Eating disorders have undergone a dramatic upsurge in both clinical and public interest over the last few decades. Recognised as a prevalent problem in modern society, they represent a significant public health concern, with those affected experiencing debilitating and potentially life-threatening consequences.
What are eating disorders?
Essentially, an eating disorder is a psychological condition characterised by a persistent, severe disturbance in a person’s eating attitudes and behaviours, defined as an intense preoccupation with fatness, leading to extreme attempts to control body weight1. A guide to eating disorders and their principal diagnostic criteria accompanies this article. In addition to anorexia nervosa and bulimia nervosa, there is a third diagnostic group: atypical eating disorders (the equivalent American diagnostic term being ‘Eating Disorder Not Otherwise Specified’).
Eating disorders are one of the most common psychiatric disorders to affect young women in Western society2, with a notable increase in occurrence among minority populations since the 1990s3. The prevalence of eating disorders has been estimated from large-scale population studies: with a mean onset age of 16 to 17 years, it is suggested the incidence of anorexia nervosa is 19 in 100,000 females per year, and two in 100,000 males per year. Among females, teenagers (13 to 19 years) have been found to have the highest rates at 51 cases per 100,000 per year. Around one in 250 women and one in 2,000 men will experience anorexia nervosa at some time in their lives.
Bulimia nervosa is around five times as common as anorexia nervosa, with a later mean onset age of 18 to 19 years. More common in females (a female to male ratio of 10:1), it affects 0.5 to 1.0 per cent of young women, with an even social class distribution. Recent evidence would suggest that atypical eating disorders have much higher incidence, with a suggested prevalence greater than that for anorexia nervosa and bulimia nervosa combined4.
The role of primary care
Given the severe complications associated with eating disorders, primary prevention and early recognition is considered crucial. Prompt identification and intervention has been demonstrated to significantly improve the outcome for the eating disordered client5. Initial diagnosis often falls on primary care services, which are frequently responsible for instigating the assessment process and organisation of treatment, as well as determining the need for emergency medical or psychological help.
There are, however, some very general problems to be faced in the assessment of eating disorders. The secretive nature of an eating disorder generates obstacles for clinicians in everyday practice including ambivalence about treatment, poor compliance and denial of the illness. Equally as challenging, eating disorder symptoms experienced by the client may not be viewed as problematic; the client may instead present with complaints not specific to body shape, weight or dietary intake. Nevertheless, clinicians within primary care services are in a unique position to detect eating disorders at the earliest stages, providing the opportunity to intervene and prevent progression to a more severe and chronic state.
When considering the existence of an eating disorder (particularly where cases present ostensibly with other complaints or have atypical features), exploring specifics such as eating patterns and satisfaction with bodily appearance can provide clinicians with vital information; Table 1 illustrates some of the specific screening elements to assist in identification.
Essential management of eating disorders
Over the past 25 years, considerable progress has been made in the development and evaluation of psychological treatment for eating disorders. Research into treatment of bulimia nervosa has attracted considerable attention, with a body of evidence pertaining to effective treatment now fully established.
Reliable studies into the treatment of anorexia nervosa and atypical eating disorders have, in comparison, been limited, leaving treatment recommendations open to debate. Of note, treatment of male clients currently follows the same principles of that of female clients. Aside from essential management of physical risks, the National Institute for Health and Clinical Excellence (NICE)6 advocates provision of psychotherapy in the treatment of eating disorders. CBT is clinically recommended as the treatment of choice for bulimia nervosa and binge eating disorder, and recommended in the treatment of anorexia nervosa and atypical eating disorders. Other psychotherapies suggested include interpersonal psychotherapy (IPT) and cognitive analytic therapy (CAT).
Owing to the severe psychological and physical complications that can arise, eating disorders should ideally receive treatment by healthcare professionals trained to deliver this, though local provision of specialist services is often limited. Eating disorders are notoriously difficult to manage and treat; sometimes the mere hint of an eating disorder can fill a clinician with intense dread and prompt an immediate referral onwards! Nevertheless, clients often present with a number of different psychological problems which can result in eating disorders being held by clinicians whose expertise lies in other domains. This in itself can leave both client and professional exasperated and concerned, each unsure of the best way to move forward. Of course, effective case conceptualisation, identification and treatment of the primary problem is always key, yet with clients frequently presenting with interwoven complexities, treatment is rarely so ‘clear cut’. When the eating disorder is secondary to mood or anxiety problems or alcohol/ substance misuse, being armed with some understanding about working with eating disorders can be advantageous, potentially enhancing the overall treatment experience the client receives.
Motivation to change can vary dramatically among clients with eating disorders, even apparent over the course of just a day. Described as essentially ‘cognitive disorders’7, all eating disorders share a distinctive core psychopathology (overevaluation of shape and weight and their control), with the sufferer frequently holding maladaptive or irrational beliefs related to eating and body shape and weight. The pervasiveness of cognitive bias often evident in eating disorders can influence implications for treatment, potentially influencing the cognitive, emotional and behavioural reactions of clients within therapy. It is important for clinicians, at the very least, to hold some awareness of underlying cognitive processes that may determine the client’s reaction to treatment approaches. Armed with this knowledge, clinicians may be more able to manage their own frustrations when faced with seeming denial and apparent resistance to intervention. It is necessary for us to observe whether change is actually happening, rather then depending solely on verbal reports or becoming lost in our own expectations about when change ‘should be’ occurring. As clinicians, we must ultimately be able to tolerate our own uncertainty and be prepared to wait several weeks before we can effectively gauge whether any change made is meaningful.
