Eating Disorders

• About

  A person has an Eating Disorder when their attitudes to food, weight, body shape or size become excessive and lead to changes in their eating and exercise habits to a degree that is harmful to their health and well being. 

  Signs of Eating Disorders can include:

  • Excessive dieting or overeating 
  • Thinking and talking about body appearance, weight and food  
  • Avoidance of social situations involving food 
  • Becoming irritable and/or withdrawing from friends and family
  • Wearing loose fitting clothing to hide weight loss
  • Wanting to eat alone
  • Playing with food 
  • Exercising often  
  • Going to the bathroom after meals 
  • Difficulty concentrating 

  Eating disorders include anorexia nervosa, bulimia nervosa and a general class of eating disorders called Eating Disorder Not Otherwise Specified (EDNOS) (which includes binge eating disorder).

  Eating disorders can have significant physical and emotional effects.  People with eating disorders can have reductions in cognitive function, emotional changes and may stop participating in their normal activities of daily life (1), and young people with eating disorders are over ten times more likely to die prematurely than their peers without an eating disorder (2-4). This increased risk includes increased risk of suicide (5) and serious physical health issues arising from effects of bingeing, purging and starvation on the body's organs and metabolism. Eating disorders are among the most common mental disorders for which young women receive hospital treatment in Australia (6).

  Burden and onset of eating disorders
  Eating disorders are common in young people, especially in female adolescents and young women, although males can also be affected (7-9). In the general population 7 percent of boys and 13 percent of girls report some sort of disordered eating behaviours (10).

  The beginning of adolescence and the late teens are peak periods for people with eating disorders to experience their first symptoms, although eating disorders may first occur at any age (11-17). In young women, the average age at which anorexia nervosa first appears is 19 years of age (with a range of 14- 28 years of age) and bulimia 20 years (range of 10-38)(18, 19). Binge eating disorder is more likely to begin at older ages (at around 25 years of age)(18). Eating disorders generally begin later in males than in females.

  The most common category of eating disorder - as it includes a wide range of different types of disordered eating, weight loss and body image problems - is EDNOS (20). For females, across a lifetime, around 2.5 to 4.5 percent of women experience binge eating disorder, around 2.0 percent bulimia nervosa, and around 1.5 percent experience anorexia nervosa. In men, these rates are lower, with 1-3 percent of men experiencing binge eating, around 1.0 percent bulimia nervosa and around 0.5 percent anorexia nervosa at some point in their lives (13, 21).

  It is common for eating disorders to co occur with other mental health and substance use disorders. These can include anxiety and depression (22); substance abuse (especially with bulimia); and personality disorders such as obsessive-compulsive personality disorder (23). Eating disorders that co-occur with other mental health disorders typically have poorer outcomes than those without co morbid conditions.

  Risk factors:
  Relatively little is known about the risk factors for eating disorders. Possible risk factors include (11, 24, 25):

  • Dieting
  • Being female
  • Body image concerns
  • Adolescence and early adulthood 
  • Genetic vulnerability and family history
  • Certain occupations

  
  References:

  1. Klump, KL, Bulik, CM, et al. Academy for eating disorders position paper: eating disorders are serious mental illnesses. The International journal of eating disorders. 2009 Mar;42(2):97-103. 

  2. Birmingham, CL, Su, J, et al. The mortality rate from anorexia nervosa. Int J Eat Disord. 2005 Sep;38(2):143-6.

  3. Steinhausen, HC, Weber, S. The outcome of bulimia nervosa: findings from one-quarter century of research. Am J Psychiatry. 2009 Dec;166(12):1331-41.

  4. Steinhausen, HC. Outcome of eating disorders. Child Adolesc Psychiatr Clin N Am. 2009 Jan;18(1):225-42.

  5. Preti, A, Rocchi, MB, et al. A comprehensive meta-analysis of the risk of suicide in eating disorders. Acta Psychiatr Scand. 2010 Nov 24.

