Review article: recognition and treatment of eating disorders in primary and secondary care

Authors


Robinson Department of Psychiatry, Royal Free Hospital, Pond Street, London NW3 2QG, UK. E-mail: paulhrobinson@compuserve.com

Abstract

Eating disorders are serious illnesses affecting 1–2% of young women. Patients may present to any doctor, sometimes atypically (e.g. unexplained weight loss, food allergy, infertility, diarrhoea), delaying diagnosis and leading to needless investigation. The cardinal signs are weight loss, amenorrhoea, bingeing with vomiting and other compensatory behaviours, and disturbances in body image with an exaggeration of the importance of slimness. When other causes have been excluded, useful investigations are serum potassium, bone mineral density scanning and pelvic ultrasound. In emaciated patients multiple systems may fail with pancytopaenia, neuromyopathy and heart failure. Clinical assessment of muscle power is used to monitor physical risk.

Treatment may involve individual, group or family sessions, using cognitive-behavioural, psychodynamic and family approaches. More severe or intractable illness is treated with day care, with in-patient care in a medical or specialist psychiatric unit reserved for the most severely ill patients. Antidepressants have a place in the treatment of bulimia nervosa unresponsive to psychological approaches, and when severe depressive symptoms develop. The children of people with eating disorders may have an increased risk of difficulties. Support for the patient and family, and effective liaison between professionals, are essential in the treatment of severe eating disorders.

INTRODUCTION

Human eating serves many functions in addition to nutrition. It is prominent in the regulation of social life, and of sexual activity, from the box of chocolates to the wedding feast. For young girls, eating and weight gain serve to herald and encourage pubertal breast development and the onset of menstruation and fertility, while boys undergo less dramatic, but nevertheless critical changes in body form and function. Many young people are sensitive about their changing bodies, and society, at least in cultures subscribing to a Western view, dictates that to be thin is good and beautiful and connotes health, attractiveness, energy and vitality, while to be overweight is to invite the judgement that one is lazy, unattractive and less worthy. These judgements are directed at girls, for whom thinness is the perceived ideal more than boys, who are exhorted to be muscular but not fat.

It is not surprising therefore that concerns about eating arise during adolescence. Surveys have suggested that many young girls are already feeling overweight by the age of 8 years, although they are within the normal weight range.1 Restriction of caloric intake becomes increasingly common and, in its extreme form, is seen in anorexia nervosa as severe self-imposed energy restriction. Dietary restriction is therefore on a continuum of severity from everyday dieting to the severe restriction of the patient with anorexia nervosa. When weight has been lost to a body mass index (BMI, applicable to over 16 years) of under 17.5, the weight criterion for anorexia nervosa has been met. Feeling sensitive, especially about the normal slightly protuberant abdomen of the pubertal girl, is very common. The young woman with anorexia nervosa will, however, usually feel fat, even though she may look pitifully thin and wasted. Feeling negative about one’s own body is also a common experience. The person with an eating disorder expresses deep revulsion about her body, its shape and consistency. The body image distortion and body image disparagement of anorexia nervosa and bulimia nervosa is an extreme form of the common feeling of being fat or ugly. The former is more pronounced in anorexia nervosa, and more remarkable as it is being expressed by an emaciated person, and the latter more evident in bulimia nervosa.

A third feature of eating disorders that occurs in a less severe form in the general population is overeating. Many people, especially those on diets, find that from time to time they consume larger amounts of food than they would wish. For most people, the rate is infrequent, and not much distress is caused, although there may be some regret. When it is associated with distress and loss of control over eating, the behaviour is termed bulimia. Bulimia refers to episodes of binge eating and these occur on their own in binge eating disorder. They also occur in association with bulimia nervosa and anorexia nervosa, in which case they are accompanied by one or more behaviours aimed at compensating for the, sometimes very large, caloric intake during a meal. The most common of these behaviours in eating disorders are self-induced vomiting and abuse of laxatives. Other examples are prolonged starvation, abuse of anorectic drugs, thyroxine or diuretics, and exercise abuse. All of these behaviours may also be employed by patients with anorexia nervosa, whether or not they overeat, to minimize the absorption of food or increase its rate of utilization. These behaviours, when regular and frequent, usually indicate a serious eating disorder requiring treatment.

