Download 031104Understanding eating disorders

CLINICAL
FOCUS
Understanding eating disorders
Fairburn, C.G. et al (1993) CognitiveBehavioural Therapy for Binge Eating
and Bulimia Nervosa: A Comprehensive
Treatment Manual. In: Fairburn, C.G.,
Wilson, G.T. (eds) Binge Eating: Nature,
Assessment and Treatment. New York,
NY. The Guilford Press.
Fairburn, C.G. (1995) Overcoming
Binge Eating. New York, NY.
The Guilford Press.
Fairburn, C.G. (1997) Interpersonal
Psychotherapy for Bulimia Nervosa. In:
Garner, D.M., Garfinkel, P.E. (eds)
Handbook of Treatment for Eating
Disorders: New York, NY.
The Guilford Press.
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
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;
● Self-harm;
● Drug and alcohol misuse.
The physical consequences of eating disorders can
BOX 1. SIGNS AND SYMPTOMS OF EATING DISORDERS
ANOREXIA NERVOSA
eliberate weight loss to a point at least 15 per cent
D
below that expected for age, sex and height
● Changes in hormone levels, which in females result in
amenorrhoea. If the weight loss occurs before
puberty, sexual development will be delayed and
growth
may cease
● The person feels driven to lose weight because he/
she sees him/herself as fat, even at a subnormal
weight
● The person is intensely afraid of becoming fat and is
preoccupied with worries about body size and shape
● The person directs all his/her efforts towards
controlling his/her weight by restricting food intake,
but may also binge eat, self-induce vomiting, misuse
laxatives or diuretics (purging behaviours), exercise
excessively or misuse appetite suppressants
●
BULIMIA NERVOSA
F requent episodes of binge eating, in which the
person consumes a large amount of food within a
short time
● An overwhelming urge to binge. The person can only
stop eating once it becomes too uncomfortable to eat
●
20 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).
any
morefeels unable to control his/her appetite and
the
person
● Feelings
of gain
guilt, anxiousness and depression,
fears
weight
because
● T
he person tries to regain control by getting rid of the
calories consumed. The most common method is
vomiting, but may involve misuse of laxatives, diuretics
or appetite suppressants, fast or excessive exercise
● The person is usually within a normal weight range,
but may be obese
ATYPICAL EATING DISORDER
T he person does not quite meet the diagnostic criteria
for anorexia nervosa or bulimia nervosa (for example,
laxative abuse)
● The person may vomit after eating small amounts of
food
● The person may admit to chewing food and then
spitting it out
● The person may binge eat, but not attempt to get rid
of the calories consumed, known as binge eating
disorder (Garfinkel, 2002). The phrase compulsive
eating is sometimes used, but has never been
adequately defined
● The person may eat for emotional reasons (comfort
eating), but not eat large amounts of food at one time
●
SPL
REFERENCES
Anderson, A. (2002) Eating Disorders in
Males. In: Fairburn, C.G. and Brownell,
K.D. (eds) Eating Disorders and
Obesity: A Comprehensive Handbook.
New York, NY. The Guilford Press.
AUTHORS Sam Clark-Stone, clinical coordinator, Eating
Disorders Project, Gloucestor, Heidi Joyce, clinician,
Eating Disorders Project, Gloucester.
ABSTRACT Clark-Stone, S., Joyce, H. (2003) Understanding eating disorders. Nursing Times; 99: 44,
20–23.
Eating disorders can be severe and enduring mental
illnesses that have serious physical, psychological and
social consequences. They can also have a significant
effect on the person’s friends and family. 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. Eating disorders can be mild and
self-limiting, but they commonly run a chronic course
unless treatment is successful. Nurses play an important role in early detection, assessment and treatment.
NT 4 November 2003 Vol 99 No 44 www.nursingtimes.net
KEYWORDS
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;
● Shoplifting.
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).
Predisposing factors
These can be:
● Psychological and emotional – including low selfesteem 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.
Precipitating factors
■
Mental health ■ Eating disorder ■ Therapy
BOX 2. PHYSICAL EFFECTS AND CONSEQUENCES
OF AN EATING DISORDER
1. SEVERE WEIGHT LOSS – BMI<13
This can lead to:
● Hunger;
● Decreased heart rate, blood pressure, temperature
and respiration;
● Poor peripheral circulation (feeling cold);
● Cuts or bruises healing slowly;
● Excess hair growth (lanugo) on the body;
● Sleep disturbance;
● Hormonal changes lead to a loss of libido and
amenorrhoea;
● Thinning of the bones (osteoporosis);
● Weight loss or failure to make expected weight gain
in children will stop or prevent pubertal
development and can lead to failure to grow in
stature;
● Anaemia;
● Low blood glucose (can cause fainting);
● Loss of physical stamina and muscle control;
● Delayed gastric emptying;
● Constipation;
● Binge eating;
● Death.