  6. ABS. Australian Bureau of Statistics. 2007 National Survey of Mental Health and Wellbeing: Summary of Results. (Document 4326.0). 2008.

  7. Currin, L, Schmidt, U, et al. Time trends in eating disorder incidence. Br J Psychiatry. 2005 Feb;186:132-5.

  8. Keel, PK, Heatherton, TF, et al. Point prevalence of bulimia nervosa in 1982, 1992, and 2002. Psychol Med. 2006 Jan;36(1):119-27.

  9. Kendler, KS, MacLean, C, et al. The genetic epidemiology of bulimia nervosa. Am J Psychiatry. 1991 Dec;148(12):1627-37.

  10. Neumark-Sztainer, D, Hannan, PJ. Weight-related behaviors among adolescent girls and boys: results from a national survey. Arch Pediatr Adolesc Med. 2000 Jun;154(6):569-77.

  11. Patton, GC, Selzer, R, et al. Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ. 1999 Mar 20;318(7186):765-8.

  12. Hudson, JI, Hiripi, E, et al. The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry. 2007;61(3):348-58.

  13. Watson, H, Elphick, R, et al. Eating Disorders prevention, treatment and management: An Evidence Review. National Eating Disorders Collaboration. 2010.

  14. Garfinkel, PE, Lin, E, et al. Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups. Am J Psychiatry. 1995 Jul;152(7):1052-8.

  15. Kinzl, JF, Traweger, C, et al. Binge eating disorder in males: a population-based investigation. Eat Weight Disord. 1999 Dec;4(4):169-74.

  16. Kinzl, JF, Traweger, C, et al. Binge eating disorder in females: a population-based investigation. Int J Eat Disord. 1999 Apr;25(3):287-92.

  17. Woodside, DB, Garfinkel, PE, et al. Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry. 2001 Apr;158(4):570-4.

  18. Oakley Browne, MA, Wells, JE, et al. Lifetime prevalence and projected lifetime risk of DSM-IV disorders in Te Rau Hinengaro: the New Zealand Mental Health Survey. Aust N Z J Psychiatry. 2006 Oct;40(10):865-74.

  19. Fosson, A, Knibbs, J, et al. Early onset anorexia nervosa. Arch Dis Child. 1987 Feb;62(2):114-8.

  20. Machado, PP, Machado, BC, et al. The prevalence of eating disorders not otherwise specified. Int J Eat Disord. 2007 Apr;40(3):212-7.

  21. Hoek, HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry. 2006 Jul;19(4):389-94.

  22. Braun, DL, Sunday, SR, et al. Psychiatric comorbidity in patients with eating disorders. Psychol Med. 1994 Nov;24(4):859-67.

  23. Godt, K. Personality disorders in 545 patients with eating disorders. Eur Eat Disord Rev. 2008 Mar;16(2):94-9.

  24. Striegel-Moore, RH, Bulik, CM. Risk factors for eating disorders. Am Psychol. 2007 Apr;62(3):181-98.

  25. Fairburn, CG, Harrison, PJ. Eating disorders. Lancet. 2003 Feb 1;361(9355):407-16.  

• Assessment

  The current formal systems for the diagnosis of mental illness (DSM-IV criteria for relevant Eating disorders) (ICD-10 codes for relevant mood disorders) define two major types of eating disorder and a third general class. These categories are:

  • Anorexia nervosa: people with Anorexia are very controlling of their weight and food intake.
    • They have substantially lower than normal body weight (for their age and height);
    • try to avoid weight gain by refusing to or eat or through use of pills, fasting, vomiting, excessive exercise and other means to control weight gain. Some people with anorexia binge eat and then 'purge';
    • an intense fear of becoming fat and denial of the seriousness of being underweight; 
    • a disturbed view of their body image and of the importance of body image to self worth; 
    • and often, physical health changes (including loss of normal menstrual periods for females). 
  • Bulimia nervosa: people with Bulimia tend to feel out of control when it comes to food. 
    • They have frequent, often secretive, episodes of eating large amounts of food within a short time (binge eating); 
    • frequent and reoccurring attempts to offset the binges and avoid weight gain through use of pills, fasting, vomiting, excessive exercise and other means; and heightened perception the importance of body image to self worth. People with Bulimia are usually within the healthy weight range. 
  • Eating disorder not otherwise specified (EDNOS): EDNOS includes a range of different unhealthy and extreme disturbance in body image, weight, eating behaviours and relationship with food. Binge eating disorder is a specific type of ENDNOS. People with binge eating disorder have bouts of out-of- control eating, where they eat large amounts of food within short periods of time. They also experience guilt and distress because of their eating which leads to further bingeing.

  Assessment tools
  Early detection of eating disorders symptoms is important to improving the chances of achieving better outcomes for people experiencing, or at high risk of, eating disorders. To decide whether a young person is experiencing an eating disorder, a comprehensive assessment by a mental health professional is required. As a first step, the assessment involves asking questions about a range of aspects of a person life including:

  • Home and Environment; 
  • Education and Employment; 
  • Activities; 
  • Drugs and Alcohol; 
  • Relationships and Sexuality; 
  • Conduct Difficulties and Risk-Taking; 
  • Anxiety and Eating; 
  • Depression and Suicide; 
  • Psychosis and Mania

  A comprehensive assessment by a mental health professional trained in clinical assessment is required to assess specifically for the presence of an eating disorder. Tools that are used to assess and/or screen for eating disorders include the self-report Questionnaire for Eating Disorder Diagnoses [Q-EDD], the Structured Interview for Anorexic and Bulimic Disorders (SIAB)(1), the SCOFF clinical prediction questionnaire (2).

  References:
  1. Fichter, MM, Herpertz, S, et al. Structured Interview for Anorexic and Bulimic disorders for DSM-IV and ICD-10: updated (third) revision. Int J Eat Disord. 1998 Nov;24(3):227-49.

  2. Morgan, JF, Reid, F, et al. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ. 1999 Dec 4;319(7223):1467-8.

• Treatment

  Treatment of eating disorders needs to address not only the issues related to mental illness, psychological impairment and distress, but also the complicated, and potentially very serious, physical and nutritional effects of the disorder.  For most cases, this means that a multidisciplinary team is needed, ideally including members who have expertise in treating young people with eating disorders. Community-based treatment is the preferred setting for care, but emergency care, specialist unit referral or consultation may be necessary, depending on the severity of the presentation and the capabilities of the local team.

  Key aspects of treating eating established disorders in young people include (1):

  • Providing good information on the nature and course of the disease to the young person affected, their family and supports. This may include support groups.   
  • Including family members, including siblings, in the treatment of children and adolescents with eating disorders. Interventions may include sharing of information, advice on behavioural management and facilitating communication.
  • Beginning treatment as early as possible
  • Management of physical complications, which include metabolic changes, dental damage, possible medication abuse, bone fracture risk, nutritional needs and monitoring of growth and physical development
  • Adequate duration of treatment

  With support and appropriate young people with eating disorders can recover successfully, and early detection and treatment of eating disorders is associated with better outcomes. 

  Research has shown that, for individuals showing early signs of disordered eating and body image, cognitive behaviour therapy, cognitive dissonance approaches, and literacy programs can have positive effects on reducing the risk of developing further eating disorder symptoms (2, 3).

  Family therapy is recommended for young people with anorexia nervosa (1, 4). Self-help and guided self-help strategies can reduce eating disorder symptoms for adults with bulimia nervosa, binge eating disorder and eating disorder not specified (EDNOS) (5) and has been recommended as a first step for therapy for these disorders (1). Other psychological therapies such as cognitive behavioural therapy (CBT, including a specifically adapted forms of CBT for bulimia nervosa and binge eating), interpersonal therapy (IPT), and modified dialectical behaviour therapy for binge eating are effective in reducing bulimia and binge eating behaviours (1, 6). Other therapies for anorexia nervosa are less well studied. Approaches thought to be helpful include cognitive analytic therapy (CAT), cognitive behaviour therapy (CBT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy (1).