Lastly, in anorexia nervosa, amenorrhoea is a required diagnostic criterion in females. It is weight-sensitive, and the underlying endocrinology is a hypothalamic hypogonadism. In males, sexual function is impaired with low libido and poor erectile function.

Definitions of the various eating disorders are provided in Table 1.

Table 1.  . Diagnostic criteria for eaing disorders Thumbnail image of

EPIDEMIOLOGY

The group at highest risk is young females between the ages 15 and 30, with anorexia nervosa striking a somewhat younger age group and bulimia nervosa a rather older group. The sex incidence is one male to between 10 and 20 females.2 Anorexia nervosa is over-represented in social classes one and two (professional and managerial) but bulimia nervosa appears to be distributed through all classes equally.3 Different studies produce varying estimates of the epidemiology of eating disorders. Bulimia nervosa has had a prevalence in young women of 0.5–1.1% and anorexia nervosa 0.1–0.7%.4[5][6][7]–8 Estimates of the prevalence of all clinically significant eating disorders, including those that just fail to meet full criteria (EDNOS) are 8.7% of females in the general population and 18.7% of female psychiatric out-patients.6, 9 In the latter study, the prevalence of binge eating disorder was higher in men than women, and the total prevalence of eating disorders in male psychiatric out-patients was 14.7%. There have been few prevalence studies in medical clinics, apart from surveys of diabetics in which 10% are found to have a life time prevalence of eating disorder, with no differences attributable to sex or type of diabetes.10 Inflammatory bowel disease may also complicate presentation of an eating disorder.11

DIAGNOSIS OF EATING DISORDERS IN DIFFERENT SETTINGS

Gastrointestinal presentations

Virtually any part of the gastrointestinal tract can be affected in a patient with an eating disorder, and symptoms referable to the gut can form the focus of a referral. The various problems encountered have been summarized and referenced elsewhere and can be classified into symptoms associated with under-eating, overeating, vomiting and abuse of laxatives.12

Symptoms associated with under-eating.

These include delayed gastric emptying of both solid and liquid phases, with consequent symptoms of postprandial fullness and bloating. Gastric emptying studies, preferably using ultrasound are useful and treatment with cisapride 10 mg pre-prandially is occasionally beneficial, although studies of its efficacy have been contradictory.13 An emaciated patient with severe anorexia nervosa, delayed emptying and a thin gastric wall is at risk of acute gastric dilatation and perforation, with a high mortality. Treatment of acute dilatation includes rehydration and gastric suction and perforation will require surgical management.

Symptoms associated with overeating.

Parotid enlargement occurs in patients with bulimia nervosa, anorexia nervosa and binge eating disorder, and is probably the result of chronic over-stimulation of the parotids, with sialoadenosis developing over time. It is more common in patients who induce vomiting. It may be associated with moderate elevations of serum amylase levels which, on iso-enzyme analysis, are found to be salivary in origin. Occasionally, re-feeding in a very emaciated patient can result in acute pancreatitis.

Symptoms associated with self-induced vomiting.

Dental erosion is common in patients who induce vomiting, with the palatal and lingual aspects of the anterior teeth being most vulnerable. The most likely cause is gastric acid, but consumption of sugar during bulimic episodes and large amounts of acidic carbonated drinks may also contribute. In the oesophagus, gastro-oesophageal reflux can lead to oesophagitis and bleeding, while in a proportion of patients with bulimia nervosa, spontaneous regurgitation of gastric contents into the mouth occurs.14 Vomiting has been associated with rupture of the oesophagus in a patient with bulimia nervosa.15

Symptoms associated with laxative abuse.

Unexplained diarrhoea should raise suspicion of laxative abuse, which can be very difficult to diagnose in a patient who denies the abuse. Laxatives are taken by patients with anorexia nervosa and bulimia nervosa in the belief that the intestinal hurry will retard absorption. The little evidence available does not support this view, but more research is required before we can confidently tell patients that their behaviour will not help them lose weight.16 Laxatives certainly lead to weight loss due to dehydration, and patients report a satisfying flatness which develops in an abdomen cleared of ingested material. Some patients use enemas or colonic lavage to achieve the same sense of having been ‘cleared out’. While, acutely, laxative abuse is associated with dehydration and electrolyte disturbance (typically hypokalaemic alkalosis), chronic abuse of laxatives causes degeneration of colonic autonomic innervation with consequent constipation unresponsive to increasing doses of laxatives, colonic atony and dilatation, volvulus and rectal prolapse, all associated with loss of tone on the wall of the colon.17 Some patients require colectomy and, unaccountably, resume laxative abuse post-operatively. Some laxative constituents (anthraquinones, bisacodyl, phenolphthalein, and magnesium salts) can be detected in urine and this can be used as a diagnostic test.18

Gynaecological and endocrine presentations

Whereas almost every hormone is influenced by eating disorders, especially anorexia nervosa, the most common presenting problems are in the gynaecological field. Problems relate to menstruation, fertility and pregnancy.

