How the GP can usefully intervene in eating disorders
Eating disorders have the highest mortality of any mental illness GP Dr Bill Laughey talks to consultant psychiatrist Dr Adrienne Key about practical solutions
hat is an eating disorder? How would you describe the typical girl with anorexia and the typical girl with bulimia?
An eating disorder is a mental disorder, not a mild psychological affliction, as many people wrongly assume. It has the highest mortality rate of all mental disorders. Some deaths are from suicide, but many are due to the severe physical consequences of the illnesses. The aetiology of eating disorders is strongly biological, as well as social and psychological.
It is essentially a constellation of symptoms that includes unusual food or weight manipulation (typically avoidance or binging), psychological disturbance (particularly low self-esteem) and physical consequences such as amenorrhoea.
A classic anorexic girl is in her mid teens, a high achiever at school because she studies hard, and has perfectionist traits. Her parents describe her as the perfect child who was never any trouble and who seems to have bypassed adolescence: rather angelic, adult-like, terribly responsible, almost grown up before her time.
She may disguise her thinness well by wearing layers of baggy clothes. GPs are often unaware they are looking at a girl who is underweight.
She may have unexplained lethargy, low mood or anxiety, poor concentration, amenorrhoea, anaemia or other blood abnormalities, particularly in liver function tests.
A typical girl with bulimia is a bit older, perhaps in her early 20s. She tends to be more outgoing and impulsive and may also be a binge drinker or drug taker. She takes more risks and engages in more novelty-seeking behaviour than the girl with anorexia.
The girl with bulimia may not be underweight, and may indeed be overweight. GPs can look on the backs of the hands for score lines (Russell's sign) or for swollen parotid glands on the jaw line, both caused by repeated vomiting. There may also be abnormalities in the blood results.
Many women do not fit these personality profiles, but the behavioural and physical characteristics of the illnesses will still be present. Very low self-esteem is almost always behind their struggle. Anorexia with bulimic symptoms is common. Some patients return to a normal weight and then develop full-blown 'normal weight' bulimia.
How can I make an early diagnosis in general practice?
People with eating disorders can be secretive and it is rare for them to be explicit about their eating problems in the early stages. However, they may present with stomach upsets, irregular periods or difficulty conceiving and have mildly abnormal blood tests, particularly U&Es and LFTs.
There are questionnaires to help spot the diagnosis, but they rely on the patient being open. These girls feel incredible shame about their food problems and usually seek to hide them. It's sometimes much easier for them to talk about feeling stressed or down. If you are suspicious, the easiest thing is to ask if you can weigh them.
Although classic anorexia involves a body mass index (BMI) of 17.5 and below, there are lots of people with borderline eating disorders whose BMIs are between 17.5 and 20. Some girls will stop their periods with a BMI of 20, whereas others don't stop until the BMI is under 16. If they develop amenorrhoea, biologically speaking they are starving themselves. So BMIs under 20 should raise suspicion.
In children the clue may be failure to grow they may be the right weight for their height but not growing upwards.
How old are the children and do they present differently?
The average age of onset for anorexia is 16. For bulimia it's slightly older. Our child and adolescent unit has an age range from about 12 to 17. True anorexia and bulimia are rare in primary school-age children, who tend to get other sorts of eating disorders. They may have odd eating habits and psychological problems, but lack body image disturbance or any upset about their weight.
Are eating disorders on the increase? Do you now see more men with eating disorders?
Eating disorders are increasing and not just because we are better at detecting them. It's important to recognise that most girls who flirt with weight and food manipulation do stop, but a significant proportion who probably have some biological predisposition unfortunately spiral into eating disorders. More girls are trying weight-related practices and are getting caught out.
Classic anorexia affects about 1 per cent of girls. Classic bulimia in a college population affects about 4 per cent of girls. A group we call EDNOS (eating disorders not otherwise specified) are probably even more common. Some experts call the EDNOS group borderline eating disorders or partial syndromes, although this should not convey they are less important. They have the same physical and psychological consequences as anorexia or bulimia.
Men are said to make up 10 per cent of the eating disorder population, a figure that is increasing. Personally, I have only seen a handful.
Do people with eating disorders suffer mental grief?
Yes, they have high levels of diagnosable depression and anxiety. That said, a girl with anorexia might not be explicit about her distress until she feels her world is no longer controllable through her weight. That's when she starts to experience the anxiety or depression she has kept at bay. Until then, she considers the disorder part of her personality and not odd. Bulimia and depression commonly occur together. Families feel incredibly stressed and controlled.
How do you explain eating disorders to patients, and how do you begin to persuade patients to accept treatment?
