ABC of eating disorders

80 Pages·2008·1.682 MB·English

by  Jane Morris

Eating Disorders
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Eating Disorders
EDITED BY
Jane Morris
Consultant Psychiatrist
Child and Adolescent Mental Health Service
Royal Edinburgh Hospital
Edinburgh, UK
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This edition fi rst published 2008, © 2008 by Blackwell Publishing Ltd
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Library of Congress Cataloging-in-Publication Data
ABC of eating disorders / edited by Jane Morris.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-7279-1843-5
1. Eating disorders. I. Morris, Jane, 1951-
[DNLM: 1. Eating Disorders--Handbooks. WM 34 A134 2008]
RC552.E18A23 2008
616.85’26--dc22
2007038358
ISBN: 978-0-7279-1843-7
A catalogue record for this book is available from the British Library.
Set in 9.25/12 pt Minion by Newgen Imaging Systems Pvt. Ltd, Chennai, India
Printed and bound in Singapore by COS Printers Pte Ltd
1 2008
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Contents
Contributors, vi
Preface, vii
1 Diagnosis of Eating Disorders, 1
Jane Morris
2 Causes of Eating Disorders, 5
Bob Palmer
3 Body Image Disturbance in Eating Disorders, 9
Glynis Read and Jane Morris
4 Compulsive Exercise and Overactivity in Eating Disorders, 15
Jane Morris
5 Medical and Psychological Consequences of Eating Disorders, 20
Geoffrey Wolff and Janet Treasure
6 Comorbidity, 26
Alex Yellowlees
7 What can a GP do? Management of Eating Disorders in Primary Care, 30
Jane Morris and Nadine Harrison
8 Psychological Support within the General Practice, 34
Jane Morris and Nadine Harrison
9 Advice, Education and Self-help, 39
Chris Williams and Ulrike Schmidt
10 Specialist Referral, 43
Jon Arcelus and Bob Palmer
11 Medico-legal and Ethical Issues in the Treatment of Eating Disorders, 47
Anne Stewart and Jacinta Tan
12 Children with Eating and Feeding Disorders, 52
Jane Morris and Fiona Forbes
13 Eating Disorders in the Family, 56
Jane Morris and Fiona Forbes
14 Eating Disorders in Boys and Men, 59
Brett McDermott
15 The Sufferer’s and Carer’s Viewpoint, 62
Jane Morris, Ian MacDonald, Rosemary Stewart, Grainne Smith and Heather Marrison
Index, 67
v
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Contributors
Jon Arcelus Ulrike Schmidt
Consultant Psychiatrist, Leicester Eating Disorders Professor of Eating Disorders, Section of Eating Disorders,
Service, Leicester General Hospital, Leicester, UK Institute of Psychiatry, King's College London, London, UK
Fiona Forbes Grainne Smith
Consultant Psychiatrist, Child and Adolescent Mental Health Carer and Writer, Stonehaven, UK
Service, Royal Edinburgh Hospital, Edinburgh, UK
Anne Stewart
Nadine Harrison Consultant Adolescent Psychiatrist, Oxfordshire and
General Practitioner, Richard Verney Medical Centre, Buckinghamshire Mental Health Partnership NHS Trust and
University of Edinburgh, Edinburgh, UK Honorary Senior Lecturer, University of Oxford, Oxford, UK
Ian MacDonald Rosemary Stewart
Carer, Glasgow, UK Carer and Counsellor, Edinburgh, UK
Jacinta Tan
Heather Marrison
Senior Clinical Research Fellow and Honorary Consultant Child and
Former Service User, Edinburgh, UK
Adolescent Psychiatrist, The Ethox Centre, University of Oxford, Oxford, UK
Brett McDermott
Janet Treasure
Associate Professor, Mater Child and Youth Mental Health
Professor, Department of Academic Psychiatry,
Service, University of Queensland, South Brisbane, Australia
King’s College London, London, UK
Jane Morris Chris Williams
Consultant Psychiatrist, Child and Adolescent Mental Health Senior Lecturer in Psychiatry and Honorary Consultant
Service, Royal Edinburgh Hospital, Edinburgh, UK Psychiatrist, NHS Greater Glasgow and Clyde Psychological
Medicine, Gartnavel Royal Hospital, Glasgow, UK
Bob Palmer
Honorary Professor of Psychiatry, University of Leicester, and Consultant Geoffrey Wolff
