Anorexia nervosa is a critical eating disorder characterized by an abnormally low body weight, an overwhelming fear of weight gain, and distorted body image, leading to severe calorie restriction and behaviors to prevent weight gain. This potentially life-threatening condition requires prompt recognition and appropriate treatment to mitigate long-term health consequences.
Understanding Anorexia Nervosa
Anorexia nervosa is a recognized psychiatric disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It frequently occurs alongside other mental health conditions, including anxiety disorders, depression, and substance use disorders.
Anorexia nervosa is typically categorized into two subtypes:
- Restricting Type: Characterized by severe calorie restriction, often accompanied by excessive exercise, without engaging in binge eating or purging behaviors.
- Bingeing/Purging Type: Involves episodes of binge eating followed by compensatory purging behaviors such as self-induced vomiting or misuse of laxatives, diuretics, or enemas.
Due to the body being deprived of essential nutrients, anorexia nervosa can severely impact every organ system. Early intervention is essential to prevent serious and long-term health problems such as heart failure, kidney dysfunction, and osteoporosis.
Anorexia nervosa has a significant mortality rate and a challenging remission rate. Treatment is often complex due to the patient’s potential denial or lack of acknowledgment of their eating disorder. Treatment goals are centered on weight stabilization and restoration, eliminating restrictive and compensatory behaviors, addressing underlying psychological issues, and fostering sustainable long-term changes in behavior and thought patterns.
The Nursing Process in Anorexia Nervosa Care
Nurses play a crucial role in the care of patients with anorexia nervosa across various healthcare settings. In medical settings, nurses may encounter these patients admitted for complications like electrolyte imbalances, cardiac arrhythmias, and severe malnutrition. Psychiatric nurses are also involved in caring for patients with anorexia nervosa, particularly in cases involving suicide attempts, depression, and anxiety. Nursing care focuses on vigilant monitoring, management of medical complications, cautious and gradual refeeding strategies, and the implementation of intensive psychological therapy.
Nursing Assessment for Anorexia Nervosa
The initial step in providing nursing care is a comprehensive nursing assessment. This involves gathering subjective and objective data encompassing the patient’s physical, psychosocial, emotional, and diagnostic aspects.
Review of Health History
1. Patient and Family Interviews: Conduct thorough interviews with the patient and their family or support system. Ask targeted questions designed to uncover signs and symptoms of disordered eating. It is important to note that many individuals with anorexia nervosa may be in denial about their condition or unaware of its severity. Often, medical attention is sought due to concerns raised by family members.
2. Identifying Presenting Complaints: Assess for common complaints reported by individuals with anorexia nervosa, such as:
- Difficulty concentrating
- Headaches
- Irritability
- Constipation
- Dizziness
- Fatigue
- Amenorrhea (absence of menstruation)
3. Weight History Tracking: Carefully document the patient’s weight history. Anorexia nervosa is defined by significantly low body weight, an intense fear of gaining weight, and a distorted perception of body weight. Note any significant weight fluctuations or patterns of weight loss.
4. Eating Behavior Assessment: Elicit descriptions of the patient’s eating behaviors from both the patient and their family. Patients with anorexia nervosa may develop ritualistic behaviors around food, such as obsessive calorie counting, hoarding or hiding food, or refusing to eat certain foods or entire food groups. Family members might report observing behaviors like frequent bathroom visits immediately after meals, dishonesty about food intake, or discovery of laxatives or diuretics.
5. Activities for Weight Loss: Inquire about methods the patient employs to lose weight, which may include:
- Fasting or extreme calorie restriction
- Excessive exercise regimes
- Self-induced vomiting (purging)
- Misuse of laxatives, enemas, diet pills, appetite suppressants, or herbal weight loss remedies.
6. Perceptions of Appearance: Explore the patient’s beliefs and perceptions about their body appearance. Individuals with anorexia nervosa often perceive themselves as overweight, even when severely underweight. They may fixate on perceived “fat” areas and persistently seek weight loss despite reassurance from others.
7. Peer Influence Assessment: For children and adolescents, assess the role of peer pressure. Peer influence can be particularly potent in young individuals, and weight control may be seen as a means of social acceptance. Social media also significantly influences perceptions of attractiveness, often promoting thinness, dieting, and excessive exercise.
