VOL: 99, ISSUE: 44, PAGE NO: 20
Sam Clark-Stone, clinical coordinator, Eating Disorders Project, Gloucestor
Heidi Joyce, clinician, Eating Disorders Project, Gloucester
Eating disorders are classified as mental disorders and can be divided into two main diagnostic categories: anorexia nervosa and bulimia nervosa (Garfinkel, 2002). People who do not fit these categories but have a clinically significant problem are diagnosed as having an atypical eating disorder. Although there are important differences between each diagnosis, most people with eating disorders share similar attitudes, behaviours and feelings.
In this patient group, control of body shape, weight or eating is over-valued and becomes the main or only way of judging self-worth. People with an eating disorder typically move from anorexia nervosa or bulimia nervosa to an atypical eating disorder. Signs and symptoms for each are given in Box 1. Eating disorders can be mild and self-limiting, but they commonly run a chronic course unless treatment is successful.
Most people with eating disorders do not seek help, but some suffer severe, enduring illnesses that require treatment in hospital. However, those who are diagnosed are referred to mental health services. About half of patients with eating disorders seen by mental health services are atypical (Fairburn and Harrison, 2003).
The effects of eating disorders
Eating disorders cause physical, psychological and social suffering and can have a damaging effect on the lives of friends and relatives. Psychological features include:
- Intrusive thoughts about food;
- Impaired concentration;
- Preoccupation with food;
- Poor alertness, comprehension and judgement;
- Tearfulness and irritability;
- Anxiety and depression;
- Obsessional behaviour;
- Drug and alcohol misuse.
The physical consequences of eating disorders can affect almost every part of the body and are potentially fatal. They include anaemia, amenorrheoa, dental erosion, dehydration and low blood glucose (Box 2).
Social consequences include:
- Avoidance of eating in public;
- Decreased sociability, sense of humour and camaraderie;
- Increased social anxiety;
- Social withdrawal, anxiety, depression;
- Mothers with an eating disorder can have problems relating with their children regarding feeding and play;
- Rigid/obsessional or erratic/disorganised behaviour;
- Debt due to binge eating;
The causes of eating disorders
The current expert consensus view is that eating disorders are caused and maintained by combinations of predisposing, precipitating and perpetuating factors (Garner, 1997).
These can be:
- Psychological and emotional - including low self-esteem and perfectionism;
- Physical - including a probable genetic component;
- Gender - women are far more at risk;
- Interactional - including relationship difficulties;
- Cultural - including pressures on women to diet.
The causes of low self-esteem are multifactorial. Some people with eating disorders have experienced trauma, but many have not. Whatever the cause, low self-esteem leaves some people vulnerable to believing that weight loss will improve their self-worth and confidence.
These vary from person to person, but most eating disorders start with dieting. Any event or threatened event that causes stress can lead to a sense of being overwhelmed and out of control, pushing the person to find a way to manage those feelings. The interpretation of events is probably more important than the events themselves, as precipitating factors are often a normal part of growing up.
If the developing eating disorder relieves stress, the behaviour will continue. Dieting, binge eating, exercise, vomiting and laxative misuse quickly become the only stress management tools used. While losing weight, the person views his or her behaviour as a solution to problems and initially feels better than before. Even if eating becomes chaotic, he or she strives to regain control, blaming loss of control over eating for the problems.
- Physical - including hunger and the effects of starvation or purging;
- Psychological and emotional - including over-valuation of shape, weight and control of eating, avoidance of life difficulties, cognitive distortions, depression and anxiety;
- Interactional - including relationship problems and secondary gain;
- Cultural - including pressures on women with regard to their appearance.
Alongside over or under-eating, the individual becomes preoccupied with and highly sensitised to his or her appearance, investing heavily in controlling and managing his or her shape and weight. The core psychopathology of eating disorders involves the over-evaluation of weight, shape and control of eating. The individual judges self-worth almost exclusively in terms of controlling these areas and being ‘thin’ becomes synonymous with enhancing self-esteem and confidence.
