Dissatisfaction with one’s appearance and dieting behaviors, combined with disturbances in self-esteem, emotion regulation, and problems in relationships, can promote the onset of eating disorders at critical life stages. Recent studies indicate an increasing incidence of psychologically related eating disorders. The ICD-10 distinguishes anorexia (AN) and bulimia nervosa (BN), binge eating disorder, and unspecified eating disorders. Early diagnosis is necessary considering the risks. Sufficient treatment includes psychoeducation, disorder-oriented elements, and the treatment of background conflicts with attention to the motivation for therapy. Integrative cooperation between all parties involved is indispensable.
Eating disorders affect more women than men and are more common in developed industrialized nations than in developing countries. A study commissioned by the Swiss Federal Office of Public Health showed lifetime prevalences of anorexia nervosa (AN) and bulimia nervosa (BN) in women of 1.2% and 2.4%, and 0.2% and 0.9% in men, comparable with international studies [1]. High-risk groups include athletes in the aesthetic and endurance sports and diabetes mellitus type I patients associated with BN. Eating disorders most often begin in adolescence with a peak onset of illness for AN of approximately 16 years and for BN of 18-19 years. The 10-year mortality rate is increased more than tenfold (suicides, infections, cardiovascular complications) compared to the general population, at approximately 5%. The long-term course is more favorable overall in BN than in AN, although eating disorder-typical attitudes and conspicuous eating behavior often persist.
Disturbance patterns
Common to anorexia and bulimia nervosa is a clear fear of being too fat and a pronounced striving for “thinness.”
In anorexia nervosa, body weight is 15% below that expected for sex, height, and age (adult BMI <17.5 kg/m2). Weight loss is self-induced and maintained by limiting the amount of food eaten, avoiding high-calorie foods, and other measures such as excessive exercise. Malnutrition leads to endocrine dysfunction, particularly of the hypothalamic-pituitary-gonadal axis. A distinction is made between a restrictive and a bulimic form of AN, in which there are binge eating episodes followed by counter-regulatory measures.
Bulimia nervosa focuses on a persistent preoccupation with food and an irresistible craving for food, resulting in binge eating episodes that are experienced as uncontrollable. Excessive amounts of food are consumed within a very short period of time. Because of the fear of gaining weight, patients counteract this by self-induced vomiting, restrictive eating behaviors, abuse of medications, and excessive exercise. Self-esteem is strongly dependent on one’s own body image.
Early detection and psychiatric diagnosis
Early recognition of an eating disorder is crucial for further treatment success. In addition to determining height and weight, screening questions such as:
- Are you satisfied with your eating habits?
- Are you worried about your weight or diet?
- Does your weight affect your self-esteem?
- Are you worried about your figure?
- Do you eat in secret?
- Do you throw up when you feel uncomfortably full?
- Do you worry because sometimes you can’t stop eating?
The diagnosis of a treatment-relevant eating disorder should be made according to the criteria of the ICD-10 (Tab. 1 and 2), or DSM-IV.
For a more in-depth assessment of specific psychopathology, the use of structured interview guides is recommended, e.g., the Eating Disorder Examination [2] or the Eating Disorder Inventory [3].
Differential diagnosis and comorbidity
Symptoms of eating disorders such as weight loss and conspicuous eating habits can also occur in the context of other psychiatric disorders, e.g., affective disorders, schizophrenia, or obsessive-compulsive disorder. In such cases, the weight loss is involuntary. Likewise, the disturbance of the body schema and the importance of figure and weight for self-esteem are absent.
Comorbid affective disorders, anxiety and obsessive-compulsive disorders, substance abuse, and personality disorders of the borderline, anxious-avoidant, and obsessive-compulsive types are frequently present in AN and BN, and influence the development and course.
Medical complications and diagnostics
The persistent malnutrition, binge eating and vomiting lead to numerous physical sequelae (Table 3). In order to identify the vital risk and any complications in good time and to rule out physical causes, comprehensive medical diagnostics should be performed at the outset (Tab. 4).
A weight with a BMI below 13 kg/m2, or a rapid weight loss of more than 30% of the initial weight within three months, is considered a significant danger indicator.
Risk factors and disturbance models
The development and maintenance of eating disorders are explained multifactorially. A summary is provided by Fairburn’s transdiagnostic model [4] (Fig. 1). The main risk factors are the socio-cultural ideal of slimness, dissatisfaction with one’s own appearance and figure, and dieting behavior.