Providing clients with information about their eating disorder is fundamental. Emotional disturbances, including anxiety, depression, relationship problems, social withdrawal and isolation, and occupational difficulties, are common. Psycho-education on the effects of starvation, binge eating, laxative abuse and self-induced vomiting should also be shared with clients. This must also include facts on the consequential physical complications such as osteoporosis, hypokalaemia (low potassium levels leading to potentially fatal heart complications), renal abnormalities and gastrointestinal issues. The eating disorder can disguise itself under a superficial blanket of positives. It can provide the sufferer with structure and routine, acting as a tailor-made coping mechanism in a world that any one person has little control over; to the sufferer it feels familiar and safe. It is, therefore, not surprising that a person may be ambivalent to living life without it to lean on, and introducing clear facts pertaining to the negative physical and emotional consequences of eating disorders is crucial in order to stimulate desire for recovery.
When to refer on
- If the diagnostic criteria for anorexia nervosa and/or bulimia nervosa are met, referral on to specialist services should be made.
- More severe cases of atypical eating disorders (whereby the eating disorder puts the sufferer at increased physical and psychological risk) should also be referred on. Some atypical cases may be more appropriately held within primary care settings (see below) and primary care clinicians’ work to treat the primary disorder, whilst being mindful of the presence of eating difficulties and receptive to any further deterioration within this domain.
- Depending on the individual and the problems they present with, effective joint working between services may be required.
Presentations that might be held in a primary care setting
Jessie is a 21-year-old female in her final year of university and is finding all the coursework particularly stressful. She describes recent heightened awareness of her body shape and weight and feeling unhappy with her current body weight (BMI 24.9kg/m2). Jessie reports increasing difficulty with making food choices and has noticed she sometimes avoids social interactions that may involve eating out. Jessie also disclosed she has engaged in occasional (approximately once weekly) laxative use in a bid to reduce her weight. Jessie reports no previous eating problems. There is no other psychiatric history and she is generally in good physical health.
Although Jessie describes some difficulties with eating, these may be as a consequence of university commitments and may subside in time. In Jessie’s instance, a watchful wait, provision of information, information about any self-help or support groups available, and a request for relevant blood tests would be apt. This should be managed by a GP. If symptoms similar to those indicated in Jessie’s case are reported whilst a person is already in receipt of treatment (for anxiety or depression) in primary care services, their clinician should instigate the arrangement of an appointment with their GP to discuss these symptoms further; thus ensuring the interventions indicated above are effectively overseen. Though it would be fitting for the clinician involved to provide relevant psycho-education and signposting in addition to this.
Eve is a 27-year-old female who reports some recent weight loss: approximately 4kg over a six-month period, giving her a body mass index (BMI) of 21.2kg/m2. She expresses some issues around low self-esteem and body dissatisfaction. A desire to lose more weight is evident and in a bid to achieve this, she has eliminated carbohydrates from her diet and describes preoccupation with calorie counting. She denies any other compensatory behaviours (such as long periods of restriction or purging). She separated from her partner of two years six months ago that resulted in severe deterioration in her mood and disruption to her daily functioning. She is due to commence a course of CBT with a view to targeting her low mood. There is no evidence of risk. Of note, Eve was diagnosed with anorexia nervosa at the age of 13. At this time she received professional help and support, her symptoms improved and she has maintained a healthy BMI since the age of 16.
Despite a history of anorexia nervosa, Eve’s current and predominant problem appears to be a depressive episode. Again, provision of appropriate psycho-education would be valid and she might also be enlightened with regards to any agencies or resources where she may be able to access further help or support (such as online resources and self-help materials). It would be appropriate for Eve to engage in a course of CBT focused on tackling her low mood. If, upon completion of therapy, her eating remains problematic, referral to specialist services for assessment would be a suitable care pathway to follow.
The primary care setting offers a distinct opportunity to facilitate assessment, diagnosis and treatment of an eating disorder during its initial and fundamental stages. Early detection can only contribute to reduction and possible prevention of the vast psychological and physical harm that a chronic eating disorder creates. Armed with correct understanding, as health professionals, this is a role we can all play a part in.
Jayne Joy is a senior practitioner and cognitive behavioural therapist working within a specialist outpatient eating disorder service for Cheshire and Wirral Partnership NHS Foundation Trust. Her current interests lie in acceptance and mindfulness-based treatment approaches to eating disorders.
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4 National Collaborating Centre for Mental Health (2004). Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. National Institute for Health and Clinical Excellence; 2004.
5 Bursten MS, Gabel LL, Brose JA, Monk JS. Detecting and treating bulimia nervosa: how involved are family physicians? Journal of American Board of Family Practitioners. 1991; 9:241-248.
6 National Institute for Clinical Excellence (NICE). Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders (Clinical Guideline 9). London: NICE; 2004.
7 Fairburn CG. Cognitive behaviour therapy and eating disorders. New York: The Guilford Press; 2008.