8. Mental Illness History: Document any personal or family history of mental illness. There is a recognized genetic component to anorexia nervosa. Individuals with a female relative who has had anorexia nervosa are at a heightened risk. Many patients also present with co-existing psychiatric disorders or have a family history of mental illness. Monitor for conditions such as anxiety disorders, major depressive disorder, or obsessive-compulsive disorder.
9. Trauma History: Assess for a history of trauma, including physical, emotional, or sexual abuse. Traumatic experiences can contribute to body image issues and eating disorders in some individuals, with disordered eating potentially serving as a maladaptive coping mechanism.
10. Emotional State Evaluation: Evaluate the patient’s emotional state. Patients with anorexia nervosa are often highly self-critical and have a strong need for control. They may withdraw from social interactions with friends and family. Nurses should specifically assess for suicidal thoughts, as suicide is a leading cause of mortality in anorexia nervosa.
11. History of Disordered Eating: Explore any past history of disordered eating. Anorexia nervosa shares similarities with other eating disorders. Avoidant/Restrictive Food Intake Disorder (ARFID), for instance, can occur in children and involve extreme picky eating or lack of interest in food, potentially progressing to anorexia nervosa. Other eating disorders to consider include bulimia nervosa, binge eating disorder, pica, and rumination disorder.
12. Predisposing Factors: Identify predisposing factors for anorexia nervosa, which is more prevalent in:
- Females
- Adolescents (typically with onset between 13 and 18 years of age)
- Caucasians (over 95% of cases)
- Individuals with perfectionistic personality traits
- Patients who have difficulty expressing emotions
- Patients with challenges in conflict resolution
- Patients with low self-esteem
- Patients whose mothers encourage weight loss
- Athletes in sports that emphasize leanness, such as gymnastics, dance, and long-distance running.
Alt text: A concerned parent is discussing healthy eating habits with their teen at home, highlighting the importance of open communication and support in addressing potential eating disorders.
Physical Assessment
1. Comprehensive Physical Examination: Perform a thorough physical assessment to identify complications of anorexia nervosa that can affect multiple body systems. Physical signs may include:
- Thinning and brittle hair and nails
- Lanugo (fine, downy hair covering the body)
- Edema (swelling, particularly in ankles and feet)
- Stomach pain or bloating
- Cold hands and feet
- Breast atrophy (reduction in breast tissue)
- Loss of muscle mass
- Cardiac arrhythmias
2. Signs of Purging Behaviors: Observe for physical indicators of purging activities:
- Dental enamel erosion
- Parotid gland enlargement (swelling of salivary glands)
- Esophagitis (inflammation of the esophagus)
- Gastrointestinal bleeding
- Russell’s sign (calluses on the knuckles of the hand used to induce vomiting)
3. Vital Signs Monitoring: Monitor vital signs closely. Patients with anorexia nervosa may exhibit orthostatic hypotension, bradycardia, and hypothermia due to inadequate caloric intake and metabolic changes.
4. Height and Weight Measurement: Accurately measure the patient’s height and weight to calculate Body Mass Index (BMI) and evaluate treatment progress. Patients with anorexia nervosa typically present with a significantly low BMI.
5. SCOFF Questionnaire: Utilize the SCOFF questionnaire as a screening tool to assess the likelihood of an eating disorder. The SCOFF questions are:
- Do you make yourself Sick because you feel uncomfortably full?
- Do you worry you have lost Control over how much you eat?
- Have you recently lost more than One stone (14 pounds) in a 3-month period?
- Do you believe yourself to be Fat when others say you are too thin?
- Does Food dominate your life?
Answering “yes” to two or more SCOFF questions suggests further investigation for a potential eating disorder.
Diagnostic Procedures
1. Blood Tests: Order blood tests to evaluate for medical complications of starvation and guide treatment. Common tests include:
- Complete blood count (CBC)
- Complete metabolic profile (CMP)
- Urinalysis
- Renal function panel
- Liver function tests
- Thyroid-stimulating hormone (TSH)
- Hormone tests (including testosterone levels)
2. Cardiovascular Assessment: Assess cardiovascular status due to the high risk of cardiac complications in anorexia nervosa, which are a leading cause of morbidity and mortality. Obtain an electrocardiogram (ECG) to detect potentially life-threatening arrhythmias.