Physical attractiveness represents an essential source of female self-esteem. During the development of a separate identity in adolescence, being thin can become an exclusive source of self-esteem for some women.
A negative self-esteem concept, like a perfectionist drive for achievement, is well documented as a risk factor. Difficulties in emotion regulation may contribute to and be compensated by an eating disorder, either by avoiding unpleasant emotions at a low weight or by coping with them through binge eating.
At the individual level, learning experiences (e.g., early feeding difficulties), biological factors, a body schema disorder, and cognitive characteristics are considered risk factors. It describes a pre-existing and enduring style of thinking characterized by obsession with detail, rigidity, and little flexibility.
Underlying food-related behavior are irrational thought patterns in the form of selective abstraction, generalizing, exaggeration, and magical thinking. Finally, certain family relationship patterns (enmeshment, rigidity, overprotection, conflict avoidance, and shifting coalition formation) are discussed in relation to eating disorders.
The onset of AN or BN is often preceded by external events (e.g., experiences of separation and loss, fear of performance failure, physical illness, critical comments from loved ones, athletic goals) that involve adjustment efforts that the individual does not feel up to at the time.
The altered eating behavior in AN and BN causes pronounced psychological and physical changes, which in turn lead to a maintaining
contribute to the maintenance of the disturbance. Studies of dieting subjects have shown that malnutrition alone leads to a strong mental preoccupation with food and a bizarre approach to food. Physiological reactions as a result of malnutrition intensify the feeling of ravenous hunger and thus trigger increased binge eating. This increases the fear of weight gain in eating disordered patients and the resulting restrictive eating behavior. Psychologically, depressed mood and irritability develop over time, as well as cognitive impairment. Due to the abnormal eating behavior and pronounced feelings of shame, those affected withdraw socially and limit their other interests, so that self-esteem-enhancing experiences are absent and reinforce the attempt to stabilize self-worth by controlling figure and appearance.
Therapy of anorexia and bulimia nervosa
For the treatment of eating disorders, the effectiveness of different therapeutic methods has been investigated in studies: cognitive behavioral therapy, family therapy, psychodynamically oriented methods, interpersonal psychotherapy, and dialectical behavioral therapy. Due to small samples, a high drop-out rate, exclusion of patients with pronounced underweight, and lack of comparative studies, a definite assessment is currently not possible. However, a disorder-oriented approach proved superior to a nonspecific approach. The following recommendations are mainly based on the S3 guidelines for the diagnosis and treatment of eating disorders [5].
Motivation and therapeutic relationship
On the part of the patients, there is usually a pronounced ambivalence towards therapeutic changes in view of previous unsuccessful therapies, feelings of pride about one’s own discipline, the identity-forming character of the eating disorder, as well as feelings of shame and fear. This requires the permanent support of the therapy motivation. Helpful are the joint derivation of an individual disorder model as well as the open and value-free discussion of chances and risks of a therapy on the basis of detailed information. In the therapy relationship, it is important to find a balance between empathic understanding on the one hand and setting limits or consequences on the other. The aim is to cooperate with the patient within the framework of joint treatment planning. The existing intellectual and creative resources should be taken up in an appreciative manner.
Treatment elements
Treatment for eating disorders should include psychoeducational and disorder-oriented elements. In order to achieve a rapid regression of somatic and psychological sequelae, the short-term goal is to normalize weight as quickly as possible in AN and eating behavior in BN. Body image therapy addresses distorted perceptions of one’s body, negative body-related emotions and cognitions about figure, appearance, and weight, and dysfunctional body-related avoidance and control behaviors that are prognostically unfavorable to eating disorders. In the long run, addressing the underlying problem areas is critical to effective treatment. These include low self-esteem, perfectionistic drive for achievement, need for autonomy, lack of independence, problems in detachment from the parental home and in relationships with other people, and disorders of emotion regulation. Patients are supported to catch up on missed developmental steps in order to achieve social integration.
Especially with children and adolescents, the family should be involved in the treatment, and with adults, the partners, in order to provide concrete assistance in dealing with the disturbed eating behavior and to clarify and work on functional aspects.