Menstruation.

Since amenorrhoea is a sine qua non for anorexia nervosa, a young woman who has lost her periods may well consult a gynaecologist, endocrinologist or physician. Weight loss may have been modest, and the patient may not volunteer the information that she is encouraging her weight to fall, especially if a relative is present at the consultation. Blood will show low oestrogen, luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels, and stimulation tests will demonstrate a poor response to luteinizing hormone releasing hormone (LHRH). Pelvic ultrasound shows reduction in uterine size and an immature multifollicular or afollicular pattern of ovarian structure. Treatment with clomiphene or oral contraception at an early stage may result in resumption of menstruation, but the nutritional causes remain, and the diagnosis may have been missed. Because early treatment has been shown to improve prognosis, management of amenorrhoea in this way cannot be recommended, as it can lead to a substantial delay in effective treatment of the eating disorder.19 Similar considerations apply to the treatment of delayed menarche in a young girl who, through dietary restriction, fails to gain enough weight to trigger menstruation.

Menstrual problems, including amenorrhoea and irregularity of periods, occur in patients with bulimia nervosa. This may be due to dietary restriction and the maintenance of a suboptimal weight, or even to the presence of overeating and vomiting. It has been suggested, however, that some patients with menstrual irregularity and bulimia nervosa may be suffering from polycystic ovarian syndrome.20

Fertility.

Older women with anorexia nervosa may consult a physician for management of infertility. As long as weight is not too low, fertility may be induced using one of the treatments currently available. However, the ethics of such treatment in a woman with established anorexia nervosa are open to debate, given the problems that have been identified in the pregnancies and the children of women with anorexia and bulimia nervosa, outlined below. Weight gain in anorexia nervosa is associated with near normal fertility, and the first line of intervention for a woman with anorexia nervosa requesting fertility treatment should be treatment of her eating disorder.

Pregnancy.

In patients with anorexia nervosa who become pregnant, continued dietary restriction in pregnancy may be associated with foetal growth retardation and an increased rate of premature delivery and foetal death.21

Rheumatological

The main skeletal problem in anorexia nervosa is osteoporosis, which is detectable in increasing numbers of patients after as little as 6 months amenorrhoea.22 The cause is likely to be lack of oestrogen, poor nutrition, low weight bearing stress on bone and other metabolic and endocrine influences, such as raised cortisol. Presentation is usually asymptomatic, following a bone mineral density scan ordered because of known anorexia nervosa, although pain due to a fracture could be a presenting symptom. Osteoporosis appears to improve slowly following weight gain and return of periods, but the completeness of recovery is unknown. A normal weight patient with a history of anorexia nervosa may therefore present with complications of osteoporosis. There is no consensus on the use of hormones, either as hormone replacement therapy or oral contraception, or calcium or vitamin D treatment in patients with anorexic osteoporosis, and current opinion is that no intervention apart from weight gain and return of periods has been shown to improve this serious complication.

Psychiatric

A wide variety of psychiatric problems may present during the course of an eating disorder. Depression is very common in all eating disorders, due to genetic susceptibility, weight loss, bulimia, and the various problems that bedevil the patient in her occupational, family and social life. Treatment is best initiated to address the eating disorder, although antidepressants, especially Specific Serotonin Re-uptake Inhibitors, are often used. Fluoxetine in high doses (40–60 mg per day), along with many other antidepressants, has been shown to lead to a modest improvement in symptoms of bulimia nervosa.23 Obsessive compulsive disorder, with compulsive checking and rituals and obsessional thoughts occur in many patients with anorexia and bulimia nervosa. They are usually related to food and weight, sometimes appearing designed to prolong mealtimes and reduce calorie consumption, but can spread to other areas of life such as security (checking locks) and safety (checking switches). Such behaviour has been described in starving volunteers and weight gain can lead to improvement in the symptoms.24 Sometimes they require specific cognitive-behavioural or drug (fluoxetine or clomipramine) treatment.