3. Further Testing: Initiate further diagnostic testing as clinically indicated to investigate specific complications, which may include:
- Drug testing for substance abuse (illegal and prescription drugs)
- Chest X-ray to assess for esophageal damage from vomiting or aspiration pneumonia
- Bone density tests (DEXA scan) to evaluate for osteoporosis or osteopenia
- Serum vitamin D levels
- Fecal occult blood test to assess for gastrointestinal trauma from laxative abuse
Nursing Interventions for Anorexia Nervosa
Effective nursing interventions are crucial for the recovery of patients with anorexia nervosa.
1. Inpatient Care Considerations: Anticipate the need for inpatient hospitalization for patients with anorexia nervosa who are severely malnourished or at high psychological risk. Indications for hospital admission include:
- Significant weight loss or failure to gain weight
- Presence of significant edema
- Vital sign instability (marked alterations in heart rate, blood pressure, temperature)
- Severe electrolyte imbalances
- Cardiac disturbances (arrhythmias)
- Acute medical disorders complicating anorexia
- Altered mental status or cognitive impairment
- Psychosis
- High suicide risk
- Lack of adequate social support system
- Limited access to outpatient treatment
- Non-adherence to outpatient treatment or persistent purging behaviors
2. Continuous Monitoring: In the inpatient setting, nurses must closely monitor:
- Vital signs for orthostatic changes, bradycardia, or hypothermia
- ECG for cardiac arrhythmias
- Laboratory values for electrolyte imbalances
- Fluid intake and output to assess hydration status and kidney function
3. Pharmacological Interventions: Consider medication use when appropriate.
- Olanzapine: Often considered the first-line medication for patients who do not respond adequately to initial care. It can help with weight gain and reduce obsessive thoughts about weight and body image.
- Selective Serotonin Reuptake Inhibitors (SSRIs): May be prescribed to treat co-occurring conditions such as anxiety disorders or major depressive disorder, often after some weight restoration.
Note: Tricyclic antidepressants (TCAs) are generally avoided due to the risk of cardiotoxicity, particularly in malnourished individuals. Bupropion is contraindicated in patients with eating disorders due to the increased risk of seizures.
4. Refeeding Protocol: Initiate refeeding as a critical component of anorexia nervosa treatment. Refeeding involves gradually increasing caloric intake to achieve a healthy weight. It must be done cautiously to prevent refeeding syndrome, a potentially fatal condition involving dangerous fluid and electrolyte shifts that can occur when a severely malnourished body is refed too rapidly. Close collaboration with a registered dietitian is essential. Oral feedings are preferred, but nasogastric or intravenous tube feedings may be necessary for severely underweight patients.
5. Bone Health Management: Implement strategies to prevent bone disorders like osteoporosis, common in anorexia nervosa.
- Encourage calcium and vitamin D supplementation.
- Estrogen replacement therapy (e.g., oral contraceptives) may be considered to treat osteopenia, particularly in females with anorexia nervosa.
6. Safety Precautions: Implement safety precautions due to the increased risk of self-harm and suicide in patients with anorexia nervosa. Maintain a safe environment and monitor for suicidal ideation and behavior.
7. Psychotherapy Initiation: Psychotherapy is a cornerstone of treatment for eating disorders.
- Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are frequently used and effective forms of psychotherapy.
- Family-based therapy (FBT) is essential for adolescents with anorexia nervosa, involving the family in the refeeding process and addressing family dynamics that may contribute to the disorder.
- Outpatient psychotherapy should continue for at least a year after weight restoration to address underlying psychological issues and prevent relapse.
8. Activity Restriction: Limit excessive exercise and physical activity to reduce energy expenditure and promote weight gain. Recognize that exercise may be a maladaptive coping mechanism and offer alternative activities like journaling or creative arts.
9. Progress Monitoring: Close monitoring of progress is essential to ensure weight and health are maintained and to detect any relapse into unhealthy eating patterns. Regular follow-up appointments are necessary.
10. Patient and Family Support: Provide ongoing support and education to both the patient and their family. Use active listening and demonstrate empathy in all communications. Avoid making comments about the patient’s weight or appearance, whether positive or negative. Instead, focus on their strengths, progress in therapy, and overall well-being.
