Eating disorders

Young people with an eating disorder have negative beliefs about themselves and about their eating, body shape and weight. This has an impact on their physical and mental health, education, relationships and quality of life.

There are five main eating disorders:

  1. Anorexia Nervosa
  2. Bulimia Nervosa
  3. Binge Eating Disorder
  4. Other Specified Feeding or Eating Disorder (OSFED)
  5. Avoidant/Restrictive Food Intake Disorder (ARFID).

Most of these disorders develop in adolescence.

The exact cause of eating disorders is not known, but it’s likely that there are several factors at play, rather than one single identifiable cause; for example, a mix of social, biological, psychological and interpersonal causes.

In most cases, eating disorders start in adolescence, but they are often not picked up until adulthood. However, the earlier treatment starts, the better the long-term outcomes.

Current research supports the use of several types of psychotherapies, including Cognitive Behavioural Therapy (CBT), interpersonal and family-based therapies, as well as some medications for the treatment of eating disorders.

  • Introduction

    People who have an eating disorder have negative beliefs about themselves and about their eating, body shape and weight. This usually causes physical and psychological symptoms, some of which (may) become long-term. Young people who have an eating disorder become emotionally distressed and socially isolated, and often have a poor quality of life (Beat, 2015). These conditions affect relationships with family and friends, school life and work. The risk of early death among people with eating disorders is one of the highest among those with psychiatric disorders, either because of physical complications, such as malnutrition or heart problems, or because of suicide (Arcelus et al, 2011; Chesney et al, 2014).

    Most eating disorders develop in adolescence, with those aged under 20 making up almost half of all people receiving inpatient treatment for an eating disorder in England (BEAT, 2015). Eating disorders are thought to be the third most common chronic illness (after asthma and obesity) in adolescent girls (Yeo and Hughes, 2011). About 90% of eating disorders develop in women and girls and most are of normal weight or above (only about 15-20% meet criteria for anorexia nervosa) (NICE 2017).

    Prevalence is relatively stable, and there is little evidence that the number of young people diagnosed with an eating disorder overall is increasing, with many cases remaining unidentified (NICE 2017). A recent study in UK general practice suggests that anorexia nervosa and bulimia nervosa rates have remained stable over the last decade, whilst the incidence of eating disorder not otherwise specified has increased.

    Eating disorders are grouped into the following conditions (NICE, 2017, APA, 2013):

    • Anorexia Nervosa. This is when a young person maintains a low body weight because of either a fear of being fat or in the pursuit of thinness. It is relatively rare in children under 13 years (Nicholls et al., 2011), and usually begins in adolescence between the age of 15 and 19 (Micali 2013). Lifetime prevalence in young women is estimated to be between about 2% and 4.5%, and for men it is around 0.2% to 0.3% (Smink et al, 2012). Anorexia nervosa has the highest rate of mortality among all mental disorders, due both to suicide and physical sequelae (NICE, 2017; Arcelus et al, 2011).
    • Bulimia Nervosa. This is when a young person has episodes of binge-eating, which is when they eat a large quantity of food in a short period of time with a sense of loss of control over the amount of food eaten. In people with bulimia nervosa these episodes are followed by self-induced vomiting, use of laxatives, fasting, or excessive exercise (singly or in combination), in order to avoid weight gain. It mainly starts between the age of 15 and 24 (Smink et al., 2012) and the one-year prevalence is around 1% in women and 0.1% in men (van Hoeken et al., 2003)
    • Binge Eating Disorder (BED) occurs when someone eats significantly more food in a short period of time (usually less than 2 hours) than most people would eat. People with binge eating disorder often feel out of control in their eating, but don’t take part in other behaviours such as vomiting or fasting. Compared with the other eating disorders, BED is more common in men and boys and older people. The lifetime prevalence of BED is around 1.1% for women and 3.1% for men (Raevuoria et al, 2014))
    • Other Specified Feeding or Eating Disorder’ (OSFED) or Unspecified Feeding or Eating Disorder (UFED). This is when a person has some of the symptoms of an eating disorder such as anorexia nervosa or bulimia nervosa, but does not meet the precise diagnostic criteria for them. Lifetime prevalence of OSFED has been estimated to be around 1.9 % for women and 0.3 % for men (Preti et al, 2009). It’s the most commonly diagnosed eating disorder in men and boys (NICE 2017).