Psychiatrist, Leicester Eating Disorders Service, Leicester, UK Consultant Psychiatrist, Gerald Russell Eating Disorders Unit, South
London and Maudsley NHS Foundation Trust, London, UK
Glynis Read
Alex Yellowlees
Senior Therapist, Head of Training, Castle Craig
Hospital, Blyth Bridge, Edinburgh, UK Consultant Psychiatrist, Medical Director, Priory Hospital, Glasgow, UK
vi
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Preface
A few years ago we wondered why on earth there was no ABC of to Eleanor Lines of BMJ Books for her enthusiasm and refusal to
Eating Disorders in the well-known series. Accessible paperbacks let me give up, and to Mary Banks and Adam Gilbert at Blackwell
and websites are devoured avidly by patients and their families, and Publishing for taking over, taking care to preserve what was
there is no lack of scholarly works by and for specialists. General good and encouraging me to expand the scope of the book from a
practitioners frequently fi nd themselves less knowledgeable than the ‘picture book’ to a more authoritative account.
patients or parents so desperate for their help––or so self- destructively It is certainly still an ABC––informing a compassionate Attitude,
avoiding it. General psychiatrists have focussed their expertise on psy- understanding Background causes and formulating effective Caring
choses and depressive disorders, with the result that a general adult strategies. I have become steadily more convinced, though, that
psychiatric ward can be the most dangerous place to admit someone ‘Eating Disorders’ is an unhelpful misnomer for conditions whose
with anorexia nervosa. Meanwhile hospital physicians and nurses roots are merely refl ected in eating––as well as other––behaviours,
fi nd it hard to tolerate the apparent self-destructiveness. and which certainly do not respond to treatments aimed in a
There was clearly a need for basic primer for doctors, spanning blinkered way at ‘correcting’ weight and eating.
but differentiating Anorexia and Bulimia nervosa and Childhood I am grateful to authors and co-authors for their generous
eating disorders. In fact we have aimed the text at professional read- response and for burning midnight oil to write to deadlines after
ers of all disciplines who work with eating disorders––either as a their long day jobs. And to Alice Nelson who has miraculously
primary diagnosis or arising in the course of something else. Many helped us all meet the deadlines. Particular thanks to the suffer-
lay carers and sufferers themselves will be able to read and appre- ers and carers who agreed to revisit painful memories and to write
ciate the information. It may still have something to teach those frankly about them––I resisted suggestions that we might tone
embarking on specialist eating disorders careers but the primary down criticisms of our profession. However, it is to our wonder-
aim is general practitioners and their colleagues in the commu- ful medical students––particularly those who aspire to General
nity who––more than ever––need to incorporate a sophisticated Practice––that I should like to dedicate the ABC of Eating Disorders,
awareness of this fi eld into their professional practice. in the hope and faith that a future generation of doctors will be able
It was naïve, though, to think that meeting such an obvious need to offer a more intelligent and compassionate approach.
would be straightforward. Like many of my young patients, this
book has had to survive a series of transitions. Particular thanks Jane Morris
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CHAPTER 1
Diagnosis of Eating Disorders
Jane Morris
OVERVIEW Box 1.1 Mortality in eating disorders
(cid:127) ‘Eating disorders’ is a misnomer for obsessive weight-losing
Sten Theander’s early follow-up studies found that a shocking 20%
disorders (‘anorexia nervosa’) and other body image-related
of anorexic patients died of causes related to the disorder. Even
disorders (‘bulimia nervosa’ and ‘binge eating disorder’).