Alt text: A nurse is educating a patient about healthy eating habits and balanced nutrition, providing support and guidance for recovery from an eating disorder.
Nursing Care Plans for Anorexia Nervosa
Once nursing diagnoses are identified, nursing care plans are developed to prioritize assessments and interventions to achieve both short-term and long-term care goals. Common nursing diagnoses for anorexia nervosa and associated care plan examples include:
Deficient Fluid Volume
Patients with anorexia nervosa may develop deficient fluid volume due to restricted fluid intake and purging behaviors aimed at weight control.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- Purging behaviors (self-induced vomiting, laxative, or diuretic misuse)
- Insufficient fluid intake
- Extreme food and fluid restriction
As evidenced by:
- Altered skin turgor
- Decreased blood pressure (hypotension)
- Decreased urine output
- Dry skin
- Dry mucous membranes
- Thirst
- Weakness
- Tachycardia (rapid heart rate)
- Increased hematocrit
Expected outcomes:
- Patient will maintain blood pressure, temperature, and heart rate within normal limits for age.
- Patient will exhibit improved hydration status as evidenced by normal skin turgor and moist mucous membranes.
Assessment:
- Hydration Status Assessment: Evaluate hydration status by reviewing hematocrit, electrolyte levels, urinalysis, and renal function tests for indicators of fluid volume deficit.
- Vital Signs and Capillary Refill: Monitor vital signs, including blood pressure, heart rate, and capillary refill, for signs of dehydration. Hypotension, tachycardia, bradycardia, and delayed capillary refill can indicate decreased circulating volume.
- Purging Behavior Assessment: Assess for any history of purging behaviors, as these directly contribute to fluid loss and electrolyte imbalances.
- Symptoms of Deficient Fluid Volume: Inquire about subjective symptoms such as headache, dizziness, fatigue, and difficulty concentrating, which may indicate hypovolemia.
Interventions:
- Intake and Output Monitoring: Implement strict intake and output monitoring, especially in inpatient settings, to accurately assess hydration status and treatment adherence.
- Purging Behavior Prevention: Educate the patient about the ineffectiveness and dangers of purging behaviors for weight control, emphasizing that they primarily result in water loss and electrolyte imbalances, not fat loss. In outpatient settings, advise family members on strategies to monitor and prevent purging, such as bathroom supervision and checking for laxatives or diuretics.
- Fluid and Electrolyte Replacement: Administer intravenous fluids and electrolytes as prescribed to correct fluid deficits and electrolyte imbalances, reducing the risk of complications.
- Orthostatic Hypotension Monitoring: Monitor for orthostatic hypotension by assessing blood pressure in lying, sitting, and standing positions to detect significant drops indicative of hypovolemia.
Disturbed Body Image
Patients with anorexia nervosa suffer from a distorted perception of their body size and shape, leading to significant body image disturbance.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Mental health disorder (anorexia nervosa)
- Eating disorder psychopathology
As evidenced by:
- Expressing feelings of being fat despite being underweight
- Fear of negative evaluation by others related to their body
- Negative self-feelings about their body
- Feelings of hopelessness or powerlessness related to body image
- Self-harm behaviors related to body dissatisfaction
- Frequent body checking behaviors (e.g., mirror gazing, pinching areas of perceived fat)
- Obsessive weight checking
- Avoidance of eating in public due to body image concerns
Expected outcomes:
- Patient will verbalize more positive feelings about their body and self-perception.
- Patient will gradually participate in eating meals in social settings or in the presence of others.
- Patient will actively engage in therapy and psychological counseling to address body image distortions.
Assessment:
- Self-Description Assessment: Ask the patient to describe how they see themselves and how they believe others perceive them to gauge the extent of body image distortion.
- Negative Self-Talk Monitoring: Listen for and document negative self-talk and comments related to body image during conversations.
- Behavioral Observation: Observe behaviors related to body appearance, such as body checking rituals, attempts to conceal their body, or expressions of shame or disgust about their body.
Interventions:
- Cognitive Behavioral Therapy (CBT) Encouragement: Encourage participation in CBT, which is effective in improving body image by helping patients identify and modify dysfunctional thoughts, feelings, and behaviors related to their body.