    A relatively newly classified eating disorder is Avoidant/Restrictive Food Intake Disorder (ARFID). This is an extreme form of picky eating, where a child or young person has an apparent lack of interest in eating or food, where avoiding food is based on the sensory characteristics of it and concern about aversive consequences of eating (APA, 2013). Children and young people with ARFID will persistently not eat enough in terms of their energy needs, and eat poorly in terms of the nutritional value of the food (APA, 2013). This usually leads to weight loss, poor nutritional state and emotional problems, and sometimes to tube feeding (APA, 2013).

    There are two additional eating disorders:

    • PICA defines situations in which a child eats non-food items (such as sand, pebbles, hair, faeces, lead and plastic) for at least one month at an age when this kind of behaviour is not appropriate (APA, 2000). This can be benign, or it may have life-threatening consequences, depending on what the child is eating.
    • Rumination Disorder is either voluntary or involuntary regurgitation and re-chewing of partially digested food that is then either re-swallowed or spat out (APA, 2013). These two disorders are unusual and are not covered in any further detail here.

    The impact of eating disorders is wide ranging. The UK eating disorder charity, Beat, says that most people are trapped in a repeating cycle of seeking help, waiting for diagnosis, waiting for and receiving treatment and ultimately relapsing and requiring repeat treatment. For more than half of people with an eating disorder, the recurring cycle lasts for more than 6 years (Beat, 2015).

    Living with an eating disorder can have implications for a young person’s education, personal development, growth (including a delay in puberty) and physical and mental health (Schmidt et al, 2016). Long-term and severe eating disorders can cause heart and circulatory, muscle, joint and metabolic problems, such as osteoporosis, impaired immune system, heart failure, infertility and irregular heart rhythms (NICE 2017). Eating disorders also often co-exist with other mental health problems, including (NICE 2017):

    • anxiety disorders (particularly social anxiety/phobia)
    • obsessive-compulsive disorder
    • depression
    • self-harm
    • alcohol and drug use
    • personality disorders

    Given all these factors, it’s no surprise that families, carers and loved ones also have high levels of stress. Indeed, research shows that the burden placed on carers of people with eating disorders is often higher than other mental health conditions (Treasure et al., 2001).

  • What we already know

    Causes

    Finding a specific cause for eating disorders is difficult.  It’s likely that there are several factors at play, rather than one single identifiable cause, for example, a mix of social, biological, psychological and interpersonal causes (Culbert et al, 2015).

    If a young person’s parent has an eating disorder, they are at increased risk of developing one themselves, particularly if they are female (Bould, et al 2015). This is likely to be due to a combination of shared genetic factors and environmental factors (e.g. feeding practices, cognitive styles) (Bould, et al 2015).

    Eating disorders are often long-term conditions, so there are some factors which ensure that the disorder is maintained. These include (NICE 2017):

    • social isolation
    • anxiety and depression
    • body image disturbance
    • cognitive difficulties such as poor concentration, narrowed thinking and memory problems

    Diagnosis and assessment

    Eating disorders usually start in adolescence, but they’re often not picked up until adulthood (NICE 2017). The earlier treatment starts, the better the long-term outcomes (Linardon et al, 2016). However, this is difficult because the tools to identify eating disorders are limited, and even very underweight children and young people routinely go unidentified by both clinicians and families (NICE 2017).

    Treatment

    In general, treatment for eating disorders could be better.  There are few evidence-based treatments and those that are available can have poor outcomes and high drop-out rates.

    Current research supports the use of several types of psychotherapies, including Cognitive Behavioural Therapy (CBT), interpersonal and family-based therapies, as well as some medications, such as SSRI (selective serotonin reuptake inhibitor) antidepressants for the treatment of eating disorders (BN and BED).  However, there are significant limitations in the evidence base, including lack of data, uniformity of the samples, inconsistent efficacy and the need for tailored approaches (Peterson et al 2016).

    Studies in the community show that most people with an eating disorder don’t have any treatment at all. This may be because:

    • they are never identified in the first place
    • they refuse treatment because of the stigma attached to an eating disorder diagnosis,
    • they do not recognise the serious nature of their condition
    • of shame or denial

    (Attia et al, 2013).

    Alongside mental health treatment for eating disorders, active management of physical health problems, restoring weight and good nutritional intake is vital. Any treatment should involve family members where appropriate and ensure they are also well supported (NICE, 2017).

    Psychological interventions

    Family therapy is an effective treatment for eating disorders (Coutourier et al, 2013, Fisher et al, 2010, NICE, 2017).

    CBT as a treatment for anorexia nervosa has a positive effect on body mass index and eating-disorder symptoms, but it’s not consistently better than other treatments (including dietary counselling, non-specific supportive management, interpersonal therapy, behavioural family therapy) (Galworthy Francis and Allen 2014).