  Antidepressant medication, in particular fluoxetine, has also been shown to be effective for adults experiencing bulimia- and combing this medication with psychological therapies is even more effective -but individuals receiving treatment may prefer psychological therapy alone (7, 8). Antidepressants have not been shown to be effective for people experiencing anorexia nervosa, however, and caution is recommended in the use of any medication as treatment for anorexia(1, 9).

  The evidence map provides reference details for studies of prevention and treatment interventions for eating disorders in young people. 

  References:
  1. Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. 2004;NICE clinical guideline CG9.

  2. Stice, E, Shaw, H, et al. A meta-analytic review of eating disorder prevention programs: encouraging findings. Annu Rev Clin Psychol. 2007;3:207-31.

  3. Watson, H, Elphick, R, et al. Eating Disorders prevention, treatment and management: An Evidence Review. National Eating Disorders Collaboration. 2010.

  4. Fisher, CA, Hetrick, SE, et al. Family therapy for anorexia nervosa. Cochrane Database Syst Rev. 2010;4:CD004780.

  5. Perkins, SJ, Murphy, R, et al. Self-help and guided self-help for eating disorders. Cochrane Database Syst Rev. 2006;3:CD004191.

  6. Hay, PP, Bacaltchuk, J, et al. Psychological treatments for bulimia nervosa and binging. Cochrane Database Syst Rev. 2009;4:CD000562.

  7. Bacaltchuk, J, Hay, P, et al. Antidepressants versus psychological treatments and their combination for bulimia nervosa. Cochrane Database Syst Rev. 2001;4:CD003385.

  8. Bacaltchuk, J, Hay, P. Antidepressants versus placebo for people with bulimia nervosa. Cochrane Database Syst Rev. 2003;4:CD003391.

  9. Claudino, AM, Hay, P, et al. Antidepressants for anorexia nervosa. Cochrane Database Syst Rev. 2006(1):CD004365.  

• Guidelines

  The following authoritative guidelines provide evidence-based information about the practical treatment of eating disorders:

  Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa (2004) Royal Australian and New Zealand College of Psychiatrists.

  Eating disorders toolkit, a practice based guide to the inpatient management of adolescents with eating disorders, with special reference to regional and rural areas (2008) MH-Kids, New South Wales Health.

  Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. (2004) NICE clinical guideline CG9.  United Kingdom

  Treatment of Patients With Eating Disorders, Third Edition (2006) American Psychiatric Association. United States of America.

• More info

  The following selected articles and web sites provide more information about anxiety disorders and anxiety intervention research:

  Striegel-Moore, RH, Bulik, CM. Risk factors for eating disorders. Am Psychol. 2007 Apr;62(3):181-98.

  Belinda M Pratt, Susan Woolfenden Interventions for preventing eating disorders in children and adolescents Cochrane Database Syst Rev. 2009(1):CD002891

  Russell S, Fuscaldo G and Ealey W. Eating Disorders with Comorbid Depression and Anxiety: Literature Review. 2008. Beyond Blue Limited: Melbourne.

  Couturier J, Lock J. A review of medication use for children and adolescents with eating disorders. J Can Acad Child Adolesc Psychiatry. 2007 Nov;16(4):173-6.

  Sarah S J Perkins, Rebecca RM Murphy, Ulrike US Schmidt, Chris Williams. Self-help and guided self-help for eating disorders Cochrane Database Syst Rev. 2009(1):CD004191 

  Watson, H, Elphick, R, et al. Eating disorders prevention, treatment and management: An evidence review. 2010. National Eating Disorders Collaboration. 2010.