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Assessment and Management of Eating Disorders: an Update VOLUME 36 : NUMBER 5 : OCTOBER 2013 ARTICLE Assessment and management of eating disorders: an update Phillipa J Hay Risk factors Professor School of Medicine and SUMMARY Eating disorders are associated with heritable Centre for Health Research Eating disorders are common, but treatment psychological and physical vulnerabilities, most University of Western is often delayed despite good outcomes with notably: Sydney therapy. • a predisposition for perfectionism and School of Medicine compulsivity James Cook University Family-based treatment is recommended Townsville for children and adolescents with anorexia • mood intolerance and impulsivity Queensland nervosa. • obesity (more likely in bulimic and binge eating disorders). An extended form of cognitive behaviour Key words therapy is effective for bulimia nervosa and Environmental factors such as adverse life anorexia nervosa, binge experiences including trauma and abuse, often eating disorder, bulimia binge eating disorder and can be used for associated with ensuing low self-worth, can also nervosa adults with anorexia nervosa. play a role. Exposure to the western ideal of being Selective serotonin reuptake inhibitors may thin and restrictive dieting appears to be a specific Aust Prescr 2013;36:154–7 help with bulimia nervosa and binge eating risk factor. disorder. Comorbidity is common. Mood, anxiety (especially Integrated primary and specialist care is social phobia) and substance use disorders occur recommended for optimal management. most frequently.3 Introduction Box 1 Definitions and features of eating disorders Up to 1 in 10 Australians will experience an eating disorder in their lifetime with a general population Anorexia nervosa point prevalence of around 5%.1 Eating disorders, • underweight for age and height including anorexia nervosa, bulimia nervosa and • self-starvation binge eating, are characterised by disturbances in eating behaviour and psychological distress centred • compulsive exercising is common on food, eating and body image (Box 1).1-3 • with or without episodes of binge eating and extreme weight control behaviours Diagnostic criteria for eating disorders are in a state • self image that is unduly influenced by weight and shape of revision with new criteria introduced in 2013.4 • often age of onset in early teens or younger2 With less restrictive criteria, fewer patients fall into • 10 times more likely in females the residual category now termed ‘other specified/ Bulimia nervosa unspecified’ disorder, the most common category. • uncontrollable overeating followed by extreme weight While there is a large unmet need, outcomes with control behaviours such as vomiting or purging (laxative treatment are good with most patients making a or diuretic abuse) 5,6 sustained recovery. Even for anorexia nervosa, up • self view that is unduly influenced by weight and shape to 40% of patients will make a good recovery within • 10 times more likely in females five years, a further 40% will make a partial recovery Binge eating disorder and those with persistent illness may yet benefit from • recurrent regular binge eating supportive therapies. At least 50% of people with • patients often struggle with being overweight or obese bulimia nervosa fully recover and the outcomes with • often a midlife disorder with similar incidence in males treatment are also as good if not better for binge and females1,3 eating disorder. Other specified/unspecified feeding or eating disorder • patients who do not conform to the other categories – e.g. they have mixed or additional eating problems 154 Full text free online at www.australianprescriber.com VOLUME 36 : NUMBER 5 : OCTOBER 2013 ARTICLE Assessment Box 2 An overview of management of eating disorders Most patients present late in the course of illness. Up in primary care to 50% of adults with anorexia nervosa may never seek treatment and people with bulimia nervosa Primary prevention present on average a decade or more after onset. Promotion of healthy attitudes towards body shape and weight When people do seek help, it is most often first from Promotion of good nutrition and exercise for health and social benefits their family doctor and frequently for advice on Identification and management (where appropriate) of risk factors (e.g. obesity) weight loss, whether they are normal or overweight. People with anorexia nervosa, in particular, are Detection and treatment ambivalent about treatment. A key task for health Ask about symptoms of eating disorder practitioners is motivating patients to commit to Education and family counselling better nutrition and engaging them in psychological Supportive psychotherapy therapies to bring about sustained change. Nutritional counselling All people