Psychosis in the form of delusions and hallucinations can occur in eating disorders, either related to re-feeding in a very ill underweight patient or as a co-existing schizophrenic or affective disorder.25 The re-feeding psychosis usually resolves within a few weeks, and may require antipsychotic drugs. Because of the poor physical state of the patient, drugs with less pronounced side-effects such as sulpiride are to be preferred.

Paediatric

A child may be seen in a paediatric or child psychiatric clinic because of failure to grow, eating problems or behavioural or emotional disturbance. The differential diagnosis should include maternal eating disorder, as surveys of such mothers have suggested a high incidence of disturbances in the children.26 Mothers with eating disorders may have difficulty in correctly judging the child’s nutritional needs, and may believe, wrongly, that the child is fat. It is not unusual for mothers to express these concerns themselves, and all attempts should be made to elicit their co-operation in management of the child’s problems. Involvement of the GP, health visitor and community dietitian can be very helpful in monitoring the child and providing counselling to the mother.

Cardiovascular

Patients with severe anorexia nervosa may suffer a variety of cardiovascular problems, including syncope due to postural hypotension, cold intolerance and chilblains due to poor peripheral circulation and loss of subcutaneous fat. Patients with bulimia nervosa may suffer syncopal attacks due to hypokalaemic dysrhythmias which can have a fatal outcome. The electrocardiograph (ECG) in anorexia nervosa may show prolongation of the QT interval, indicating increased susceptibility to dysrhythmias.27

Very ill patients may develop a myopathy affecting skeletal muscle, although the heart may also be involved, with associated heart failure.28

Neurological

Very thin patients are more likely to develop pressure palsies on exposed nerves such as the common peroneal nerve.29 Progressive weight loss leads to loss of skeletal muscle fibres (especially type 2) and a profound myopathy can develop.28 Intellectual function is usually maintained in patients with anorexia nervosa, in spite of apparent cerebral atrophy observed on the magnetic resonance imaging (MRI) scan, which tends to recover with weight gain.30

Haematology

Many patients are mildly anaemic due to a combination of bone marrow under-activity and iron and vitamin B12 deficiency. Patients who vomit may have blood loss due to oesophagitis, contributing to anaemia. As weight declines, white cell numbers fall and thrombocytopaenia, with associated purpura, can occur in very malnourished patients.28

Infectious diseases

Low weight patients are at increased risk of tuberculosis with which anorexia nervosa can be confused.31 Eating disorders have been reported in association with HIV infection.32 For some gay men with HIV there is a conflict between the wish to look attractively slim, and yet not look so thin that AIDS is suspected.

Accident and emergency

The casualty officer may be presented with a patient having taken an overdose, a woman with a fracture after trivial trauma, or an acutely confused patient with Wernicke’s Encephalopathy. Any of these patients could be suffering from an eating disorder, leading, respectively, to depression or distress, osteoporosis or thiamine deficiency. Many of the other conditions described could also present to A&E, including severe dehydration with electrolyte disturbance, Mallory–Weiss Syndrome, rectal prolapse, syncope and hypothermia; consideration of an eating disorder as a major underlying illness is required in order to make a comprehensive assessment.

POSITIVE DIAGNOSTIC FEATURES

The diagnosis of an eating disorder should be made on positive evidence. A patient, especially a young woman, presenting with, for example, weight loss, should be considered as possibly having an eating disorder which should be sought in the initial interview. Failure to follow this rule can lead to fruitless, expensive and sometimes hazardous investigations, lost time for treatment, and a danger that the patient and family will conclude that an increasingly elusive ‘physical’ answer will be found if only the right test is performed. Pressure to avoid a stigmatizing diagnosis, and a psychiatric referral can perpetuate this fiction. The diagnosis can be made by considering the mental state and behaviour of the patient in a number of areas.

Body image disturbance and disparagement

This is the key diagnostic feature of an eating disorder, but may be difficult to elicit at the first, or even subsequent interviews. The patient with anorexia nervosa has an aversion to fat on her body. She regards herself as fat, often knowing that she is much thinner than other people, but, nevertheless, believing that she could be a much better person if she were thinner, so that, relative to her own ideal self, she is fat.

