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'Help us, she's fading away': How to manage the patient with anorexia nervosa
Abstract
Background:
Although integral to the early detection and treatment of anorexia nervosa, there is a paucity of clear guidance available for general practitioners (GPs). This paper attempts to bridge the gap between the specialist and generalist literature to assist the busy GP feel confident in identifying and managing these patients.
Objective:
On reading this article it is anticipated the GP will feel well equipped to screen for and provide ongoing treatment to patients who pre-sent with eating disorders, particularly anorexia nervosa. This paper provides guidance for the identification and ongoing management of patients with anorexia nervosa, and supporting their carers.
Discussion:
People affected by eating disorders, particularly anorexia nervosa, may deny having a problem, minimise their symptoms and resist treatment yet engage partially with their GP throughout the course of their illness. There are well-validated, quick screening tools that the non-specialist can use to identify patients at high risk of having an eating disorder.
... The following case study describes the utilization of CBT-E in the treatment of an individual with BN, who was a participant in an outpatient group program. The CBT-E program described had four additions to the treatment manual: the inclusion of the stages of change model (Prochaska et al., 1994), dialectical behavior therapy (DBT; Linehan, 2014), multifamily sessions, and supportive meal therapy (Redstone et al., 2014). It was hypothesized that CBT-E would assist the client to normalize her eating behavior, reduce the frequency and intensity of compensation behaviors, and improve her mood, anxiety, and stress. ...
... Chloe reported the early distress tolerance sessions were helpful prior to setting increasingly challenging food exposure goals. The program also included supportive meal therapy (Leichner, Hall, & Calderon, 2005;Redstone et al., 2014). ...
Enhanced Cognitive Behavioral Therapy (CBT-E) is an evidence-based treatment for bulimia nervosa (BN), which can be delivered individually or in a group format. This case study describes a young adult female’s progress through a CBT-E group program at an Australian community outpatient eating disorder service. She completed 20 sessions over 10 weeks. The client was administered measures for eating disorder symptoms, depression, anxiety, stress, stage of change, and clinical impairment at pre- and posttreatment. She improved on global eating disorder symptoms, food restriction, eating concern, and her stage of change. Her weight and shape concerns remained unchanged. Her levels of depression, anxiety, and stress significantly increased after treatment, highlighting the need for concurrent treatment for these comorbidities. These results support the developing literature on the efficacy of CBT-E for BN and describe in detail the progress of an individual, including their progress and challenges within a group intervention.
... Given the high prevalence rates of EDs identified in Iranian samples, it is important that reliable screening tools for detection of possible EDs are available in Persian language for use with Iranian patients. Early recognition of EDs can reduce its physical, psychiatric, psychosocial outcomes [8], improve the prognosis [9], and thereby minimize the impact on patients and their families [10]. However, timely recognition of EDs is difficult because of the variety of the signs and presentations [11]. ...
Background
Eating Disorders (EDs) are defined by abnormal eating habits. The SCOFF (Sick-Control-One stone-Fat-Food) is a simple screening questionnaire for EDs. This study was conducted to translate and evaluate the psychometric properties of the SCOFF questionnaire in Iranian university students.
Methods
A total of 310 Iranian students of the Shahid Beheshti University of Medical Sciences completed a test battery of questionnaires including the well-known screener of eating disorder symptoms, the SCOFF. All measures were presented to the participants in Persian. The 5-item SCOFF questionnaire was translated to Persian using the forward–backward method. The face, content, criterion, and construct validity of the Persian version of the SCOFF were assessed. The validity and reliability of the Persian version of the SCOFF was assessed and factor analysis was conducted.
Results
All five items of the translated questionnaire were approved after face validity. Content validity ratio was 0.73 (range 0.66–0.83) and content validity index was 0.96 (range 0.91–1), so all items were approved. Exploratory factor analysis revealed a 2-factor structure, which explained 52.47% of the variance. Confirmatory factor analysis showed a very good goodness-of-fit for the 2-factor model. 2-factor and 1-factor models indicate a very good goodness-of-fit in females and adequate goodness-of-fit in males. Criterion validity showed an acceptable correlation between the SCOFF and the EDE-Q. Reliability was acceptable based on the stability [ICC = 0.905(95% CI .760–.962 p < 0.001)] and the internal consistency (KR20 = 0.4).
