). Even having simple conversations and encouraging the use of distraction techniques can be beneficial at particularly challenging or distressing times for the patient, such as during and after mealtimes (Monaghan and Doyle 2023). Any attempts to enhance the therapeutic relationship when the patient is in distress can have a positive effect on treatment outcomes (Sly et al 2013), thus supporting their recovery.
When supporting a patient to engage with refeeding and the associated physical health monitoring, it is vital to provide as much psychological support as possible to improve adherence and optimise recovery. Nurses can find it particularly frustrating when the patient appears ambivalent about behaviour change (Tierney 2008), which may tempt the nurse to enter into a ‘battle of wills’ or to try to convince the patient with reasoning.
When the risk to life is severe, physical restraint may need to be used with an individual who is so unwell they are compelled to tamper with or decline nasogastric feeding. Due to the risk of harm associated with restraint, it should be undertaken only as a last resort for the least time possible and under the Mental Health Act 1983 (amended 2007), to ensure that all safeguards are adhered to and that other supportive techniques are used first. Restraint should also be planned and managed with mental health liaison teams. These teams are usually based in the hospital and comprise specialist practitioners, such as mental health nurses, psychologists and psychiatrists. Mental health liaison teams are well placed to support and inform care planning from a psychological perspective and with an understanding of how eating disorders may manifest and the physical complications of the illness (Royal College of Psychiatrists 2023).
Supportive techniques to encourage the patient to feel empowered in relation to their treatment should be prioritised. This might involve education on the effects of starvation and the rationale for refeeding, undertaken in collaboration with specialist dietitians, and discussing the risks associated with compensatory behaviours (Attia and Walsh 2023). It may be helpful for some patients to conceptualise oral or nasogastric food intake as ‘medicine’, which nurses can encourage if appropriate. At times of feeds, nurses can provide support by validating the patient’s effort and acknowledging their difficulties so that they feel heard and understood. These meaningful interactions can also encourage a sense of connection and foster feelings of hope, which may reduce the emotional distress and suicidal ideation a person may experience from feeling they are ‘a burden’ (Stavarski et al 2019).
Partnership working between the ward team, the mental health liaison team and specialist eating disorder services can support monitoring of the patient’s mental health and its effects on their physical health. This may be particularly useful to enhance the ward team’s understanding of the complexities of anorexia nervosa and how it may be manifesting for patients on the ward. Additionally, collaboration can support the ward team to understand and manage risks related to physical deterioration, for example if the patient is still losing weight, which may not be immediately explainable.
When a person is admitted to an acute medical ward for medical stabilisation, it is best practice for their family and carers to be involved in their care, to have a clear care and management plan across all services and to support their transition to appropriate settings, such as a specialist eating disorder unit, as part of their recovery (NICE 2018).
Caring for patients with anorexia nervosa in an acute medical ward can be highly emotive, stressful and challenging for nurses. Complications can arise when the patient is unable to agree to life-saving care due to their illness, thus complicating the dynamic between the nurse and patient and potentially preventing provision of optimal care. Knowledge of the medical risks and psychological effects commonly experienced by patients with anorexia nervosa is essential when caring for this group. To support patients’ recovery, nurses should adopt a calm, empathic and non-judgemental approach. In addition, communicating directly and honestly and attempting to maintain a therapeutic relationship with the patient can enhance the quality of care provided and improve treatment outcomes.
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