Eating Disorders

A Patient-Centered Approach

Kathleen M Berg, J Hurley Dermot, James A McSherry, Nancy E Strange

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315344416
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Providing a wide range of questions for all doctors wishing to take the Professional and Linguistics Board Test required for foreign nationals who want to practice in the UK, this title is a comprehensive primer for the examination. Presented in a workbook style, with spaces for the answers to be entered, it provides a wide range of questions examining over 1250 extended matching questions. It also includes contact details for key UK medical organizations and institutions and guidance to PLAB candidates from the General Medical Council.

1

Magnitude of the problem

James A McSherry

Eating disorders are frequently assumed to be a modern disease whose origins lie in an overstressed, prosperous world. A world where societal pressures to be slim have created epidemic preoccupation with size and shape among young women. Standards of female beauty do change from time to time, perhaps in response to changing social conditions and food availability. The glamorized ‘ideal’ female shape, as defined by Western cultural standards, has changed visibly and measurably in modern times. A 1980 study found that Playboy centrefolds and Miss America contestants had become progressively lighter in weight and more ‘tubular’ in appearance over a period of 20 years, setting standards that are genetically and biologically impossible for the vast majority of women (Garner et al., 1978). In a curious paradox, the average woman’s weight has been increasing at a rate almost exactly matched by the decline in the weights of our cultural icons. There is an inverse relationship between female body weight and socioeconomic status in contemporary Western society; the higher a woman’s socioeconomic status the more likely she is to be thin and to project an image of success, self-assurance and strength. We live in a culture of ‘weight-ism’, where to be overweight is to be devalued as somehow lacking in moral fibre and disadvantaged in social and employment-related settings.

It hasn’t always been so. To be overweight when others are starving indicates a certain place on the social ladder of power and prestige, it has been argued, while being slim in an age of plenty indicates a superior degree of fastidiousness and an aloofness from the common herd. Many celebrated beauties of former ages, if alive today, would find themselves encouraged to attend an obesity clinic or ‘fat farm’ since their tendency to what we would regard as overweight runs contrary to modern taste. There is a certain face validity to this viewpoint, but the truth is that food refusal has been documented as a female assertiveness response for many centuries in times of plenty and in times of want. It is our interpretation of this behavior and our definition of the core attributes of a disordered belief system that has changed the way we look at such a phenomenon. An understanding of that disordered belief system and the role it plays in the lives of people affected by an eating disorder is fundamental to any attempt to help those people overcome conditions that have serious consequences for their physical and psychological well-being.

The Diagnostic and Statistical Manual (American Psychiatric Association, 2000b) is the standard reference book that classifies psychiatric conditions and defines the criteria by which they are diagnosed. Usually referred to as DSM, it is now in its fourth edition. DSM-IV-TR describes three specific eating disorders: anorexia nervosa, bulimia nervosa and ‘eating disorder not otherwise specified’. Anorexia nervosa and bulimia nervosa are the best known of the eating disorders because, as diagnostic categories, they define serious abnormalities of eating attitudes and behaviors that have important consequences for the physical and mental health of affected individuals. However, they fail to capture the extent to which less severe forms of both conditions appear in any given population and ‘eating disorder not otherwise specified’ (EDNOS) is the term used to describe the situation where an individual presents with features highly suggestive of an eating disorder, but lacking the severity or chronicity to justify a diagnosis of anorexia nervosa or bulimia nervosa.

Diagnostic criteria

The basic DSM-IV-TR (American Psychiatric Association, 2000b) diagnostic criteria for anorexia are:

• refusal to maintain a normal body weight for age and height, or failure to make expected weight gains at times of growth and physical development
• fear of gaining weight or becoming fat
• an abnormal body image
• cessation of menstrual periods in women who are not using any external source of estrogen, e.g. oral contraceptives.

Persons affected by anorexia nervosa believe themselves to be fat and overweight despite all objective evidence to the contrary. Bulimic and restricting subtypes of anorexia nervosa are recognized. Patients with the restricting subtype drastically reduce their daily calorie intake without binge eating, purging or using laxatives or diuretics on anything other than an occasional basis. Their eating attitudes and behaviors often have an overt obsessive-compulsive flavor with elaborate rituals around preparation of food that is frequently offered to others, but never consumed by the affected individuals. Patients with the bulimia nervosa subtype have frequent eating binge/purge episodes. Some patients with anorexia nervosa purge without binge eating, at least by objective measures.

