By Dr Joseph El-Khoury MD MSc FRCPsych, Assistant Professor of Psychiatry
Eating disorder is a category of mental health disorders that include a range of clinical presentations sharing in common a dysfunctional psychologically driven relation with food. The ICD-11 lists six official diagnoses. Preoccupation with weight and body image is a characteristic of the two better known conditions: Anorexia Nervosa and Bulimia Nervosa. For these, the peak onset is in late adolescence and early adulthood, but they may still appear later in life. Anorexia is a particularly serious illness due to high mortality associated with metabolic complications.
Initially, eating disorders perceived as ills of western developed societies, heavily influenced by modern beauty norms and the fashion industry’s obsession with thinness. Nowadays individuals who suffer from one of the eating disorders come from all walks of life, all social classes, ethnicities and religious background. The condition also affects both genders, with evidence of it having increased in men over the last decades. This may simply because of better detection of cases as a consequence of increased awareness and among healthcare professionals. With all these variables, the stereotypical image of a thin young girl is far from representative of the majority of eating disorders cases. To confuse matters further, the evolution of the illness beyond one diagnostic framework is fairly common. The consequences of having an eating disorder extend beyond the psychological (preoccupation with food, weight, body image) and social (impact on social interaction, relationships, parenting) to the physical health. A recently published large Canadian study revealed that Bulimia was associated with a higher risk of cardiovascular events and related deaths than the general population.
Anyone who has worked in the national Health Service will agree that current mental health services structure is poorly suited for providing the necessary support for all but the most severe cases requiring intensive therapy and hospitalization. The private sector on the other hand can only cater for a small category of privileged patients and for a short period of time. This state of affairs tends to discourage many from seeking professional help, which explains the difficulty in accurately estimating the prevalence of eating disorders in the community. Experts propose a number between 1 and 4 million across the United Kingdom.
This leaves psychiatrists with the challenge of diagnosing conditions that will most likely not receive the needed attention. In terms of what works and what does not work for eating disorders only a few pharmacological agents have shown at best moderate efficacy. These include antidepressants such as SSRIs, some mood stabilizers and stimulants. Others have been investigated inconclusively. Instead medications are used to alleviate comorbidities such as depression, anxiety or insomnia for example. Psychological intervention remains the go-to treatment with several strategies having been tested. The strongest evidence is in favor of specialized versions of Cognitive Behavioural Therapy (CBT) with also an established role for interpersonal therapy and family therapy, particularly in younger patients.
Recognizing and treating eating disorders should be an essential part of the skillset of every general psychiatrist and licensed psychologist. Reliance on specialist services should be reserved for the most challenging cases. It is hoped that raising awareness will help contribute to this desired goal.