Secondly, she disparages her body, believing it to be ugly and ill-shaped. She will point to her hips, stomach and thighs as particularly unpleasant. Body image disparagement is observed in patients with anorexia nervosa, but is often more pronounced in those with bulimia nervosa.

Calorie or fat avoidance

The patient’s behaviour is geared to avoiding calorie intake, especially in the form of fat. She will avoid butter, cheese (except cottage cheese), meat and oil. She may become a vegetarian to help avoid fatty foods. Some patients have received a diagnosis (sometimes with dubious evidence) of extensive food allergies involving many fat-containing foods, which has helped them reduce calories and lose weight. Such a patient may be extremely difficult to help, because she has split the medical profession into at least two groups, with treatments that may be poorly compatible with each other.

Resistance to weight gain

Just as the patient is resistant to consuming fat, she is also resistant to gaining weight. She may justify her failure to gain weight as a symptom of an underlying medical condition, such as a gastric problem (gastric delay, a symptom of anorexia nervosa), and may profess her wish to recover, but even when admitted to hospital, she will demonstrate that she is firmly opposed to weight gain, by failing to finish meals, playing with food at meal times, disposing of food and avoiding meals if possible.

Self-induced weight loss, vomiting or laxative abuse

The patient who admits that her weight loss, vomiting and laxative abuse is under her control presents no diagnostic problem. In order to exclude organic disease, such as Crohn’s disease, or a malignancy, a full history and examination should be performed and selected investigations arranged. This is the case even if the patient is found, on the above criteria, to have an eating disorder. It is possible for an eating disorder to be present in a young woman who has another disorder. Indeed, the presence of a wasting disorder such as Crohn’s disease, diabetes mellitus or thyrotoxicosis, can trigger an eating disorder by convincing the patient that weight loss, even though induced by disease, is a desirable goal. Such patients may then neglect their treatment, be it steroids, insulin or carbimazole, in order to let the disease lead to weight loss. If the patient does not admit to inducing weight loss, or vomiting, or abusing laxatives, the assessment may have to be left incomplete, while she develops a trusting relationship. This is safe, as long as serious disease has been reasonably excluded, and monitoring continues (see below). The alternative is to admit the patient to hospital for observation of her eating, exercise, and possible vomiting and other behaviour and confront her with the findings. Such an approach should only be necessary if weight is falling rapidly, or hypokalaemia or other dangerous physical complications develop.

MANAGEMENT

The management of an eating disorder requires a good relationship with the patient, effective monitoring, accurate advice, and willingness to respond to emergencies and to arrange specific forms of therapy known to improve outlook in eating disorders. Patients with eating disorders are often unpopular with doctors and nurses because they are seen as inflicting harm on themselves, not co-operating with treatment, deceiving staff and being ungrateful and unappreciative. All of this has some basis, and the task of staff who are charged with caring for such patients is to develop an understanding of the disorders which will allow them to deal with their own anger about the patients’ behaviour. The same discussion could be conducted about people with drug dependence, alcohol abuse and dependence and, for that matter, carcinoma of the bronchus due to smoking.

Enhancing motivation to change

It is recognized that, in a patient for whom behavioural change is medically advisable, the patient’s enthusiasm for change often fails to match the doctor’s. As in the treatment of the smoking asthmatic, a patient who fails to change in the recommended way may be seen as uncooperative, at fault and perhaps even not meriting some treatments. The technique of motivational enhancement has attempted to address this problem.33 The current motivational state of the patient is assessed by considering whether he/she is: (i) not even considering change; (ii) aware of the merits of change and thinking about it; (iii) ready to embark co-operatively on a programme of change; (iv) well established in a new, healthier type of behaviour, but at risk of relapse. Depending on the motivational state, the patient is encouraged to consider both positive and negative aspects of staying the same and of changing, and, in a few sessions, by challenging beliefs and attitudes, an attempt is made to help him/her shift to a higher level of motivation. Whether this is done formally by a person trained in motivational enhancement therapy (MET) or whether time is simply allocated to discussion of these issues, is a matter for the individual clinician and patient. In the area of eating disorders, the clear (to the clinician) disadvantages include chronic physical, psychiatric and social morbidity, osteoporosis and infertility. The patient may deny the seriousness or even the existence of these problems, but may come to address them in treatment.

In-patient or out-patient treatment?

