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12 Eating disorders from a primary care perspective
Kay A Wilhelm and Simon D Clarke Personal dissatisfaction and interpersonal difficulties are sometimes expressed in excessive attempts to control bodyweight. |
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Synopsis - Introduction - The psychology of eating - Adolescence and eating - Eating and control - Risk factors - The role of the general practitioner - Diagnosis - Treatment in primary care - Referral to specialist services (Box 5) - Acknowledgements - References - Recommended reading for general practitioners - Authors' details - Box 1: What are anorexia nervosa and bulimia nervosa? - Box 2: Natural history of anorexia and bulimia - Box 3: Questions to be asked when an eating disorder is suspected - Box 4: Food-related communication - Box 5: When is specialist referral necessary? - Case history 1: A girl with anorexia - Case history 2: Weight loss as a distress call - Case history 3: Anorexia and depression - Short course - --> Contents list Synopsis |
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Introduction
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In adolescent girls, eating disorders are the third most common
disorder behind obesity and asthma. In Western cultures, 0.5% of
young women have anorexia nervosa and 2% have bulimia nervosa at some
time.1 Rates for males are 5% to 10%
of those for females,1 but males are increasingly
subjected to the same pressures regarding body image that in the past
have predisposed females to eating disorders.2
| These disorders are only the clinically evident peaks of a widespread dissatisfaction with body image in developed countries, where food is abundantly available and cleverly marketed as a source of fun, comfort and pleasure, while lifestyles are increasingly sedentary. As a result, the proportion of the population that is overweight is increasing. Yet young people are growing up against a backdrop of media images of "ideal" but impossibly thin body shapes. A Sydney study of adolescents aged 11 to 15 reported that 16% of the girls and 7% of the boys had already employed at least one potentially dangerous method of weight reduction, including starvation, vomiting and laxative abuse,3 and a Victorian study of adolescents aged 12 to 17 years classified 38% of girls and 12% of boys as "intermediate" to "extreme" dieters (i.e., at risk of an eating disorder).4 The prevalence of eating disorders is directly related to the rates of dieting behaviour.1 Only a minority of young people who diet go on to develop an eating disorder, but when dieting and the desire to be thin combine with problems with self esteem or interpersonal relationships eating disorders are a possible outcome. This article focuses on anorexia nervosa and bulimia nervosa (defined in Box 1), disorders with the risk of death or serious lasting damage to health (Box 2). General practitioners are likely to see young people with incipient eating disorders for various reasons,10 but frequently the patient will not identify eating as a problem. The task for the general practitioner is to identify who is particularly at risk and who has already embarked on disordered eating behaviour likely to lead to medical and psychiatric morbidity. General practitioners are at the front line in early recognition and assessment, with an important part to play in initiating treatment before disordered eating patterns become entrenched. The psychology of eating |
Dieters' eating behaviour is based not on hunger cues but on the
premise that they are "too fat" and that losing weight will solve the
problem. Thus, "the most insidious effect of dieting is its
interference with the perception of normal hunger and satiety
signals. To be successful, a dieter must overcome such signals; that
is, she must learn not to eat when hungry and to stop eating in response
to arbitrary signals that occur well before satiety".11 Dieters find
that these "arbitrary signals" are less effective during times of
distress or depression, so that chaotic eating behaviours can occur
as they are no longer in touch with the normal hunger and satiety
cues.11 Girls who diet tend to have
greater misperceptions about their actual size,12-14 whereas
boys who diet are more likely to have experienced a period of obesity
and have a higher rate of gender-identity conflicts.2
| While dieters learn not to eat when they are hungry, other people eat when they are not hungry. This can be normal (e.g., when done so as not to offend a host, or because the food looks tasty). It may reflect a state of "emotional hunger", where food provides solace for feelings of emptiness, distress or anxiety in the context of low self esteem, poor interpersonal skills or interpersonal difficulties.13,14 Binge eating is a form of comfort eating in which a would-be dieter loses control of her or his restricted food intake. In a vicious cycle, anxiety and low self esteem lead to unsustainable efforts to restrict food intake, which in turn leads to binge eating. Binge eating can produce abdominal bloating or weight gain that creates guilt and reinforces difficulties with self image. More strenuous efforts to control diet may follow, with vomiting, purging and drug use. Some binge eaters will win their battle for control and proceed to anorexia. Others will engage in uncontrolled comfort eating and progress to bulimia. A third group may oscillate between the two. Adolescence and eating |
Adolescence involves several developments that have an impact on
eating behaviour: puberty, changing body shape, new sexual feelings
and risk-taking urges. An increasing intake of "junk" foods and
alcohol during adolescence can lead to obesity, particularly if