- Therapeutic Nurse-Patient Relationship: Establish and maintain a therapeutic nurse-patient relationship based on trust, empathy, and acceptance. This is fundamental for addressing the sensitive issues related to body image and eating disorders.
- Co-morbidity Consideration: Recognize and address co-occurring mental health disorders, such as anxiety, depression, and personality disorders, as these can significantly impact body image and eating disorder symptoms.
- Media Literacy and Beauty Standards: Educate patients, especially adolescents, about unrealistic beauty standards portrayed in media and social media. Help them critically evaluate these messages and understand that these ideals are often unattainable and unhealthy.
- Suicidal Ideation Monitoring: Closely monitor for suicidal ideation and behavior, as severe body image dissatisfaction and hopelessness can increase suicide risk. Implement appropriate safety measures and mental health interventions as needed.
Imbalanced Nutrition: Less Than Body Requirements
Nutritional deficits are a hallmark of anorexia nervosa due to severe restriction of food intake and/or purging behaviors.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Eating disorder (anorexia nervosa)
- Limited food intake and calorie restriction
- Malnourishment and starvation
- Self-induced purging
- Excessive exercise expenditure
As evidenced by:
- Excessive weight loss and low BMI
- Fatigue and weakness
- Hair loss
- Brittle nails
- Dry skin
- Electrolyte imbalances
- Anemia
- Amenorrhea (loss of menstruation in females)
Expected outcomes:
- Patient will verbalize understanding of their nutritional needs for health and recovery.
- Patient will demonstrate gradual weight gain towards a healthy weight range, as evidenced by an increasing BMI (target BMI of at least 19, but individualized goals are crucial).
- Patient will adhere to dietary interventions and treatment recommendations.
Assessment:
- Weight and BMI Assessment: Determine current body weight and calculate BMI to assess the degree of underweight and nutritional deficit. Track weight changes over time.
- Nutritional Status Evaluation: Assess overall nutritional status through physical examination, dietary history, and laboratory tests (e.g., electrolytes, protein levels, albumin, prealbumin). Identify specific nutritional deficiencies.
- Eating Pattern Assessment: Obtain a detailed history of the patient’s eating patterns, including typical daily intake, food preferences and avoidances, meal frequency, and any disordered eating behaviors.
Interventions:
- Weight Goal and Nutritional Requirements: Establish a minimum weight goal with the patient and treatment team, focusing on health rather than an ideal weight. Determine individualized daily nutritional requirements in collaboration with a dietitian.
- Small, Frequent Meals: Initially, provide smaller, more frequent meals and snacks to ease re-introduction to food and prevent gastric distress. Gradual increase in meal size and frequency as tolerated.
- Selective Menu and Food Choices: Allow the patient some choices within a structured meal plan to increase feelings of control and autonomy. Offer a selective menu with nutritionally balanced options.
- Holistic Health Markers: Emphasize that weight is not the sole indicator of health. Monitor other markers of improved nutritional status and overall well-being, such as improved digestion, return of menses, increased energy levels, improved sleep, and mental stabilization.
- Parenteral Nutrition Consideration: Consider parenteral nutrition (TPN) if oral or enteral intake is insufficient to meet metabolic needs, particularly in severely malnourished patients or those with medical instability. Use TPN cautiously due to risks.
- Dietitian Consultation: Collaborate closely with a registered dietitian who is experienced in eating disorders. The dietitian provides specialized nutritional assessment, meal planning, and ongoing dietary support.
Ineffective Adolescent Eating Dynamics
This diagnosis addresses disordered eating patterns in adolescents, particularly in the context of anorexia nervosa.
Nursing Diagnosis: Ineffective Adolescent Eating Dynamics
Related to:
- Anxiety and depression
- Poor self-esteem
- Excessive stress
- Peer pressure and media influences
- Unhealthy dietary habits learned within the family
- History of abuse or trauma
- Negative parental influence on eating behaviors
As evidenced by:
- Depressive symptoms
- Avoiding participation in family mealtimes
- Food refusal or extreme picky eating
- Inadequate appetite
- Undereating and calorie restriction
- Episodes of overeating or binge eating (may or may not be present in anorexia, but relevant to broader eating dynamic issues)
Expected outcomes:
- Patient will establish and maintain healthier eating patterns, as demonstrated by regular meal consumption at appropriate times and adequate caloric intake for growth and development.