now, mortality in anorexia nervosa is 10 times that in the general
(cid:127) Sufferers value weight loss, and see their weight-losing population and is among the top three or four causes of death in
behaviour as essential to avoid fatness. A sympathetic climate of teenagers. Today’s lower mortality fi gures partly refl ect changes in
awareness is essential for diagnosis. diagnostic criteria—we now require only 15% body weight to be
(cid:127) At low weight, the physical and psychological consequences of lost before making the diagnosis (or BMI below 17.5) compared
starvation amplify the obsessive drive for thinness and cause risk with 25% (BMI below 15).
to life. Improved management may also contribute to more favourable
(cid:127) At low weight physical risk results from impaired resistance to longevity—it is now acknowledged that a tolerant, respectful
infection, self-poisoning (accidental or deliberate), electrolytic relationship allows long-term physical monitoring and support to
instability and damage to heart muscle. be offered during the years it often takes for patients to summon
the motivational strength to overcome their obsessive weight-losing
(cid:127) Quality of life can be improved long-term by diagnosing eating
behaviour. A signifi cant minority do not fully recover but are at least
disorders and remaining engaged so that risk can be managed
enabled to live valuable or tolerable lives.
during the long recovery process.
Some deaths result from ambivalently-taken overdoses that would
not have killed healthy weight individuals. Although starvation
almost inevitably results in depression, we cannot conclude that
Most people occasionally experience disordered eating, and resolve all these ‘suicides’ were intended as such. Likewise, the effects of
to be more restrained. Women—who make up 90% of sufferers substance abuse are greatly amplifi ed at low weight. The majority of
from eating disorders—especially struggle between appetite and deaths occur in winter months: hypothermia, infections (including
food adverts on one hand, and the dictates of fashion designers and tuberculosis) and organ failure account for many more fatalities. The
warnings of obesity experts on the other. Ten per cent of teenage starved heart is especially vulnerable when overexercised.
girls induce vomiting from time to time, and 4% of young women
will develop a signifi cant eating disorder during their life. How
can we distinguish between transient disordered eating and more
self-induced vomiting, compulsive activity and exercise, use of
lasting problems that damage health—and, in the extreme, threaten
laxatives, diet pills, herbal medicines and deliberate exposure to
life itself (Box 1.1)?
the cold are some of the behaviours seen in the pursuit of thinness.
Eating behaviours span a range of body weights, behavioural and
For the majority of eating disordered people today, the pursuit of
psychological disturbances (Figure 1.1). There are core diagnostic
thinness seems like a culturally endorsed solution to life’s diffi cul-
criteria for anorexia nervosa (AN) (Box 1.2), bulimia nervosa (BN)
ties and a route to better self-esteem (Box 1.4). For the minority
(Box 1.3) and—most recently—for binge eating disorder (BED).
with low weight AN, cultural factors coexist with a predisposition
Patients should be treated according to the ‘best fi t’ of symptoms.
to experience satisfaction or relief as a result of weight loss. This
‘addiction’ to self-starvation can exist even in the absence of cul-
What are ‘eating disorders’? tural approval of thinness.
In fact eating is not the only disordered behaviour in what might
What is anorexia nervosa?
be better thought of as ‘weight-losing disorders’. Self-starvation,
The core feature of AN is deliberate weight loss, with fear of
ABC of Eating Disorders. Edited by J. Morris. © 2008 Blackwell Publishing, weight gain, and a problem of body image which translates all the
ISBN: 978-0-7279-1843-7. patient’s distress into a perception that their body is too fat. To meet
1
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2 ABC of Eating Disorders
BED Box 1.4 Eating disorders in ethnic and cultural minorities
(cid:127) Wilful starvation may not be associated with an overvaluation of
weight and shape even in Westernized families.
AN BN
(cid:127) For some patients—particularly devout young Muslim girls—an
Obesity
association with religion may be apparent, with starvation-induced
obsessionality dictating many extra prayer rituals, and with fasting
carrying religious rather than ‘slimming’ overtones.
(cid:127) Community religious advisors can help discriminate between
culturally appropriate dietary restriction and obsessionality.
