Consultant child and adolescent psychiatrist Dr Jane Morris offers GPs her advice on managing eating disorders
1 ‘Anorexia’ and ‘eating disorders’ are misnomers. Appetite is not lost and eating is not the only thing that is disordered. Think of ‘OWLS and other BIRDs’ – Obsessive Weight Losing Syndromes and other Body Image Related Disorders.
2 Bear in mind the range of strategies and behaviours. Strategies used to increase fat burning include excessive physical activity, purging – vomiting, laxatives and diuretics – diet pills and ‘slimming aids’ of all sorts. Body-checking behaviours such as weighing, measuring and mirror-gazing are compulsive. These are not only obstacles to weight gain, they also damage quality of life and make people social outcasts.
3 Eating disorders are not crimes. Patients say they are ‘accused’ of anorexia. Ask about body image worries and suggest in a matter-of-fact way that people often find themselves trying to manipulate body shape as a way to feel better. Remember that at least 10% of sufferers are male.
4 Patients who can maintain very low weight for long periods may be genetically and neurochemically different from normal-weight bulimic patients. Low-weight patients are at massively increased risk from binge-purge behaviours, electrolyte shifts, infections, accidents and overdoses. Psychological symptoms secondary to starvation cannot be treated without renutrition.
5 Patients who have relapsed repeatedly are more vulnerable, and those with co-morbid physical conditions are especially fragile. Life-threateningly ill patients need you to take control – this is a GP’s medicolegal duty. Admission to a specialist unit or an experienced medical ward is preferable as general adult psychiatric wards rarely have appropriate resources.
6 Map trends in weight. Anorexic patients who gain weight may display florid distress, while those who lose weight dangerously seem calm. Clinicians who don’t know the patient’s weight will be unable to assess mood and risk accurately. Plotting a graph is the most sensitive index of whether renutrition is proceeding healthily. Tell patients they are less likely to need hospital admission if they can tolerate outpatient monitoring. Weigh people shoeless in light indoor clothing after they have emptied their bladder, at the same time of day. Explain that patients often ‘fake’ weight, loading pockets or orifices, or ‘waterloading’ – a dangerous practice. This frustrates the collaborative effort.
7 All starved patients become depressed but antidepressants won’t work at low weight. Conversely, normal-weight bulimic patients benefit from high-dose antidepressant medication whether or not they meet criteria for depressive disorder. Fluoxetine 60mg daily has the most extensive evidence base. Prescribe alongside bibliotherapy – see further reading.
8 Use a ‘motivational enhancement’ approach.
• Anticipate Ambivalence – patients are terrified that if they give up their habitual behaviours they will get fat.
• Express Empathy – with open-ended questions and reflective listening skills. People are more likely to act upon ideas that come out of their own mouths.
• Roll with Resistance – don’t get into a fight leading to a situation where you are attacking the eating disorder and the sufferer is defending it.
• Support Self-efficacy – help sufferers draw up a realistic programme for change, identifying personal goals and strengths.
9 Family psychopathology is as likely to be the result as the cause of compulsive weight-losing behaviour. Family-based work is the best evidenced treatment for anorexia nervosa. Straightforward support and psycho-education for parents may be superior to conventional ‘conjoint’ therapies.
10 Normal weight is not the only criterion of recovery. Others include normal eating behaviour, appropriate social and psychosexual skills, the ability to live and work independently, accepting an imperfect body image, and exercising normally without obsessive overactivity.