Conclusion
Appropriate psychometric properties of the 5-item Persian version of the SCOFF (both models) were confirmed, suggesting its use as a valid questionnaire in EDs screening.
Educational counselors have a significant role in identifying Eating-Disorders in the
early stages, referral for treatment, and follow-up. In addition, they directly support the adolescent, his parents, and the educational staff. The present study examines the experience and perceptions of counselors in post-primary schools in relation to Eating Disorders. Data were collected through a semi-structured interview, based on an interview guide. The interviews were transcribed and subjected using thematic content analysis. Counselors felt lacking in the knowledge and professional ability to detect and accompany adolescence with Eating-Disorders. In addition, they report a lack of up-to-date prevention, accompaniment, or treatment programs. In addition, they describe the difficulty of meeting parents who often do not cooperate and refuse treatment. Finally, counselors reported personal distress and excessive concern that their private children would develop eating disorders. This study suggests that there is a need for clear training and explanation regarding eating disorders for the counseling staff that includes ways of locating and accompanying them. The study also offers practical tools for detecting adolescents with eating disorders.
This paper examines the provision of primary care for young people with an eating disorder within the UK from the perspectives of three key stakeholder groups: young people with an eating disorder, carers of young people with an eating disorder and General Practitioners (GPs). Twenty‐two young people with an eating disorder (aged 16–25) and 10 carers completed qualitative questionnaires or participated in interviews about their experiences of seeking primary care from GPs. Forty‐one GPs participated in either focus groups or interviews about delivering care to young people with eating disorders. Interviews and focus groups were audio‐recorded and transcribed verbatim. All data were then analysed qualitatively using thematic analysis. Our analysis indicates that GPs often felt they lacked the necessary knowledge and/or resources to provide adequate support to young people with an eating disorder who they also often viewed as a “difficult” patient group. Young people and carers expressed mixed but predominantly negative experiences; reporting that GPs often lacked adequate understanding of eating disorder, failed to take participants' concerns seriously, and delayed referring patients to specialist services. Our findings indicate a need for interventions that will improve primary care provision and access to appropriate support for young people with an eating disorder.
To describe the establishment and the main characteristics of the Flinders Medical Centre Paediatric Eating Disorder Program.
While the programme is still in its infancy, it is hoped that our model of care can provide a sustainable, long term contribution to the management of paediatric eating disorders.
© The Royal Australian and New Zealand College of Psychiatrists 2015.
Background
Structural imaging studies demonstrate brain tissue abnormalities in eating disorders, yet a quantitative analysis has not been done.
Methods
In global and regional meta-analyses of 9 voxel-based morphometry (VBM) studies, with a total of 228 eating disorder participants (currently ill with anorexia nervosa), and 240 age-matched healthy controls, we compare brain volumes using global and regional analyses.
Results
Anorexia nervosa (AN) patients have global reductions in gray (effect size = −0.66) and white matter (effect size = −0.74) and increased cerebrospinal fluid (effect size = 0.98) and have regional decreases in left hypothalamus, left inferior parietal lobe, right lentiform nucleus and right caudate, and no significant increases. No significant difference in hemispheric lateralization was found.
Conclusions
Global and regional meta-analyses suggest that excessive restrained eating as found in those with anorexia nervosa coincides with structural brain changes analogous to clinical symptoms.
Long-term outcome studies of anorexia nervosa have shown that a significant number of individuals do not fully recover from their eating disorder symptoms. Individuals who develop chronic eating disorders may express either strong ambivalence about symptom reduction or a complete lack of interest in change. As a result, clinicians can find this group particularly challenging. This report expands upon a treatment stance based on principles of Motivational Interviewing that addresses difficulties typically encountered in working with this population. The stance outlines a mission statement and specific clinician behaviours that promote engagement and alliance with this group, including the communication of beliefs that foster client self-acceptance, not making assumptions, being curious, active, and on the same side, and maximizing client responsibility for change. Copyright © 2001 John Wiley & Sons, Ltd and Eating Disorders Association.
Cognitive behavioral therapy (CBT) is the leading evidence-based treatment for bulimia nervosa. A new "enhanced" version of the treatment appears to be more potent and has the added advantage of being suitable for all eating disorders, including anorexia nervosa and eating disorder not otherwise specified. This article reviews the evidence supporting CBT in the treatment of eating disorders and provides an account of the "transdiagnostic" theory that underpins the enhanced form of the treatment. It ends with an outline of the treatment's main strategies and procedures.