    A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for treating bulimia and other common related syndromes, such as binge eating disorder. There is a small amount of evidence that CBT for bulimia nervosa and similar syndromes works, but the quality of evidence is variable and sample sizes are often small (Hay et al, 2009).

    Interpersonal psychotherapy also works as a treatment for young people with bulimia (Hay et al, 2009) and there is some low-quality evidence that suggests that group CBT is effective compared with no treatment (Polnay, 2014).

    Binge eating disorder treatment includes CBT, interpersonal psychotherapy and guided self-help. All can lead to a remission of the disorder or fewer binge eating episodes (SBU, 2016).

    Other treatments

    The 2017 NICE Guidelines recommend that medication should not be used by children and young people as a sole treatment for any eating disorder. However, there is research which shows that antidepressants may be effective for the treatment of bulimia nervosa (Bacaltchuk 2003) and binge eating disorder (AHRQ 2015). The evidence for their use in treating acute anorexia is unclear (Claudino 2006).

  • Areas of uncertainty

    Despite the reasonably large body of research exploring the possible risk factors for eating disorders, we still don’t know the exact cause of these disorders, or understand the interaction between different causes (Rikani, 2013). In cultures where there there is exposure to the media, perceived pressure to be thin and thinness as the perceived ideal, these factors have been shown to predict increased levels of disordered eating thinking and behaviour (Culbert et al, 2015). But, whether these influences increase the risk of developing an eating disorder has yet to be established (Culbert et al, 2015).

    We don’t know enough about how eating disorders could be prevented, because the research is low quality and because the causes are largely unknown. Media literacy approaches appear to help reduce eating disorders risk factors for adolescents, and CBT may reduce eating disorders risk factors in some groups. Higher quality research in this area is needed (Le et al, 2017).

    There are several tools and measures that can be used to assess for eating disorders, but we don’t know how reliable these are in children and young people, as most are developed from adult tools (Micali et al, 2010). There is also debate about whether self-report questionnaires, interviews or computer-based instruments work best and whether parental reports should be included as part of assessment.

    In people with binge eating disorder, antidepressant medicines (selective serotonin reuptake inhibitors or SSRIs) and lisdexamfetamine can lead to a remission period or fewer binge eating episodes. The effect of these medicines once treatment ends isn’t clear though, and more research exploring their long-term use and adverse effects, and the effect of treatment for children and adolescents is needed (SBU, 2016).

    Many young people with bulimia nervosa don’t access psychological therapies, so online interventions have been developed to improve access to therapies such as CBT. These range from therapies that simulate face-to face sessions with a therapist online using video to self-directed self-help programmes that have no therapist contact. But, we don’t know whether these apps or online programmes are effective interventions for bulimia nervosa (Hay and Claudinio, 2015; Loucas et al, 2014).

    Avoidant/Restrictive Food Intake Disorder (ARFID) has only recently been classified as a disorder in its own right. So, the evidence base is poor, and for now, there are no evidence-based treatment recommendations. However, clinical experience suggests that interventions are likely to differ depending on the circumstance of each individual child. For example, a child who is refusing food because of fear of choking might respond best to cognitive strategies to help address these fears, whereas a child with longstanding poor growth because of severe selectivity of food might need a combined psychological and behavioural approach (Norris, 2016).

  • What's in the pipeline?

    There is evidence from brain scans of people with anorexia that there is altered activity in some areas of the brain, such as the pre-frontal cortex which plays an important role in self-control. Transcranial Magnetic Stimulation (TMS) is a non-invasive method of brain stimulation which works by producing a magnetic field. TMS is currently being used as a treatment for depression in the US. Researchers are now exploring the effects and therapeutic potential of TMS in eating disorders, such as anorexia (Kings College, 2017)

    People with eating disorders often wait a long time for effective treatment. To bridge this gap, researchers are exploring the effectiveness of online guided self-help programmes, based on cognitive behavioural therapy (Kings College, 2017).

    Cognitive remediation therapy (CRT) consists of mental exercises aimed at improving cognitive strategies, thinking skills and information processing through practice. It promotes reflection on thinking styles, encourages thinking about thinking and helps people to explore new thinking strategies in everyday life. Using CRT had proved to be effective for adults with anorexia nervosa, with systematic reviews showing medium to large effect sizes in improved cognitive performance. CRT has potential as a supplementary treatment for young people with anorexia nervosa, warranting further investigation using randomised treatment trials (Tchanturia et al, 2017).

  • Useful resources and websites

    NICE Guidelines: Eating disorders: recognition and treatment. 2017
    https://www.nice.org.uk/guidance/ng69/chapter/Context

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