Bulimia nervosa is characterized by:

• recurrent episodes of uncontrollable binge eating followed by such inappropriate attempts at compensation as self-induced vomiting, misuse of laxatives and excessive exercise
• preoccupation with size, shape and weight.

Eating binges are episodes of rapid consumption of large quantities of food over relatively short periods of time and should occur at least twice a week for at least three months to satisfy the DSM-IV criteria. Once triggered, eating binges are perceived as beyond the affected individual’s personal control until they are terminated by running out of food, experiencing intolerable physical discomfort, involuntarily vomiting or some kind of social interaction that produces an enforced distraction. There is evidence for a significant overlap of abnormal attitudes and behaviors between anorexia nervosa and bulimia nervosa (Bulik et al., 1997) since as many as 50% of patients with anorexia nervosa may develop bulimic symptoms and patients with bulimia nervosa may display anorexic symptoms.

Atypical eating disorders

The DSM-IV category ‘EDNOS’ is essentially a classification that captures individuals whose behaviors are clearly abnormal and clinically significant, but fail to match exact diagnostic criteria for anorexia nervosa and bulimia nervosa, the so-called ‘atypical eating disorders’. Diagnostic criteria are artificial concepts at best, arbitrary constructs that define conditions of unequivocal severity where abnormal eating attitudes and behaviors are clearly pathological and have recognizable consequences that are harmful to the affected person. The 10th edition of the World Health Organization’s International Classification of Diseases (ICD-10) identifies ‘atypical eating disorders’ as those conditions in which the general features support a diagnosis of anorexia nervosa or bulimia nervosa, but one or more of the key features are missing or present only in minor degree.

Frequency and outcome

The lifetime prevalence of anorexia nervosa in women is between 0.5% and 3.7% (Garfinkel et al., 1995; Walters and Kendler, 1995) and between 1.1% and 4.2% for bulimia nervosa (Garfinkel et al., 1995; Kendler et al., 1991).

Anorexia nervosa appears to be uncommon outside Western society, but immigrants from less-developed to more-developed countries are more likely to develop eating disorders than their sisters who stayed in their countries of origin (Vandereycken and Hoek, 1992). The observation that the onset of an eating disorder frequently coincides with puberty suggests that young women may misinterpret their changing shape as ‘getting’ fat and engage in dieting behavior in an attempt to regain their former ‘slim’ androgenous shape. It is also possible that young women may find themselves uncomfortable in their new role as developing adults and feel threatened by a sexuality with which they have not previously had to deal. Weight loss and regression of secondary sexual characteristics effectively resolve these issues. Both anorexia nervosa and bulimia nervosa occur most often in college and university women, but are far from exclusive to them (Marciano et al., 1988). Primary care physicians recognize only 40% of patients with anorexia nervosa, and bulimia nervosa in only 11% (Hoek, 1991). The category EDNOS recognizes that many women suffer from disorders of eating attitudes and behaviors that cannot be assigned to a specific diagnostic category, but are, nevertheless, important causes of psychological distress, physical health problems and reduced quality of life for those affected.

The following ‘prayer’ was given to the author (McSherry, 1984) by one of his patients and seems to express many of the frustrations experienced by such women.

The Prayer of the Pleasing Child

• I feel fat.
• Yesterday I felt fat,
• but today I ate.
• Why does my stomach rule my mind?
• I just want to stop eating, period.
• No food,
• Just quit... cold turkey.
• That is a bad expression for a dieter.
• Tomorrow I have to force my body into submission.
• I have to love myself.
• I hate myself when I eat,
• So, if I don’t eat,
• Even though it hurts,
• I love myself.
• Oh, I feel so gross!
• If only I could peel myself like a banana,
• Release the true me,
• Under the layer of flab
• which stops me from interacting, from loving, from living.
• I have to stop eating.
• Chains we cannot see,
• Come release us, Lord,
• From chains we cannot see,
• But how we feel them!
• I want to be a pleasing child.
• Until that final day,
• God please help me get control again.