This open trial of Family-Based Treatment for Anorexia Nervosa was completed in order to assess the dissemination of this treatment, including effectiveness, fidelity, and acceptability. Fourteen adolescents with Anorexia Nervosa were recruited with mean age 14.0+1.5 years (range 12-17 years). Therapists were trained using a workshop, manual and weekly supervision. Sessions were videotaped and rated for treatment fidelity. Pre- and post- treatment assessments were compared. Weight was significantly increased by an average of 7.8 kg. Dietary restraint showed significant improvement, as did interoceptive deficits and maturity fears. Of the 9 participants who had secondary amenorrhea at baseline, 8 had regained menstrual function. Treatment fidelity was rated as at least considerable 72% of the time in phase I of the treatment. Adolescents and parents found the treatment to be acceptable. This preliminary investigation of the dissemination of Family-Based Treatment for adolescents with Anorexia Nervosa indicates that this treatment is effective not only for weight restoration, but also in improving some psychological symptoms including dietary restraint, interoceptive deficits, and maturity fears. In addition, this treatment was adopted with considerable fidelity and was acceptable to adolescents and parents.
Individuals with anorexia nervosa have a relentless preoccupation with dieting and weight loss that results in severe emaciation and sometimes death. It is controversial whether such symptoms are secondary to psychosocial influences, are a consequence of obsessions and anxiety or reflect a primary disturbance of brain appetitive circuits. New brain imaging technology provides insights into ventral and dorsal neural circuit dysfunction - perhaps related to altered serotonin and dopamine metabolism - that contributes to the puzzling symptoms found in people with eating disorders. For example, altered insula activity could explain interoceptive dysfunction, and altered striatal activity might shed light on altered reward modulation in people with anorexia nervosa.
Structural changes have been observed in the brains of low-weight patients with anorexia nervosa (AN), including increased cerebrospinal fluid (CSF) volumes and decreased gray matter and white matter volumes. We hypothesized that subjects who are weight-recovered from AN would show elevated CSF volumes and reduced gray matter volumes compared with controls.
We used magnetic resonance imaging to compare the brains of 12 subjects who are weight-recovered from AN (time since weight recovery, 1-23 years) with those of 18 healthy control subjects and 13 low-weight patients with AN. Axial, dual-echo scans of the whole brain were segmented into gray matter, white matter, and CSF compartments by means of a computerized volumetric approach. Brain measures were corrected for the significant effects of intracranial volume and age, based on regression analysis of a larger group of 30 healthy female controls.
Tests showed that the weight-recovered group had significantly greater CSF volumes and smaller gray matter volumes than the control group. By comparison with low-weight patients, the weight-recovered subjects had significantly smaller CSF volumes and significantly larger gray matter and white matter volumes. In the weight-recovered group, neither the CSF elevations nor gray matter deficits were correlated with the length of time since weight recovery.
The persistent gray matter volume deficits in subjects who are weight-recovered from AN suggest that there may be an irreversible component to the brain changes associated with the illness. The neuropathological features of this irreversible component have yet to be characterized.
Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues. A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care. Most patients can be effectively treated in the outpatient setting by a health care team that includes a physician, a registered dietitian, and a therapist. Psychiatric consultation may be beneficial. Patients may require inpatient care if they are suicidal or have life-threatening medical complications, such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight below 85 percent of their healthy body weight. For the treatment of binge-eating disorder and bulimia nervosa, good evidence supports the use of interpersonal and cognitive behavior therapies, as well as antidepressants. Limited evidence supports the use of guided self-help programs as a first step in a stepped-care approach to these disorders. For patients with anorexia nervosa, the effectiveness of behavioral or pharmacologic treatments remains unclear.
Eating disorders affect 2-3% of people and 90% of sufferers are women. Only a minority of sufferers present for treatment. Effective treatments are available and the outcome can be very good. General practitioners have an important role in the diagnosis and treatment of eating disorders. Anorexia nervosa is preferably treated in a specialist centre with access to inpatient facilities. Bulimia nervosa and related eating disorders, such as binge eating disorder, respond to a number of psychotherapeutic approaches, particularly cognitive behaviour therapy. A selective serotonin reuptake inhibitor may be effective in the short term.