People with eating disorders often engage in repetitive body-checking behaviours, for example viewing parts of their body in the mirror, frequent weighing or measuring body parts (Fairburn et al, 2003). These behaviours contribute to the person overestimating his or her size thus reinforcing the eating disorder behaviours and distress. Alternatively they may avoid weighing and body checking, not challenging their anxieties about shape and weight.
People with eating disorders become increasingly negative and disparaging about their bodies, judging themselves in a dichotomous (all or nothing) way and misinterpreting comments from others. They become extremely self-critical and focus on the negative aspects of themselves and their bodies. They also tend to mislabel emotional states as ‘feeling fat’ (Fairburn et al, 2003).
Men and eating disorders
Eating disorders are typically associated with young females, and sometimes stereotyped as ‘female disorders’. However, men constitute five to 10 per cent of cases of anorexia nervosa (Hoek, 2002). There is an increased prevalence in certain subgroups of males vulnerable to weight and shape concerns, for example wrestlers and gay men.
Despite the uneven distribution, the clinical features, prognosis and treatment of males and females with eating disorders are broadly similar (Anderson, 2002). Box 3 shows features specific to males.
Management and treatment
People with eating disorders typically have mixed feelings about change. The prospect of treatment and recovery can feel incredibly frightening. Their behaviours may give a sense of being in control, albeit in an insecure and distressing way. Letting go of an eating disorder can increase fears of loss of control, evoking a deep fear of change.
Recovery involves a collaborative effort between the individual and the therapist. It requires sufficient motivation to change and adequate support and guidance. Children and young adolescents are often unable to collaborate with efforts to help them in the early stages of treatment, making parents’ and families’ involvement especially important. The therapist needs to understand the patient’s dilemmas and ambivalent feelings, while promoting the possibility of change and recovery.
The broad aim of intervention is to engage people in working towards their own recovery. An approach that encourages active participation by the patient is more likely to achieve this aim. This involves:
- Establishing a healthy eating pattern
- Gradually restoring weight to a normal range;
- Ceasing purging behaviour;
- Improving self-esteem and diminishing over-evaluation of weight and shape;
- Using healthier coping strategies;
- Developing relationship and communication skills.
Evidenced-based treatment is possible for bulimia nervosa. A specific form of cognitive behavioural therapy (CBT) (Fairburn et al, 1993) has been developed and tested and is considered the treatment of choice (Wilson and Fairburn, 2002). CBT focuses on tackling the behavioural and cognitive processes that maintain the eating disorder. Binge eating declines rapidly, but only about 40-50 per cent of patients recover completely.
An alternative treatment that is as effective at one-year outcome, but takes longer to work, is interpersonal psychotherapy (IPT) (Fairburn, 1997). IPT has no focus on eating, but instead encourages patients to make changes in their relationships, thereby improving self-esteem and problem-solving skills.
Antidepressants, specifically fluoxetine, have been shown to reduce binge eating rapidly in some patients, but they have no effect on over-evaluation of weight and shape, and therefore leave patients vulnerable to relapse. There is no long-term outcome data available for antidepressants (Wilson and Fairburn, 2002).
There are very few treatment studies for anorexia nervosa and the results do not show clear evidence in favour of any particular psychotherapy. However, most patients can be treated as outpatients using an approach that focuses on improving eating and weight as well as providing psychotherapy for the underlying maintaining factors (Wilson and Fairburn, 2002).
Treatment for children and adolescents should usually involve the family, but individual therapy is probably more effective for adults. However, there are often occasions when it makes sense to involve family members, even if it is simply to provide education about eating disorders and their effects. Medication has little role to play in the treatment of anorexia nervosa, other than for co-morbid conditions, although fluoxetine may help to prevent relapse (Wilson and Fairburn, 2002). A small number of patients with anorexia nervosa will require hospital admission due to extreme weight loss and risk to physical health, or failure of previous outpatient treatment. Day care programmes increasingly provide therapy for patients once physical safety has been restored.
There have been no published treatment trials for atypical eating disorders, other than binge eating disorder. Treatment can follow that advised for whichever eating disorder most resembles the patient’s difficulties.
Binge eating disorder can be chronic and severe, but is commonly episodic in response to life stress. Evaluated treatments include self-help (using a self-help book), guided self-help, antidepressants (fluoxetine), CBT, IPT and behavioural weight loss programmes.