- Patient will achieve and maintain a BMI within a healthy range for their age and developmental stage.
Assessment:
- Nutritional Status and BMI Assessment: Assess the adolescent’s current nutritional status and BMI. Compare BMI to age- and gender-appropriate growth charts to determine underweight status.
- Psychological Disorder Screening: Screen for co-existing psychological disorders, particularly anxiety and depression, which are common in adolescents with eating disorders.
- Social Relationship Assessment: Assess the adolescent’s social relationships, peer interactions, and exposure to bullying or social pressures related to body image and eating.
- Eating-Related Goals: Explore the adolescent’s personal goals and beliefs related to eating, weight, and body appearance. Identify any distorted beliefs or unhealthy goals.
Interventions:
- Minimum Weight Goal and Nutritional Requirements: Establish a minimum weight goal and daily caloric intake requirements in collaboration with a dietitian and the adolescent (when appropriate), emphasizing health and recovery rather than ideal body shape.
- Meal Supervision: Supervise the adolescent during and after meals, as appropriate, to provide support, encouragement, and ensure adherence to the meal plan, especially in inpatient or residential settings.
- Family Meal Encouragement: Encourage family meals as a way to improve dietary intake, model healthy eating habits, and strengthen family relationships. Family meals should be a positive and supportive experience, not a source of stress or conflict.
- Family-Based Therapy (FBT) Referral: Refer the adolescent and family to family-based therapy (FBT), which is considered the gold standard treatment for adolescent anorexia nervosa. FBT empowers parents to take an active role in weight restoration and addressing family dynamics.
Risk for Impaired Skin Integrity
Nutritional deficits and dehydration in anorexia nervosa increase the risk of impaired skin integrity.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Alteration in nutritional state (malnutrition, vitamin deficiencies)
- Purging behaviors (effects of vomiting and laxative abuse)
- Emaciation and loss of subcutaneous fat
- Dehydration
As evidenced by:
- (Risk diagnoses are not evidenced by actual signs and symptoms, as the problem has not yet occurred. Evidence is based on risk factors.)
Expected outcomes:
- Patient will verbalize understanding of how poor nutrition and dehydration affect skin health.
- Patient will demonstrate preventive measures to maintain skin integrity and prevent skin breakdown.
- Patient will exhibit improvement in skin appearance and hair growth as nutritional status improves.
Assessment:
- Skin and Hair Assessment: Regularly observe the patient’s skin and hair for signs of poor nutrition, such as thinning hair with breakage, dry and brittle hair, thin and brittle nails, and dry, flaky, or itchy skin.
- Pressure Point Inspection: Inspect skin surfaces, particularly pressure points (e.g., elbows, heels, sacrum), for signs of redness, breakdown, or potential pressure ulcer development, especially in severely underweight and immobile patients.
Interventions:
- Bathing Frequency: Encourage bathing every other day rather than daily to prevent excessive drying of the skin. Use mild, non-drying cleansers and avoid scrubbing the skin vigorously.
- Skin Moisturizing: Instruct and assist the patient to use skin cream or lotion frequently, especially after bathing, to lubricate the skin and prevent dryness and cracking.
- Vitamin Supplementation: Encourage the intake of a balanced multivitamin, including biotin, which is often beneficial for hair and nail strength. Ensure adequate intake of vitamins A, C, and E, which are important for skin health.
- Position Changes and Pressure Relief: Educate the patient on the importance of frequent position changes, especially if mobility is limited due to weakness. Use pressure-relieving devices as needed to prevent pressure sores in bedridden or chair-bound patients.
- Fluid and Nutrition Education: Emphasize the importance of adequate fluid intake and proper nutrition for maintaining skin health. Explain how improved hydration and nutrition enhance skin elasticity, suppleness, and overall integrity, and prevent dryness and cracking.
References
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
- National Eating Disorders Association (NEDA). (n.d.). Anorexia Nervosa. Retrieved from https://www.nationaleatingdisorders.org/anorexia-nervosa
- Smolak, L. (2011). Body image development in childhood. In T. F. Cash & L. Smolak (Eds.), Body image: A handbook of science, practice, and prevention (pp. 27-36). Guilford Press.