To review the recent literature about the epidemiology, course, and outcome of eating disorders in accordance with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The residual category 'eating disorder not otherwise specified' (EDNOS) was the most common DSM-IV eating disorder diagnosis in both clinical and community samples. Several studies have confirmed that the DSM-5 criteria for eating disorders effectively reduce the proportion of EDNOS diagnoses. The lifetime prevalence of DSM-5 anorexia nervosa among women might be up to 4%, and of bulimia nervosa 2%. In a cross-national survey, the average lifetime prevalence of binge eating disorder (BED) was 2%. Both anorexia nervosa and bulimia nervosa are associated with increased mortality. Data on long-term outcome, including mortality, are limited for BED. Follow-up studies of BED are scarce; remission rates in randomized controlled trials ranged from 19 to 65% across studies. On a community level, 5-year recovery rates for DSM-5 anorexia nervosa and bulimia nervosa are 69 and 55%, respectively; little is known about the course and outcome of BED in the community.
Applying the DSM-5 criteria effectively reduces the frequency of the residual diagnosis EDNOS, by lowering the threshold for anorexia nervosa and bulimia nervosa, and adding BED as a specified eating disorder. Course and outcome studies of both anorexia nervosa and bulimia nervosa show that no significant differences exist between DSM-5 and DSM-IV definitions.
Purpose of review: Eating disorders remain hard to treat, and difficult to prevent. Recent publications on the outcome of eating disorders, and structured analyses of attempts at prevention, point to a field in need of fresh approaches.
Recent findings: The outcome of anorexia nervosa does not appear to have altered in the last 50 years. A recent large-scale outcome study found that existing treatments for eating disorders seemed without effect, though many patients with bulimia nervosa did well without making use of specialized treatment. Comprehensive reviews failed to find primary prevention programs to be of benefit and existing theories of the causation of eating disorders seem to lack specificity.
Summary: Much of the literature on the treatment and outcome of eating disorders lacks methodological robustness and ignores basic epidemiological principles. The absence of authoritative evidence for treatment effectiveness makes it increasingly hard to protect resource intensive treatments in anorexia and bulimia nervosa, and existing theories of the causation of the disorders are too non-specific to generate effective programs of prevention. New models are urgently required.
The onset of eating disorder psychopathology is most common in the adolescent age group. Acute psychopathology or subsyndromal eating disorders are perhaps less intractable in these young patients. Subsyndromal eating disorders in children and adolescents are not only clinically significant in their present state, but may represent legitimate candidates for preventive efforts in light of: (i) a risk of progression from subthreshold anorexia nervosa (SAN) to AN or subthreshold bulimia nervosa (SBN) to BN; (ii) the detrimental effects on outcome of delaying treatment; and (iii) the refractory, severe nature of eating disorders once the diagnostic threshold is crossed. Moreover, children and adolescents with SAN and SBN may in fact be exhibiting early 'caseness' of these disorders. Given that AN is notoriously difficult to treat, and there are limited efficacy data for adolescent BN, attempts to disrupt these disorders in what is arguably their early phases is an important goal in preventing more chronic and treatment-resistant forms of these disorders. Future research should address whether the best interventions for SAN and SBN should be derived from the prevention or intervention fields.
The first aim of this work was to examine whether high expressed emotion (EE) would be associated with psychological distress and negative appraisal of caregiving. The second aim was to examine whether could replicate the findings of (Uehara et al., Compr Psychiatr, 42, 132-138, 2001) regarding a reduction in EE in association with a psycho-educational intervention.
A prospective exploratory follow-up assessment of 47 caregivers in which EE was measured by Five Minutes Speech Sample, Experience of Caregiving Inventory and General Health Questionnaire (GHQ-12).
High EE ratings were found in 26/47 (55%) carers at baseline. The high EE group had a higher negative aspects of caregiving (high EE = 109.8 vs. low EE = 93.7, p = 0.04). The number of carers with high-EE fell from 55% to 24% after intervention, and remained below at follow-up. The levels of distress and caregiving burden of the caregivers were also reduced.
Fifty-five percent of the caregivers have high EE. High-EE relatives noted a higher caregiving burden than low-EE relatives particularly on the 'dimension of loss'. The level of EE was reduced following a skills training program.
