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Eating Disorders - The Facts

Anorexia nervosa and bulimia nervosa are the most commonly recognised eating disorders, but other diagnostic categories exist including binge-eating disorder and eating disorder not otherwise specified (EDNOS). It probably reflects the paucity of research into this most complex area of medicine that EDNOS is in fact the most common presentation of eating disorders i.e. a mixture of both anorexia and bulimia.

The rate of prevalence of eating disorders in the population is not clearly understood. Most sufferers never come to the attention of doctors or researchers but it is estimated that the prevalence is around 30 people per 100,000 of the population, with up to 2 per cent of young women thought to have full-syndrome eating disorders.

The rates of anorexia appear to have remained the same over time and indeed historically anorexia has been recognised as a condition for hundreds of years. Bulimia, on the other hand, has only relatively recently been identified as a major condition and its incidence appears to be increasing. There have been many reasons suggested for this but it is likely that social factors may be the cause of these apparent increases. These factors include value placed on slimness and dieting in society, also other underlying reasons such as genetics and characteristic personality traits such as perfectionism, over-compliance and negative self evaluation.

Traditionally, family issues are often highlighted although this may be a response to the illness rather than being the cause. The stereotype is of a rather enmeshed, overprotective or rigid family structure for anorexia, whilst bulimia is often considered to be linked to families with poor boundaries and difficulty resolving conflicts. The truth is clearly much more complicated and whilst family or systemic therapy has the best evidence of any treatment for anorexia, it is vitally important that families do not feel blamed – rather that they need to learn new ways of responding and relating to each other.

Bulimia has a developed, robust evidence base for treatment. In contrast, little progress has been made with evidence-based recommendations for anorexia despite significant suffering, morbidity and cost. Guidance on anorexia outlined in the NICE eating disorders guidelines remains predominantly the result of expert consensus rather than clear evidence as to the most effective treatments.

There are a number of reasons why this might be so. There is little doubt that there has been limited robust research. Perhaps this is because the complexity of eating disorders makes comparisons between sufferers of relatively limited validity. There are so many reasons why a person might develop the symptoms of anorexia or bulimia. Often all that links them is the manifestation of their symptoms – fear of gaining weight etc. The reasons for developing these symptoms might be due to overwhelming life events, personality features (e.g. excessive rigidity or compliance), losing one’s way in life, the result of an obsessive compulsive disorder, an attempt to manage overwhelming emotions, or a complex mixture of all of the above or more.

In essence, treatment involves a variety of areas. At very low weights or BMIs (Body Mass Index, a crude measure of a body’s relative weight compared to the normal population), specialist medical treatment is often unavoidable. Anorexia probably carries the highest probability of death of any psychiatric disorder. Once medically stable, specialist treatment can begin. This treatment needs to address a variety of areas and use many treatment modalities.

Unfortunately, medication is of little use in the treatment of anorexia.. Once the conditions become moderately severe, eating disorders require a specialist and comprehensive assessment. Treatment then needs to be tailored to the individual nature of the problems. Having said that, the physiological effects of starvation produce predictable patterns of symptoms, behaviour and thinking – often to the extent that sufferers and their families forget the extent to which an individual’s personality might have appeared to change.

Treatment requires optimism, consistency, hope, thoughtful confrontation, motivation, psychotherapy, medial monitoring, and experience. Eating disorders are deceitful conditions, often rendering the sufferer seemingly manipulative. Most often this is the “voice” of the illness, overwhelming the sufferer with a morbid fear of food and weight and trying to dominate and control. Indeed relinquishing control is the thing the what the patient fears the most.

Treatment needs to address the totality of what has become of an individual’s life. Often anorexia limits relationships and normal development. Friends, education, and hobbies can all fall by the wayside and treatment must address this, otherwise what is to be gained by taking the courageous step of challenging one’s deepest fears?

A proportion of patients have such ingrained or overwhelming fears that constant specialist support is necessary to overcome anorexia. Bulimia less frequently requires lengthy inpatient stays, unless accompanied by low weight. Current trends mean that inpatient treatment is denied to many unless physical health is dangerously threatened. Unfortunately, this means that there is often a complete breakdown in social networks and relationships, making recovery that much more difficult.

Eating disorders can be beaten. Recovery requires a holistic approach to treatment, but, with comprehensive support, it can be achieved. Organisations such as BEAT can provide guidance, support and information. Many Health Authorities offer some specialist treatment but unfortunately many still do not. Once of moderate severity, specialist intervention is usually required.