exercise levels are decreased. Many girls decrease their exercise
during the high school years, while, for boys, greater participation
in team sports can maintain fitness. Exercise also elevates mood and
suppresses appetite,15 but can become
pathological (the "gym junkie").16
| During this life stage, young people have an inbuilt need to take risks to test their own courage and mortality.17 Some societies provide initiation rituals and it has been suggested that, in the absence of formal rituals, young people devise informal ones involving alcohol, drugs, sex, tattoos and, for some, eating disorders.18,19 Socially accepted "ideals" of thinness, perpetuated by media images, provide a distorted representation of self control, fitness and physical attractiveness to young women.12 At the same time, young women are reporting increased stress related to social expectations that they can "do anything". Their personal development is unfolding against a backdrop of increasing materialism, wide but doubtful career choices and high-pressure marketing of "lifestyle products" promoting a superficial view of life.12,13 Young men also are experiencing more social pressures towards improved body image, and the shifting role of women in society is having an impact on their sense of identity and career opportunities.2 Eating and control
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Disturbed eating behaviours can be seen as an attempt to create
tangible goals and a sense of control over part of one's life in
response to confusing messages from society and stressful
situations at home, work or school. These behaviours can provide a
personal means of testing limits and self control that is so
encompassing that peer pressure to be involved in other risky
behaviours is side-stepped. They can also divert attention from
other important issues, such as marital breakdown between parents,
physical or sexual abuse12,13 or family
dysfunction.13,19
| Disordered eating behaviours in one or more members of a family may also represent underlying family problems. Such families are reported to suppress emotions rather than deal assertively with issues. They may "present a strong facade of togetherness but have an underlying theme of avoidance of emotional confrontation concerning difficult issues".20,21 Risk factors
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Individual risk factors for eating disorders include female sex,
genetic vulnerability, family history of psychiatric disorder,
premorbid obesity, perfectionistic and somewhat obsessional
personality style, dysfunctional family and social systems,
obsessive-compulsive disorder, preceding depressive disorders,
borderline personality disorder (poor sense of identity, mood
instability and a tendency to engage in impulsive self-harming or
risk-taking behaviour, such as wrist slashing, substance abuse and
promiscuity), and a previous history of sexual abuse.9,22-26
Precipitating factors may include comments about body shape or fall
in self esteem leading to dieting, leaving home, onset of puberty,
commencing intimate relationships, loss and illness.
| The role of the general practitioner Diagnosis
Box 3:
Often the first contact is from parents seeking to discuss their
suspicions concerning weight loss, amenorrhoea, delayed puberty,
irritability, or depression in their child. Friends, teachers,
colleagues may also seek advice -- virtually anyone but the potential
patient! However, patients with incipient eating disorders often
consult general practitioners on other health issues in the years
preceding onset of their eating disorder.10 With all young people, a
clinical history should include such personal habits as eating and
diet, exercise, menstruation, sexual activity and drug use.
Some questions that may help to identify problem areas are
included in Box 3.
| The physical dimensions may be overlooked "because patients are perceived as being active, energetic and therefore apparently physically well"22 and patients underplay any physical problems. In anorexia nervosa, physical examination may reveal hypotension, bradycardia, excessive sensitivity to cold, loss of body fat and lanugo hair (which are adaptations to starvation). Body temperature may be low in really thin patients. Baseline investigations include full blood count, erythrocyte sedimentation rate, tests of liver function, thyroid function and renal function (sodium, potassium, chloride, magnesium, calcium and phosphate), random blood sugar level, chest x-ray and electrocardiogram.9,22,24,25,28 If anorexia nervosa has not been diagnosed previously, the first presentation may be with the physical complications24,28 that arise from starvation, idiosyncratic feeding habits, purging and vomiting. Anorexia nervosa may be the underlying diagnosis in patients with unexplained weight loss, amenorrhoea, infertility, osteoporosis, pathological fractures, electrolyte abnormalities, cardiac arrhythmias, cardiac failure or renal failure.28 In bulimia nervosa, physical examination is usually normal and the diagnosis is often overlooked, particularly in boys. In long-established bulimia, there may be enlarged parotid glands, carious teeth (lingual and occlusive surfaces) and acid damage to the nails of middle and index fingers. First line investigations for bulimia nervosa consist of the same electrolyte tests as for anorexia.22
Treatment in primary care
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Most dieters do not go on to develop an eating disorder. As many young
people will report at least one or two disordered eating traits,
intervention should be considered when there is substantial loss of
weight, impairment in daily functioning and/or significant family
problems.