This paper explores shame and shame‐based responses in eating disorders. Research linking shame with eating disorders and the possible role of shame and pride in the onset and maintenance of eating disorders is reviewed. The experience of shame is likely to be complex, dynamic and variable. However, the key to identifying shame is often via the various coping strategies adopted, which in turn may form part of a maintenance cycle for eating disorder beliefs and behaviours. An outline model of shame and pride cycles in the main‐tenance of eating disorders is presented with clinical implications. Copyright © 2009 John Wiley & Sons, Ltd.
Key Practitioner Message: Shame and pride need to be addressed in the assessment and treatment of eating disorders.
The purpose of this review is to appraise the literature regarding psychological distress, burden and expressed emotion (EE) in caregivers of people with eating disorders (EDs). Electronic databases were searched up until October 2008. Selected studies contained carers of people with ED and employed one measure of burden, EE or psychological distress. Twenty studies were identified measuring psychological distress burden and EE. Most of the studies examined these features in families of anorexic patients. The majority of the studies found high levels of psychological distress, burden and EE in this population. Only few studies included a control group. Carers of people with ED presented high levels of psychological distress and burden. ED carers tend to have levels of EE resembling that found in families of depressed patients, rather than schizophrenic patients. There is some evidence (particularly for EE) that these factors can impact the outcome of ED.
This article describes the three-stage development of the SCOFF, a screening tool for eating disorders.
Study 1 details questionnaire development and testing on cases and controls. Study 2 examines reliability of verbal versus written administration in a student population. Study 3 validates the test as a screening tool in primary care.
The SCOFF demonstrates good validity compared with DSM-IV diagnosis on clinical interview. In the primary care setting it had a sensitivity of 84.6% and a specificity of 89.6%, detecting all true cases of anorexia nervosa and bulimia nervosa and seven of nine cases of EDNOS. Reliability between written and verbal versions of the SCOFF was high, with a kappa statistic of 0.82.
The SCOFF, which has been adapted for use in diverse languages, appears highly effective as a screening instrument and has been widely adopted to raise the index of suspicion of an eating disorder.
Clinical report suggests that therapists have strong and sometimes difficult-to-manage reactions to patients with eating disorders (EDs); however, systematic research is largely absent. The purpose of this study was to explore the emotional responses, or countertransference (CT) reactions, clinicians experience when working with patients with EDs, and to identify clinician, patient, and therapy variables associated with these responses.
One hundred twenty clinicians reported on multiple variables related to an adolescent female patient they were treating for an ED.
Six patterns of reactions were identified: angry/frustrated, warm/competent, aggressive/sexual, failing/incompetent, bored/angry at parents and overinvested/worried feelings. The factors showed meaningful relationships across clinician demographics, patient characteristics, and treatment techniques.
Overall, clinician's reactions were most frequently associated with the clinician's gender, patient's level of functioning and improvement during treatment, and patient personality style. These issues have important implications for treatment, training and supervision.
This study examined the influence of primary care physicians' knowledge of and attitudes to eating disorders on their treatment decisions.
A sample of primary care physicians completed self-report measures on eating disorders and their attitudes towards such patients. They also indicated their diagnosis and treatment decisions in response to case vignettes.
Physicians had substantial gaps in knowledge of the eating disorders. Attitudes to anorexia nervosa clustered differently to those toward patients with bulimia nervosa. However, for both disorders, the factor that explained the most variance was illness duration and consequences. There was no association of knowledge and attitudes, and these variables did not predicted the likelihood of diagnosing an eating disorder. However, those with higher knowledge scores were more likely to ensure that a follow-up appointment took place, particularly when they held the attitude that people with anorexia nervosa had personal control over their problem.
There is a need for greater education of primary care physicians regarding the diagnosis and treatment of the eating disorders, and for that information to be more readily accessible when it is needed. Their clinical actions need to be guided by more objective sources of information and protocols.
A questionnaire examining attitudes to patients with eating disorders was completed by 352 medical and nursing staff in a general hospital. Patients with eating disorders were less liked than patients with schizophrenia and were seen as responsible for their illness almost to the same degree as recurrent overdose takers. Factor analysis showed a first factor in which patients with eating disorders were construed as vulnerable to external pressures (from others, the media) while also self-inducing their illness, and this was associated with treatment recommendations for education, urging the patient to take self-control and psychotherapy. The professions differed significantly in attitudes.