Fairburn, C.G., Harrison, P.J. (2003)
Eating disorders. The Lancet, 361, 407–
416.
Fairburn, C.G. et al (2003) Cognitive
behaviour therapy for eating disorders:
a ‘transdiagnostic’ theory and
treatment. Behaviour Research and
Treatment, 41, 509–528.
Garfinkel, P.E. (2002) Classification and
diagnosis of eating disorders. In:
Fairburn, C.G., Brownell, K.D. (eds)
Eating Disorders and Obesity: A
Comprehensive Handbook. New York,
NY. The Guilford Press.
Garner, D.M. (1997) Psychoeducational
principles in treatment. In: Garner, D.M.,
Garfinkel, P.E. (eds) Handbook of
Treatment for Eating Disorders. New
York, NY. The Guilford Press.
2. VOMITING (more than twice a day)
This can lead to:
● Irregular menstrual periods;
● Excess consumption of carbohydrate causes a
temporary increase in temperature, pulse rate and
fluid retention;
● Discomfort and distension of the stomach;
● Dental erosion;
● Dehydration and loss of essential body salts
(electrolytes);
● Loss of potassium (hypokalaemia);
● Cardiac arrhythmias and occasionally cardiac arrest;
● Tiredness, weakness, pins and needles and muscle
spasms;
● Occasionally, epileptic fits or kidney damage occurs;
● Enlargement of salivary glands;
● Sore throat;
● Rebound fluid retention on stopping laxatives;
● Damage to the functioning of the bowel.
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.
● Interactional – including relationship problems and
secondary gain;
● Cultural – including pressures on women with regard
to their appearance.
Perpetuating factors
Body image
These include:
● 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;
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-
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REFERENCES
This article has been double-blind
peer-reviewed.
For related articles on this subject
and links to relevant websites see www.
nursingtimes.net
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FOCUS
REFERENCES
Hoek, H.W. (2002) Distribution of eating
disorders. In: Fairburn, C.G., Brownell
K.D. (eds) Eating Disorders and
Obesity: A Comprehensive Handbook.
New York, NY. The Guilford Press.
Luck, A.J. et al (2002) The SCOFF
questionnaire and clinical interview for
eating disorders in general practice:
comparative study. British Medical
Journal, 325, 755–756.
Morgan, J.F. et al (1999) The SCOFF
questionnaire: Assessment of a new
screening tool for eating disorders.
British Medical Journal, 319, 1467–
1468.
Stein, A. (2002) Eating Disorders and
Childrearing. In: Fairburn, C.G., Brownell,
K.D. (eds) Eating Disorders and
Obesity: A Comprehensive Handbook.
New York, NY. The Guilford Press.
Wilson, G.T., Fairburn, C.G. (2002)
Treatments for eating disorders. In:
Nathan, P.E., Gorman, J.M. (eds) A guide
to treatments that work. London:
Oxford University Press.
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).
T he hormonal disturbance in men results in loss of
libido, loss of early morning erections and sexual
performance
● Males display higher rates of co-morbid depression
and substance misuse
● Studies suggest men have lower bone mineral
density, thus heightening the risk of osteoporosis
● Men have a higher rate of pre-morbid obesity (50
per cent)
● Figures suggest a raised rate of homosexual
orientation (20 per cent)
● Increasing prevalence of the reverse form of
anorexia nervosa – ‘muscle dysmorphia’, where
people develop their muscles, but perceive
themselves as puny. This is associated with male
body builders and abuse of steroids
●
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.
22 BOX 3. MALE-SPECIFIC FEATURES OF EATING
DISORDERS (ANDERSON, 2002)
Treatment options
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 oneyear 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
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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).
Practice nurses
The role of nurses in prevention
and early intervention
Health visitors
School nurses, practice nurses and health visitors all have
a role to play in the detection and initial management of
people with eating disorders.
School nurses
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.
BOX 4. THE SCOFF QUESTIONS*
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 in a
three-month period?
Do you believe yourself to be Fat when others say you
are too thin?
Would you say that Food dominates your life?
*One point for every ‘yes’; a score of two indicates a
likely case of anorexia nervosa or bulimia
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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 selfhelp 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).
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
Current research
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).
Conclusion
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. ■
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