presenting with an eating disorder need Cognitive behaviour therapy (with appropriate training) psychiatric and physical assessment. The history Monitor for medical complications should include questions about: Correct electrolytes and any deficiencies e.g. iron Consider pharmacotherapy • diet and attitudes to food Specialist referral (where appropriate) – with shared-care responsibility • weight, shape and body image • common comorbidities, for example depression Usual investigations and associated complications and/or an anxiety disorder Renal function and electrolytes (dehydration and hypokalaemia) • risk of self-harm and suicide Additional investigations in anorexia nervosa • predisposing factors. Full blood count (anaemia, leucopenia) Physical examination should include cardiovascular Magnesium and phosphate (low levels can precede re-feeding syndrome) status and a calculation of body mass index (BMI) Liver function (raised liver enzymes) based on weight and height (kg/m2). Potential Thyroid function (‘sick euthyroid’ syndrome) complications and important biochemistry tests are Fasting glucose (hypoglycaemia) listed in Box 2. Iron, vitamin B12 and folate (may be deficient) In anorexia nervosa, physical complications of Electrocardiogram (risk of arrhythmia) starvation are also present. While amenorrhoea may Bone densitometry (for osteopenia related to sustained hypogonadism) be removed from diagnostic criteria, it remains a useful indicator of starvation severity and the need for bone densitometry in women. Testing hormone levels will confirm hypogonadism, but is not essential. Women with eating disorders may present for Box 3 Screening questions for identifying eating disorders infertility treatment. For those who become pregnant, in primary care it can be a stressful and challenging time.7 Role of the general practitioner The SCOFF questionnaire 8 S – do you make yourself Sick because you feel uncomfortably full? GPs play a key role in early identification of eating disorders and the SCOFF questionnaire is a reliable C – do you worry you have lost Control over how much you have eaten? and valid screening tool that can be used (Box 3).8 O – have you recently lost more than 6.35 kilograms (One stone) in a three month period? They also have a valuable role in the management F – do you believe yourself to be Fat when others say you are too thin? of these disorders (Box 2) and are the key link in F – would you say Food dominates your life? access to specialist services and psychological One point for every yes therapies. They provide important support to families A score of ≥ 2 indicates further questioning is warranted and carers, and doctors who have an interest in mental health may also provide psychotherapy. A further two questions have been found to have a high sensitivity and specificity for Cognitive behavioural guided self-help9 is suitable for bulimia (but are not diagnostic): primary care. • Are you satisfied with your eating patterns? (‘no’) • Do you ever eat in secret? (‘yes’) Anorexia nervosa Although the evidence base for anorexia nervosa continues to be the least developed of the eating Full text free online at www.australianprescriber.com 155 VOLUME 36 : NUMBER 5 : OCTOBER 2013 ARTICLE Assessment and management of eating disorders: an update disorders, a clearer understanding is emerging of Box 4 Psychological treatment what works and for whom. There is evidence from approaches in eating disorders randomised controlled trials and prospective clinical studies that early and younger age at onset (under Family-based treatment for anorexia nervosa 10 age 18 and within the first three years of illness) Parental empowerment to facilitate re-feeding the patient are together associated with good outcomes. The (including having a family meal) treatment of choice for this group is a family-based Negotiating a new pattern of relationships approach.10 This therapy moves through three phases Establishing healthy relationships between the adolescent (Box 4) in which parental experience and expertise is or young adult and the parents (with increased personal engaged as a therapeutic tool. autonomy for the adolescent) In adults with anorexia nervosa and when family- Cognitive behaviour therapy11 for anorexia nervosa, based treatment is not possible or inappropriate, bulimia nervosa and binge eating individual psychotherapy is the approach of choice. Psycho-education and introduction to daily monitoring of Cognitive behaviour therapy or other specialised relevant thoughts and behaviours individual psychotherapies (with the exception of Prescribe ‘normal’ eating and prohibit dietary restriction interpersonal psychotherapy) have support from Gradual reintroduction of avoided foods into the diet randomised controlled trials. An extended form of
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