The outcome of a disease may be defined as the long-term result of a pathological process. At this final stage, some patients are found to have recovered completely. In others the disease process has come to an end but has resulted in various defects which hamper bodily or mental functioning. In some patients the disease is still active in a severe or less severe form, in which cases the disease is said to be present in a chronic state. Some patients may have died from the disease or from health problems causally connected with the disease. The disease may also pre-dispose to other illnesses, these occurring more frequently than expected among patients who have recovered. However, not only the final outcome is of importance when assessing the total impact of a disease, but also the course of the illness over time: the total duration of the illness; the suffering and discomfort it inflicts on the patient and family; whether the course over time is stable or fluctuating; which complications may be encountered; and whether relapses are apt to occur. It is an essential part of medical knowledge to know the general course and outcome of diseases. If untreated patients are available for investigation, or if the treatments do not produce a notable effect, the course and outcome may be described as the natural course, or the natural history, of the disease. Where eating disorders are concerned, it is well-known that there is a very great variability in the course and outcome in treated as well as untreated patients. This variability is in fact one of the most prominent characteristics of these disorders. This makes it very difficult to give a simple and comprehensive description of the natural or spontaneous course, and also to evaluate the effect of various treatments. Prognosis To make a prognosis means to make a forecast or a predicition as to the probable further course and the final outcome of the disease. The term prognosis may be used in a general sense, thereby denoting the average outcome in newly ill patients. In this connection, prognosis, or the general outlook, may be used synonymously with the general
The aims of the study were to identify the characteristics of the dieters most at risk of subsequently developing an eating disorder and to evaluate the feasibility of using a brief questionnaire to identify such dieters in advance.
A general population cohort of 2,992 young women who were dieting was identified. On four occasions over the subsequent 2 years, this cohort was sent a questionnaire concerning eating habits and attitudes. Participants whose responses suggested that they had developed an eating disorder were interviewed to establish their true case status. The baseline questionnaires of those who did and did not subsequently develop an eating disorder were compared to identify features that predicted future case status.
One hundred four of the dieters developed an eating disorder of clinical severity during the 2 years of follow-up. Their baseline questionnaire scores differed in many respects from those who had not developed an eating disorder. Items associated with developing an eating disorder were selected by using three different statistical methods. A simple case-predicting instrument based on one of five items scoring above an optimal cut point had a sensitivity of 71% and a specificity of 72% (overall efficiency of 72%).
Dieters who will develop an eating disorder within the next 2 years have distinctive features. It is feasible to identify them in advance with reasonable efficiency with a brief questionnaire. This questionnaire could be incorporated into routine health assessments, thereby identifying those at high risk.
The current study examined the perceptions about an individual with anorexia nervosa (AN) relative to perceptions about a healthy person and a person with another mental or nonmental illness.
Ninety-one participants recruited from the community completed questionnaires targeting perceptions about 4 individuals: a healthy person, a person with asthma, a person with schizophrenia, and a person with AN.
Evaluations of personal characteristics were most negative for persons with AN. Participants believed the person with AN was most to blame for his/her condition, was best able to pull him/herself together if he/she wanted to, and was most acting this way for attention and that biological factors were least relevant in developing the illness.
Negative perceptions of a person with AN fell into stigma categories of self-attribution and responsibility. These attitudes may contribute to reluctance to seek treatment among individuals with AN.
This review focuses on recent publications concerning medical complications in patients with eating disorders, including anorexia nervosa and bulimia nervosa.
Recent literature continues to reflect that multiple organ systems are frequently affected by eating disorders. The literature underscores the frequently cited risk of premature death in those with anorexia nervosa. A plethora of dermatologic changes have been described, some signaling serious underlying pathophysiology, such as purpura, which indicates a bleeding diathesis. Much of the literature continues to delineate the fact that diabetic patients with eating disorders are at high risk of developing diabetic complications. Gastrointestinal complications can be serious, including gastric dilatation and severe liver dysfunction. Acrocyanosis is common, and patients with anorexia nervosa are at risk of various arrhythmias. Low-weight patients are at high risk for osteopenia/osteoporosis. Nutritional abnormalities are also common, including sodium depletion and hypovolemia, hypophosphatemia and hypomagnesemia. Resting energy expenditure, although very low in low-weight patients, increases dramatically early in refeeding.