Most eating disorders are treated in out-patients using one of the techniques described below. It is generally accepted, however, that if out-patient treatment fails, or if the patient’s physical state deteriorates to a dangerous level, in-patient treatment is advisable. Units in which intensive out-patient treatment has been available have demonstrated that such treatment can be very helpful for many patients who would otherwise be admitted to hospital. The problems associated with admission, often for many months, including separation from family and friends, and excessive dependency on the hospital, can be avoided, and admission reserved for those patients with life-threatening illness.

Physical and psychiatric monitoring

Monitoring of patients with eating disorders for both acute and chronic complications is essential, and may be required in primary care, eating disorder services, and in medical units. Virtually any system in the body may be affected. However, for monitoring of a patients with anorexia or bulimia nervosa in out-patients, the following provides a minimum amount of information with which to decide on, for example, the need for admission to a medical unit.

1 Weight and body mass index (weight/height squared, kg per metre squared). If weight is falling rapidly (> 0.5 kg per week) or if body mass index falls below 13.5, risk is greatly increased and monitoring should be closer.

2 Muscle power. Two tests found to be useful are the ability to rise from squatting, and to sit up from lying flat on a hard surface with no pillow. A rough score can be applied to both tests as follows: (0) completely unable, (1) able only with help of hands, (2) able without use of hands, but with difficulty, (3) no difficulty. Sometimes patients conceal weight loss by drinking water just before weighing, and may, by titration, simulate short-term improvement. The muscle tests may deteriorate during such a time, and admission may need to be arranged which may save the patient’s life.

3 Postural hypotension. This important symptom is probably best monitored by the presence or absence of postural dizziness, rather than absolute pressures, although if the patient does complain of dizziness, a standing and lying blood pressure reading should then be taken to confirm the cause. This symptom can also be scored as follows: (0) none, (1) brief postural dizziness, (2) persistent postural dizziness, (3) unable to stand because of postural dizziness.

4 Blood tests. The most useful tests are the serum potassium, in a patient with bulimic symptoms (vomiting, laxative or diuretic abuse), which can lead to hypokalaemic alkalosis, and creatine phosphokinase level, which, if raised (with a normal cardiac enzyme fraction), can indicate skeletal muscle degeneration and advanced malnutrition. Other electrolytes, particularly sodium, are often disturbed in starvation, especially with vomiting or laxative abuse.

The above physical monitoring tests can easily be recorded on a chart or spreadsheet and sent by fax or e-mail to other health care professionals. The first three can be monitored by non-clinical personnel including the patient and family.

The following are additional points to be aware of during monitoring:

5 Psychiatric monitoring. This is important because of the possible advent of depression, with suicidal ideation, and occasional psychotic symptoms (delusions and hallucinations) in the course of an eating disorder.25

6 Chronic complications. The most important long-term physical effect of anorexia nervosa to monitor is osteoporosis.22 This can develop after as little as 6 months amenorrhoea, and can be detected using bone mineral density scanning. Other long-term complications are psychological, with depression related to social isolation being a common sequel.

7 Determination of ‘healthy’ weight. Several pieces of information may contribute to this assessment, namely the patient’s premorbid weight, reference to tables of mean population matched weight and, perhaps the most useful, menstrual weight. The latter may be heralded by the appearance of a dominant ovarian follicle on sequential pelvic ultra-sound scans34 performed during weight gain.

Diet

The help of a dietician can be useful in detecting and correcting specific nutritional defects, and to help patients alter problems with the pattern and quantity of dietary intake. In patients with anorexia nervosa gaining weight, it has been shown that a weight gain of 1 kg is associated with an mean intake of 8301 kcal, with higher values for patients with higher degrees of physical activity.35

Supportive therapy

Regular individual therapy, usually for 1 hour per week, with a counsellor or nurse trained in the treatment of eating disorders, can be effective in the treatment of anorexia nervosa, and may be more helpful in older patients no longer living with their families.19

Specific psychotherapies33

Cognitive behavioural therapy is a very popular technique used for eating disorders in which behavioural change is encouraged with, for example, the use of dietary diaries, homework, avoiding food restriction and finding techniques to deal with other problems such as vomiting, excessive exercise and laxative abuse. Cognitive change is encouraged by challenging misconceptions and distortions, for example, related to self esteem and body image. Cognitive behavioural therapy has been used extensively in the treatment of bulimia nervosa, and recovery rates range from 50 to 70%.37 Interpersonal therapy is a psychological therapy aimed at resolving problems in relationships, and symptoms are dealt with only in so far as they impinge on important relationships.37 It has a similar long-term efficacy to cognitive behavioural therapy, but is less widely available because of restricted training.