CBT and IPT should be reserved for patients with more severe and enduring binge eating, as less intensive treatments are often successful. Only behavioural weight loss programmes have any effect on weight loss, so as most patients with binge eating disorder are obese (defined as having a body mass index (BMI) >30), a behavioural weight loss programme may be the most sensible first choice treatment (Wilson and Fairburn, 2002).
The role of nurses in prevention and early intervention
School nurses, practice nurses and health visitors all have a role to play in the detection and initial management of people with eating disorders.
Many school nurses provide drop-in sessions at secondary schools, where they are approached by pupils who are concerned about their own or a friend’s eating. Careful and sensitive questioning can elicit problematic eating behaviours. Weighing and measuring the pupil allows assessment of BMI. Rapid referral to Child and Adolescent Mental Health Services (CAMHS) is recommended for any pupil who is purposely losing weight (when there is no need), self-inducing vomiting after eating, misusing laxatives or excessively exercising.
School nurses are also approached by teachers or parents and can arrange to see pupils to undertake an assessment. A high index of suspicion is advisable, as denial of problems by young people with eating disorders is common.
Practice nurses undertake the initial health screen when new patients join. Height and weight are measured so low or high BMI can be detected. Either presentation should trigger questioning on attitudes/behaviours relating to weight/body shape. It is probably worth asking all new female patients if they have concerns about weight, shape or eating. A simple screening tool such as the SCOFF assessment (Box 4) (Luck et al, 2002; Morgan et al, 1999) can quickly establish if referral to the GP is required.
Some practice nurses are developing skills in detecting and treating common mental health problems. CBT self-help books can be used effectively in primary care for mild-to-moderate mental health problems. Practice nurses can guide and encourage people to practise the strategies advised within the self-help book (Fairburn, 1995). This could take place in six to eight, 20-30 minute sessions held on a weekly to fortnightly basis. Practice nurses can also offer behavioural weight loss programmes to patients with binge eating disorder and obesity.
Health visitors are involved in the postnatal care of all new mothers and monitor the development of children below the age of five. Depression is a common experience for mothers with children younger than 12 months and assessment of attitudes and behaviours relating to eating, weight and shape is recommended for all women who have depression. Patients with eating disorders commonly report low mood, which is usually a consequence of the eating problem and does not respond to treatment for depression.
Another reason to screen mothers for eating disorders is that research shows that children of mothers with an eating disorder have lower birth weights and continue to be significantly slower in their development than children of mothers without eating disorders (Stein, 2002).
The health visitor could provide guided self-help for mothers with mild-to-moderate binge eating, but should refer patients who do not respond or who have more severe eating difficulties to the GP or Community Mental Health Team (CMHT).
The National Institute for Clinical Excellence will publish clinical guidance on eating disorders in January 2004. NICE has thoroughly reviewed the evidence in:
- Physical effects and treatments;
- Psychological treatments;
- Service organisation.
Draft guidance for clinicians and separate guidance for service users and carers is already available on the NICE website (www.nice.org.uk).
Eating disorders can be severe and enduring mental illnesses that have serious physical, psychological and social consequences. Nurses can play an important role in their early detection, assessment and treatment.
This article has been double-blind peer-reviewed.
INFORMATION FOR PATIENTS
Anorexia Nervosa: The Wish to Change by Arthur Crisp and colleagues. Psychology Press.
Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers by Janet Treasure. Psychology Press.
Eating Disorders: A Parents’ Guide by Rachel Bryant-Waugh and Bryan Lask. Penguin.
Binge Eating Disorder and other atypical eating disorders: Overcoming Binge Eating by Christopher Fairburn. The Guilford Press.
The Eating Disorders Association (EDA) is a national charity that offers information and support to sufferers, carers and professionals. It has a helpline on 01603 621414.
The association’s website www.edauk.com provides high quality information.
NHS Direct also provides useful information at www.nhsdirect.nhs.uk
Gloucestershire Eating Disorders Project provides guidance on the management of eating disorders in primary care and secondary schools on its website www.edglos.org.uk