How should we treat eating disorders?
With NICE about to publish guidelines on eating disorders, Dr Jonathan Baggott and Dr Janice Bartlett take a look at what may be recommended and what GPs can do
What are eating disorders? How should we treat them?
The National Institute for Clinical Excellence is due to publish guidelines later this month. What is NICE likely to say?
Draft guidelines have already been published and are available from various websites1,2.
The eating disorders are usually divided in to three main groups: anorexia nervosa, bulimia nervosa and atypical eating disorders. The diagnostic criteria for each of these groups are as follows:
· Low body weight (body mass index of 17.5kg/m2 or less)
· Self-induced weight loss by avoidance of fattening foods. May also use purging, vomiting, excessive exercise, various drugs.
· Body image distortion
· Binging, which is persistent
· Attempt to counteract fattening effects of food by either: self-induced vomiting; purgative abuse; alternating periods of starvation; use of drugs such as appetite suppressants, thyroid hormones, diuretics and so on.
· Morbid fear of fatness.
Atypical eating disorders
· Disordered eating of clinical severity not explained by alternative diagnoses.
How do people with eating disorders present and what should you do?
Like any condition they can present in a number of ways, either complaining of their eating problem themselves or under duress from parents or other loved ones. More rarely it may be because of their general physical state that they present. Often as their GP you may well be the first person they have informed. There may be a great deal of guilt, self-loathing and generally feeling ashamed of what they are doing.
If presenting under duress they may express a refusal to do anything about their problem. Whichever eating problem presents, the first few minutes of the consultation are often crucial. One must be empathic and the patient must view it as such. A simple question such as 'what did you feel about coming to see me today?' is often a good way to start a discussion that may well become quite complex and have much mixed feeling within it.
Problems of this complexity do not fit well into the 7.5-minute consultation and therefore inviting the patient back for a second and possible longer consultation may well be fruitful if an empathic trust has been established. Further on in the interview you may find the patient informs you of a variety of odd and bizarre methods of eating and controlling their weight. Being aware that this may happen helps modify the reaction you may inadvertently give, and enables you to present a more empathic attitude.
Additionally, understanding that the weight and eating is a way of expressing complex emotional issues that have become entangled with this most basic of biological needs will help one avoid an unhelpful judgmentalism.
What should GPs ideally do?
In anorexia the most difficult task is engagement. The ideal outcome for the GP is for the patient to agree to treatment from a mental health team specialising in eating disorders. Low-weight patients do not need to lose much more weight before they can run into extremely serious physical problems and require referral as a consequence. If severe malnutrition is the presentation it may be necessary to enlist the help of secondary care physicians. Indeed, anorexia has the highest mortality rate of any functional psychiatric illness, although the majority of patients eventually recover given time.
An empathic approach that allows the patient to trust is the key to starting to treat this illness.
There is an excellent book on the assessment and treatment of eating disorders that is also concise and inexpensive (Helping People With Eating Disorders a clinical guide to assessment and treatment by Bob Palmer). Written primarily for primary and secondary care clinicians it may also be found useful by patients and their families. Anyone who has an anorexic patient will find this little book invaluable. It covers many of the issues that cannot be covered here.
What will NICE say?
NICE is likely to suggest that most adults with anorexia nervosa be managed on an outpatient basis with a psychological treatment provided by a health care professional competent in the psychological treatment and assessment of physical risk of people with eating disorders.
Moving on to bulimia nervosa, the evidence base for treatment of bulimia is far more extensive than for anorexia. The most effective treatment to date appears to be a modified version of cognitive behavioural psychotherapy (CBT-BN)4. However, a small study published recently suggests patients treated in primary care with a self-help manual and contact with their GP did just as well as those treated at outpatient clinics5.
NICE is likely to suggest there are two possible first steps in treating bulimia nervosa:
· Encourage to follow an evidence-based self-help programme. This should be done in conjunction with encouragement and support from a health care professional, for example by using the book Overcoming Binge Eating Disorder by Professor Chris Fairburn, or Getting Better Bit(e) by Bit(e) by Schmidt and Treasure.
· Trial of antidepressant drugs (ie fluoxetine at a dose of 60mg daily, gradually build up to this level over a couple of weeks and trial at full dose for approximately six-eight weeks to assess response). Both of these approaches are suitable for primary care.
The physical status of these patients also requires attention. Persistent vomiting has the potential to cause many physical complications, in particular electrolyte disturbances, and these may cause cardiac arrthymias and potential cardiac arrest. Therefore all patients complaining of frequent vomiting should have urea and electrolytes measured as standard. Low potassium will often require replacement therapy with potassium supplements (eg Sando-K) if the vomiting continues.
Should these approaches prove insufficient, referral on for more formal psychotherapy will be necessary.
Atypical eating disorders are something of a research desert, despite being more common than either anorexia or bulimia. The pragmatic way to manage these conditions is to try to ascertain which condition it is most similar to, and use that approach. This is also likely to be the advice from NICE.
· Anorexia nervosa has the highest mortality rate of any functional psychiatric illness
· Those with anorexia should be referred on to specialist services
· Empathy and trust is the key to treating anorexia and the key to encourage patients to actually attend for an outpatient assessment
· Bulimia nervosa may be treated first-line by using an evidence-based self-help programme
· Alternatively fluoxetine at a dose of 60mg may be used as first-line treatment of bulimia
Helping People With Eating Disorders a clinical guide to assessment and treatment by
Bob Palmer. Published by Wiley. 2000
Overcoming Binge Eating Disorder by Chris Fairburn. Published by Guildford Press. 1995
Getting Better Bit(e) by Bit(e) by Schmidt and Treasure. 1993
Eating Disorders Association website. Provides education, links to self-help groups, appraisals of self-help books, a telephone helpline and suggestions of how one can get help.
3 The ICD-10 classification of mental and behavioural disorders. Clinical descriptions and diagnostic guidelines. WHO, 1992
4 Fairburn CG et al. Cognitive-behavioural therapy for binge eating and bulimia nervosa: a comprehensive treatment manual. In: Fairburn CG, Wilson GT, eds. Binge eating: nature, assessment, and treatment. New York: Guildford Press, 1993
5 Durand MA, King M. Specialist treatment versus self-help for bulimia nervosa: a randomised controlled trial in general practice. The British Journal of General Practice. 2003;53:371-377