Family interventions

Family therapy has been found to be effective in the treatment of younger patients (< 22 years old) with a shorter history (< 4 years) of anorexia nervosa.17 Parents are invited to be in firm control of their daughter’s eating, while avoiding a punitive style, and, most importantly, they are encouraged to work as a team committed to the recovery of their child. Naturally, other issues are the relationships with extended family, siblings; the parents’ relationship may require attention during the course of therapy. For older patients, it may be appropriate to encourage the parents to be somewhat less in control and to promote separation and individuation in the patient.

Social interventions

These might include attention to problems at school and work, particularly if pressures are exacerbating the eating disorder. This occurs in some occupations, including dance, theatre, sport, modelling and fitness-related work.

Treatment of severe malnutrition

General medical care.

The treatment of the severely ill patient with anorexia nervosa requires a combination of high quality medical care and an understanding that the patient may well not co-operate with treatment seen as essential by doctors. This can lead to serious difficulties in treatment and liaison between medical and psychiatric services can be very helpful. Correction of metabolic abnormalities is often best done orally, as derangements may well be chronic. Rapid intravenous correction of, for instance hypokalaemia, can cause fatal hyperkalaemia, whilst simply stopping vomiting and providing potassium-rich foods or oral supplements are a safer option. Subclavian venous lines should be inserted with great caution because of distorted anatomy and friable vessels in the extremely emaciated patient.

Hypoglycaemia should be corrected immediately, while any carbohydrate given to a severely emaciated patient should be preceded by a loading dose of thiamine to prevent Wernicke’s encephalopathy. During re-feeding, hypophosphataemia to extremely low levels can develop and may require correction.38

Use of the Mental Health Act.

Some patients refuse life-saving treatment. If this occurs the patient must be seen by a senior psychiatrist to establish whether compulsory admission and treatment under the Mental Health Act 1983 is appropriate. The Mental Health Act Commission has recently clarified its attitude to anorexia nervosa and confirmed that anorexia nervosa is a mental disorder, that the patients can be admitted compulsorily and that feeding is regarded as part of treatment for the mental disorder, and so can be given against the patient’s will.39 This ensures that patients with anorexia nervosa are not allowed to die if they refuse treatment. However, as the outlook for the disorder depends on the patient’s motivation, the Act should be used rarely, as a way of saving a severely ill patient’s life.

Staff support.

Looking after patients with eating disorders is draining and therapists and other staff may be persuaded to take the patient’s ‘side’ against the rest of the team. Splits can occur in this way within a team, or between a psychiatric team and a medical or primary care team and can be avoided by holding meetings between people working with the patient, in which to establish policy and practice. Professional supervision of therapy for staff members can also help identify and address difficulties such as over-involvement by a staff member who may identify strongly with the patient.

Treatment of osteoporosis in a patient with anorexia nervosa

The only change that is known to lead to improvement in bone density is weight gain and resumption of menstruation.22 Other interventions have been suggested, including hormone replacement therapy, oral contraception and dietary augmentation with calcium and vitamin D.22, 40, 41 However, no adequate controlled study has emerged to favour the use of medication in this condition.

Self-help

A very useful range of books is available to patients and families providing information about, and self-treatment of, anorexia and bulimia nervosa.42[43][44]–45 In some cases the provision of a self-help manual can greatly reduce the requirement for further therapy, and this approach is very suitable for primary care or the hospital out-patient setting.

Prognosis of eating disorders

The Standardized Mortality Ratio (SMR) for eating disorders is among the highest for any psychiatric condition.46 The long-term mortality for anorexia nervosa varies in different studies from 5% to 20%, with the higher figures reflecting longer follow-up.47[48]–49 Of the remainder, something over half make a full recovery, and the rest suffer different chronic eating disorder symptoms.49 For bulimia nervosa, the majority reduce their symptoms over 10 years, and treatment significantly accelerates this process.50 Early intervention in anorexia nervosa improves prognosis, and future attention should be addressed to the detection of eating disorders in adolescence within a year of onset so that chronicity and its complications can be avoided.

Ancillary