I tell them that the food restriction or manipulation is a symptom of emotional upset, and that food and weight are being used to try to keep emotions at bay. Psychologically, it gives them a sense of control over themselves, which gives them their sense of self-worth. It is not about wanting to look good, which people think it is. It is about trying to control themselves in a way that makes them feel better.
There's no point in taking somebody back up to a normal weight if they haven't resolved the problems that existed in the first place. I always explain to patients that some type of psychological intervention that helps them explore underlying feelings is important, but that it's very difficult to get to those feelings while they are starving or using food behaviours.
It is best to start by asking them what is distressing and what they would like to change.
Forming a trusting alliance and empowering the patient is vital. This includes a frank discussion about physical risk and the need for the doctor to take charge if their life is in danger. Over time we hope to help the person realise the 'solution' of weight and food manipulation just makes life worse and that finding other ways to make life liveable is needed.
What are the main medical problems arising from bulimia and anorexia and what monitoring should we do?
Osteoporosis is the main long-term problem with anorexia. Gastrointestinal disturbances are common as are heartburn and oesophagitis from repeated vomiting, constipation from poor eating and diarrhoea from laxative abuse. There may be potassium disturbances from vomiting or diuretic abuse. Starvation can affect LFTs. Amenorrhoea is common, as is infertility which should raise suspicion of an eating disorder.
Some women with anorexia or bulimia can conceive but the risks to the baby are substantial. Miscarriage rates may be doubled and perinatal mortality is six times the normal rate.
For all people with eating disorders there is a high risk of premature death from starvation, metabolic complications and suicide.
Bearing in mind not everybody will agree to be referred, who particularly needs referring? What are the good and poor prognostic signs?
Most people need referring. If the patient doesn't want to be referred you can recommend the Eating Disorder Association (www.edauk.com) which has a wealth of information for both GP and patient and runs self-help groups in lots of areas. This is sometimes the best way to find out about help without feeling pressurised.
Those with a BMI below 15 may need inpatient or day-patient care. Bulimia nervosa can usually be treated on an outpatient basis, sometimes even through self-help manuals, but again this needs to be co-ordinated by a professional in eating disorders.
Good prognostic signs include short duration of illness and generally good functioning in social and family life. Bad prognostic signs include long duration of illness, severe weight loss and co-morbid disorders such as substance misuse and personality disorders.
What treatments are effective and how successful are they? Why is a higher dose of fluoxetine used and is it always necessary?
The treatment of choice for bulimia is cognitive behaviour therapy (CBT). We have an outpatient programme in which about 80 per cent of patients improve. These are better than average rates, as the general consensus is 40 per cent of patients should improve.
The jury is out on the best treatment for anorexia. For adolescents, the best approach involves working with their families. Adults with anorexia and those with very low weight probably need to be inpatients or day-patients.
We offer a comprehensive programme of weight gain with psychodynamic individual and group therapy delivered by a multidisciplinary team. We include practical therapies and CBT. The whole treatment lasts two years. It sounds a long time but that's how difficult this illness is to treat.
Research suggests a third of anorexia patients get better, a third follow a partial or chronic course and a third become more severely ill with up to a 10-20 per cent dying.
Some individuals benefit from fluoxetine, but the value of medication is limited and the most important interventions are psychological treatments. Most trials demonstrate if you just give somebody fluoxetine they drop out of treatment.
Are there any effective interventions a GP can make early on?
You need to demonstrate to the patient you understand these disorders are linked to how they feel about themselves and their self-esteem. They may need to talk to a GP or a counsellor.
The way in is to say that 'when people are having issues with their weight or with food it usually means they are not happy about something or about themselves.... is that the sort of thing that is happening to you?'. If you can form an alliance, you can start to discuss physical consequences and improve motivation for treatment.
Are eating disorders the product of thin models and celebrities? And what about the problem with internet groups enticing girls into weight-related practices?
Although our environment must be important because eating disorders predominately arise in western society, we don't all develop them. It seems you need a genetic predisposition. Anorexia and bulimia run in families and twin studies show this is due to hereditary factors, not just family environment.
Research suggests the genetic component may be conveyed in a number of ways, including temperamental differences. People with anorexia may be hard-wired for high levels of perfectionism, anxiety and a trait called harm avoidance (avoiding novelty). These traits could lead to low self-esteem and greater susceptibility to the food- and weight-related messages that society sends out.
You're right about some internet chat rooms. I don't know what the answer is but they have the potential to wreak havoc.
How the GP can usefully intervene in eating disorders
There's no point taking somebody back up to a normal weight if they haven't resolved the emotional side~
How the GP can usefully intervene in eating disorders
Anorexia and bulimia run in families and twin studies have shown this is due to hereditary factors~