| Most episodes of disturbed eating behaviour resolve steadily with treatment. The key interventions are: Forging a therapeutic alliance. The aim behind most interventions is to develop in the patient a coherent sense of self and a positive self image. This can be advanced by establishing a working friendship between doctor and patient. For younger patients, the therapeutic alliance should include the family. Discussion of concepts of normal eating, dieting and exercise patterns. Young people may have inaccurate or inadequate knowledge about the normal range of weight, eating habits, and nutritional needs; they may have false expectations of dieting and exercise; and they may not have thought about the psychological significance of their attitudes to food (Box 4). Dietary advice from a doctor or dietitian, with institution of a diet to provide adequate nutrition. Patients need instruction about sensible ways to limit fat intake and strategies to promote weight stability after episodes of disordered eating or after stopping smoking. Instituting a food diary, looking for dietary pattern and triggers to disordered eating. Food diaries give patients a positive method of observing and controlling their eating behaviour. Encouraging regular moderate exercise. Those who have previously engaged in compulsive exercise (often at a gym) may need to consider forms of exercise with a different emphasis, such as yoga, t'ai chi or a specialised exercise program.24,29 Those who have previously been abused report that weight training, practising martial arts or doing a self defence course increases their feeling of personal control. Enquiry and advice about drug use. The patient's use of appetite suppressants, tobacco, alcohol and illicit drugs needs to be identified. Appropriate advice includes accurate information about drug effects and risks, and how to recognise and deal with peer pressure. Setting realistic short term goals and recognising achievements. This will give the encouragement needed to persevere with gradual behavioural change. Target weight is usually calculated on a BMI of 20, but discharge from hospital may be at a lower weight. For those under 16, target weight should be the 25th centile of the age-weight chart for Caucasian girls. Providing new challenges and outlets for personal expression. These enhance well-being and may also discourage "risky" behaviours. The secret is finding what suits the individual. This may be drama, art classes or sporting activities. Planning for relapses. Relapse prevention involves predicting situations likely to lead to relapse (e.g., exam pressure, relationship break-up, or continuing family stress) and planning strategies to meet them.13,30 Planning should also address the question of how to cope with a relapse if one occurs (i.e., a relapse must not become a sign of hopelessness and failure). Some general practitioners will provide counselling for stress management, improving self esteem and revising dysfunctional attitudes to food and eating, often in partnership with a clinical psychologist or dietitian. Whatever the degree of disturbed eating behaviour, the underlying premise in counselling is that eating must become a response to normal physiological cues, which implies changing attitudes to weight and shape and being more in touch with internal messages and needs.
Referral to specialist services
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Referral to a psychiatrist, clinical psychologist or other
clinician for a course of psychotherapy may be indicated for
the following:
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Family therapy is effective for younger adolescents with a disorder of recent onset, and individual cognitive, interpersonal or insight-directed therapy for older adolescents and adults. There are also group programs over a period of weeks or in a day-hospital setting, which generally offer cognitive therapy. The length and complexity of treatment are determined by the patient's age, duration of illness and motivation. Further information is available from several sources and a comprehensive review of treatment practices is available.9 If referral is made to a dietitian or eating disorders unit, the general practitioner can act as the treatment coordinator, providing regular medical assessment and support and counselling of patient and family. As coordinator, the general practitioner should clarify the tasks of various team members to ensure that patient, family and professionals are all "on the same team", with a clear management plan available to all. Whether treatment is given in or out of hospital, the family need to understand that the goal is not to simply reach a target or "ideal" weight and that a more holistic approach is generally required. They may need to be informed that they will be asked to participate in initial assessment or ongoing psychotherapy (particularly for adolescent girls). They may need encouragement, particularly if there is any "unfinished business" (such as divorce, unresolved grief, and ongoing dissent) or family secrets (such as previous adoption or sexual abuse) that are difficult to confront. A psychiatric opinion may be sought for:
Over the last decade there has been a trend away from prolonged hospital admissions to more flexible treatment programs which may be inpatient, daypatient or outpatient. However, common reasons for hospital admission for eating disorders include BMI below 15 with rapid weight loss, uncontrollable vomiting, medical complications (e.g., cardiac abnormalities, bradycardia less than 40/minute, fainting, hypotension less than 60 mm Hg systolic), suicidal behaviour, lack of response to outpatient treatment in a very underweight patient,20 and extreme family distress. Acknowledgements |
We thank Dr R Eidus, Dr H Cheung, Dr L Power, Dr Y White and Sr J Reddenbach
for helpful comments.
| References |
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Recommended reading for general practitioners |
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