Medical complications are common and often serious in patients with eating disorders, particularly those with anorexia nervosa.
The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.
General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.
The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.
Carers of people with eating disorders (ED) have high levels of distress, but little is known about the contributing factors. The aim of this study was to examine predictors of carers' distress and caregiving appraisals using a model of caregiving adapted from the previous literature.
A cross-sectional design was used.
A sample of 115 individuals currently caring for someone with an ED participated in the study. Carers completed self-report assessments of psychological distress (GHQ-12; Goldberg & Williams, 1988), experience of caregiving (Szmukler et al., 1996), illness representations (IPQ-SCV; Barrowclough, Lobban, Hatton, & Quinn, 2001) and caregiving needs (CaNAM; Haigh & Treasure, 2003). Simple and multiple hierarchical regressions were conducted.
Approximately 36% (39/109) of carers had scores on the GHQ which indicated mental health difficulties, with 17% (19/109) experiencing high psychological distress. A negative experience of caregiving was associated with carers' distress. The dependency of the individual with the ED and stigma associated with the illness were most highly predictive of carers' distress. Shorter illness duration, higher levels of needs (lower levels of support) and perceptions of high illness consequences contributed to greater negative caregiving appraisals. The belief that the illness was attributable to the sufferers' personality was related to fewer positive appraisals.
Adjusting to the impact of a family member experiencing an ED is problematic, as suggested by the relationship between shorter illness duration and greater negative appraisals of caregiving. Interventions to help reduce dependency and alleviate stigma may help to decrease carers' distress.
At the suggestion of her pediatrician, "Rachel," a 19-year-old college freshman at a competitive liberal arts college, was brought by her parents for psychiatric evaluation during spring break. According to her parents, Rachel had lost 16 lb since her precollege physical the previous August, falling to a weight of 104 lb at a height of 5 feet, 5 inches. Rachel's chief complaint was that "everyone thinks I have an eating disorder." She! explained that she had been a successful student and field hockey player in high school. Having decided not to play field hockey in college, she began running several mornings each week during the summer and "cut out junk food" to protect herself from gaining "that freshman 10." Rachel lost a few pounds that summer and received compliments from friends and family for looking so "fit." She reported feeling more confident and ready for college than she had expected as the summer drew to a close. Once she began school, Rachel increased her running to daily, often skipped breakfast in order to get to class on time, and selected from the salad bar for her lunch and dinner. She worked hard in school, made the dean's list the first semester, and announced to her family that she had decided to pursue a premed program. When Rachel returned home for Christmas vacation, her family noticed that she looked thin and tired. Despite encouragement to catch up on rest, she awoke early each morning to maintain her running schedule. She displayed a newfound interest in cooking and spent much of the day planning, shopping, and preparing dinner for her family. Rachel returned to school in January and thought she might be developing depression. Courses seemed less interesting, and she wondered whether the college she attended was right for her after all. She was sleeping less well and felt cold much of the day. Rachel's parents asked her to step on the bathroom scale the night she returned home for spring break. Rachel was surprised to learn that her weight had fallen to 104 lb, and she agreed to a visit to her pediatrician, who found no evidence of a general medical illness and recommended a psychiatric consultation. Does Rachel have anorexia nervosa? If so, how should she be treated?
Previous research on the prevalence of personality disorders in patients with eating disorders varies greatly in findings, but a general understanding seem to exist that personality disorders are rather common among eating-disordered patients. The present investigation is aimed at establishing the prevalence of DSM III-R or DSM IV personality disorders in a large population seeking treatment for eating disorders.
Five hundred and forty-five patients with DSM IV- eating disorders have been evaluated using the structured clinical interview for DSM III-R or IV-Axis II and the eating disorder examination.
The 29.5% of the population have one or more personality disorders according to DSM III-R or DSM IV criteria. Personality disorders, and specifically borderline personality disorder, are significantly more common in patients with bulimia nervosa.
The proportion of eating-disordered patients with co-morbid personality disorder may not be as large as often found in studies. This challenges the understanding of a strong overall connection between the two groups of disorder; however, the connection seems to exist in subsets of eating disorder samples.