The common theme in eating disorders is preoccupation with body weight and shape, often accompanied by dietary faddism with unusual food preferences. Depressed mood is associated with eating disorders in 50% to 75% of affected individuals (Braun et al., 1994; Hamli et al., 1991; Herzog et al., 1992). Women are affected between six to nine times more frequently than men, except in adolescence, where 19%-30% of eating disorders patients are male (Fosson et al., 1987; Hawley, 1985; Higgs et al., 1989).

A review of 68 outcomes studies published between 1953 and 1986 (Steinhausen, 1995) analyzed data from 3104 patients who had been followed for periods between one and 33 years. Forty-nine percent of patients affected by anorexia nervosa returned to normal eating behavior, while 60% returned to normal weight and menstruation. Over 40% of anorexia nervosa-affected persons could be said to have recovered, over 30% were improved and 20% had a persistent chronic illness. The overall mortality was 5%, although the studies individually reported mortality rates of 0% to 21%. Positive outcomes were found to be dependent on such variables as personality, a conflict-free relationship with parents, early treatment, risk avoidance, emotional restraint and conformity to authority. Conversely, vomiting, bulimia nervosa, profound weight loss, chronicity, impulsiveness, lack of self-esteem and distrust of others were indicators of a generally poor prognosis.

About 50% of those struggling with bulimia nervosa recover with cognitive behavioral therapy, about 30% have a persistent, less severe but chronic illness and 20% have a persistent condition that is resistant to therapy (Hsu, 1995). Although 30% of persons with normal weight bulimia nervosa have a previous history of anorexia nervosa, relapse is infrequent (Hsu, 1995).

Risk factors

Do individuals with already abnormal eating attitudes and behaviors or disturbed body image actually select particular vocations and pursuits that seem to be associated with a high prevalence of eating disorders? Is it the occupation or the hobby that produces the disorder? The answers are not entirely clear. Known factors that place individuals at increased risk for developing an eating disorder include dieting behavior, use of hazardous weight-loss measures, childhood obesity (Cooper, 1995b), sexual abuse (Welch and Fairburn, 1994), medical conditions that focus attention on nutrition and weight control, e.g. diabetes mellitus (Peveler, 1995), androgen excess syndromes, etc. (McSherry, 1990). Additionally, membership in predisposed vocational groups such as models, ballet dancers, skaters, gymnasts, wrestlers, jockeys, flight attendants, athletes, etc. increases risk (Mickalide, 1990).

Abnormal eating attitudes and behaviors, pathological weight-control measures, even eating disorders themselves are common in female athletes (Sundgot-Borgen, 1993), with the caveat that the presence of a clinically significant eating disorder will prejudice the likelihood of an affected person reaching the highest levels of performance.

The meaning of words

The term ‘anorexia nervosa’, Latin for ‘nervous loss of appetite’, was introduced into general use by Sir William Withey Gull, an English physician, in 1873. It is one of modern medicine’s greatest misnomers since patients struggling with anorexia have not lost their appetites, they are actually engaged in its rigorous suppression. Failure to understand this basic concept is a major obstacle to any understanding of the individuals affected by the disorder. The word ‘bulimia’ was introduced into the English language by Dr Samuel Johnson in his famous Dictionary. It means ‘ox-eating’ and was used by Xenophon (c. 428-354 BC) in his Anabasis to describe the voracious eating behaviors of his soldiers after a long period of semi-starvation (Parry-Jones and Parry-Jones, 1995).

The history of eating disorders

Eating disorders are modern clinical concepts based on diagnostic criteria of relatively recent origin. It is, therefore, difficult to make retrospective diagnoses except in unusually well-documented cases since the kind of medical assessment that would exclude other conditions is not available. However, it is highly likely that eating disorders, or at least instances of prolonged food refusal with binge eating and self-induced vomiting, were well established, if poorly understood, features of the health landscape long before Sir William G...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Series editors’ introduction
• Foreword
• About the authors
• Acknowledgments
• Dedication
• Introduction
• 1 Magnitude of the problem
• 2 The eating disorders: anorexia nervosa and bulimia nervosa
• 3 The illness experience: eating disorders from the patient’s perspective
• 4 Understanding the whole person: Rose’s story
• 5 The patient-clinician relationship
• 6 Management and finding common ground
• 7 A patient-centered approach to eating disorders: summary
• Index