(cid:127) People of West Indian and African origins tend to be less vulner-
able culturally to eating disorders—they are better able to relish a
Bingeing voluptuous fi gure, and also carry distressing associations of thin-
Increasing weight ness with emaciation and acquired immunodefi ciency syndrome
(AIDS)—for such people a thin body may be heavily stigmatized.
Figure 1.1 Sufferers from anorexia nervosa (AN) make up only a small (cid:127) The Curacao study found that even in ‘fat-admiring’ cultures there
minority of patients with eating disorders. There is some diagnostic overlap
is a small, core prevalence of anorexia nervosa. However, more
with bulimia nervosa (BN) in that about 50% ‘graduate’ to binge-purge
culturally sensitive bulimic disorders may occur far less.
disorders with gradually rising weight. Normal weight BN involves the most
extreme binges because of the purge behaviours which result in ‘binge-
priming’. When purging does not occur, in binge eating disorder (BED),
binges tend to be smaller but weight is often higher and may be in the diagnostic criteria, at least 15% of minimum normal weight must
overweight or obese range. So-called ‘simple obesity’ occurs when have been lost. For adults, this means body mass index (BMI) is
overeating is more general rather than characterized by discrete ‘binges’,
below 17.5. Menstruation is absent (though women who take the
and body image concern is more likely to be a secondary result rather than
contraceptive pill have withdrawal bleeds). In males low testosterone
the root cause of the overeating.
causes atrophied genitalia and absence of morning erections.
Some people with AN maintain low weight by starvation alone,
or starvation plus exercising—this is ‘restrictive’ AN. In the more
Box 1.2 DSM-IV criteria for anorexia nervosa
dangerous ‘binge-purge’ subtype, the sufferer induces vomiting or
takes laxatives, diuretics or ‘slimming pills’ in an attempt to get rid
A Refusal to maintain body weight at or above a minimally
of calories. ‘Binges’ are usually much smaller than in BN.
normal weight for age and height (e.g. weight loss leading to
maintenance of body weight less than 85% of that expected or
failure to make expected weight gain during period of growth,
What is bulimia nervosa?
leading to body weight less than 85% of that expected).
B Intense fear of gaining weight or becoming fat, even though Bulimia nervosa is characterized by dietary restriction, followed
underweight. by breakthrough ‘binges’ then purging behaviours. This sets up
C Disturbance in the way in which one’s body weight or shape is a vicious circle in which binges become larger—often involving
experienced, undue infl uence of body weight or shape on self-
thousands of calories in a single binge—and normal social life is
evaluation, or denial of the seriousness of the current low body
disrupted. Binges are not simply large snacks, but a qualitatively
weight.
different experience in which control is lost and foods normally
D In postmenarchal females, amenorrhoea, i.e. the absence of at
avoided are guiltily consumed. Binge-purge episodes become a
least three consecutive menstrual cycles.
learned response to all stress.
By defi nition, people with BN have a BMI in the normal range
(or above).
Box 1.3 DSM-IV criteria for bulimia nervosa
What is binge eating disorder?
A Recurrent episodes of binge-eating, characterized by the
following:
Binge eating disorder was formerly known as ‘non-purging buli-
(cid:127) eating in a discrete period of time (e.g. a 2-hour period) an
mia’. Binges occur without compensatory behaviours such as purg-
amount of food that is defi nitely larger than most people would
ing, fasting or exercise. Patients are more likely to be overweight or
eat during a similar period of time and similar circumstances.
(cid:127) a sense of lack of control during the episode. obese and are torn between the desire to restrain their eating to lose
B Recurrent inappropriate compensatory behaviour in order to weight and the opposing wish to stabilize their eating habits and
prevent weight gain, such as self-induced vomiting, misuse of thus their lives.
laxatives, diuretics, other medications or enemas.
C The binge-eating and compensatory behaviours occur on average
How often is a general practitioner likely
at least twice a week for 3 months.
to encounter an eating disorder?
D Self-evaluation is unduly infl uenced by body weight and shape.
E The disturbance does not occur exclusively during episodes of
The average list is likely to include two or three patients with seri-
anorexia nervosa.
ous AN, 15–20 with chronic BN, and many more with BED. Figures
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