Treatment setting
No clear criteria for the preferred choice of treatment setting can be derived from the current body of studies. In principle, outpatient treatment should be sought first. In patients with a pronounced underweight (BMI <15 kg/m2) or a rapid weight loss of more than 30% of the initial weight within the last six months, inpatient treatment is preferable. During this period, complete weight restitution should be sought, if possible, to minimize the risk of recurrence of weight loss. Other indication criteria for inpatient treatment include:
- Insufficient change in the outpatient or day-care setting.
- Lack of outpatient treatment options close to home
- Pronounced mental or physical comorbidity, suicidality
- disease severity (pronounced habituation, chaotic eating behavior)
- Significant conflicts in the social and family environment.
Anorexia nervosa
The body of studies on the treatment of AN shows moderate to low evidence regarding weight gain.
In the treatment of AN, it must be taken into account that the healing process usually takes place over a long period of time and involves several treatment episodes. This requires integrative collaboration among all stakeholders as part of an overall treatment plan.
Treatment must be adapted to the patient’s status. Initially, clear structure and focus on weight and food are required. Emotionally significant topics can only be taken up if they have sufficient weight and the necessary ability to concentrate. For chronic courses lasting more than seven years, it is recommended to focus on minimizing psychological and somatic complications and improving overall quality of life.
The primary goal is to normalize weight, with a target BMI of at least 18.5 kg/m2. Weekly weight gains of 500-1000 g are recommended in the inpatient setting, and 200-500 g in the outpatient setting. The amounts of food are based on the weight trend. For this purpose, patients should be weighed regularly in the morning in light clothing. Regarding the nutritional composition, the usual recommendations of the nutritional society apply. Foods that have been avoided should be gradually reintegrated into the diet.
Initially, a marked tendency to edema may occur as part of a pseudo-Bartter syndrome, which causes weight gain without substantial change in body mass. In patients with prolonged hunger states, hypophosphatemia (<2.5 mg/dl) may occur when food intake is resumed, with the risk of life-threatening refeeding syndrome (myelosis, heart failure, arrhythmias, clouding of consciousness), which requires regular monitoring and oral substitution if necessary. Supplemental sip feeding may be considered at the outset. Tube feeding should only be used in critical individual cases on a short-term basis to achieve an adequate nutritional status.
For the weight gain phase, therapy contracts are concluded with patients in which clear agreements are made regarding the required weight gain and the consequences of achieving or failing to achieve it in the sense of contingency management.
Psychotropic drugs have no proven effect on weight gain; in cases of constant mind-twisting or marked hyperactivity, temporary administration of low-dose neuroleptics may be considered. Antidepressants may be used for persistent depressive moods.
Bulimia nervosa
Patients with BN often have a biographical history of emotional neglect, physical and sexual violence experiences, problematic family communication patterns, and a family history of psychiatric disorders. The eating disorder is usually part of a complex psychiatric disorder, which should be taken into account in treatment planning.
The effectiveness of psychotherapeutic procedures is judged to be good in terms of reducing binge eating, vomiting, laxative abuse, and depression. Medium effects are shown with regard to the pursuit of slimness and dissatisfaction with figure and appearance.
Self-help approaches, mostly based on cognitive-behavioral therapy, represent another alternative in the sense of a stepped care approach with smaller but clearly demonstrable effects.
The primary goal in the treatment of BN is to modify restrained eating behaviors between binge eating episodes in such a way that physiological and psychological deprivation states that promote the occurrence of binge eating episodes do not occur. A balanced diet based on the patient’s own needs is gradually established with the patients. Using methods of self-observation (eating protocols), they are guided to identify psychological and psychosocial triggers of binge eating and counter-regulatory measures, and learn alternative coping strategies for dealing with unpleasant emotions. Complementary exposures are performed with respect to the foods that formerly triggered binge eating.
Pharmacotherapeutically, especially on the background of frequent depressive moods and anxiety, the administration of serotonin reuptake inhibitors can be considered, whereby only a minor effect on the core symptomatology with a slight reduction of binge eating is to be expected. The only drug approved for this indication in Switzerland is fluoxetine, with a recommended dose of 60 mg/day. A trial of treatment should be given for at least four weeks and continued for 9 to 12 months if a good response is observed.
Literature:
- Schnyder U, et al: Prevalence of Eating Disorders in Switzerland. Commissioned by the Federal Office of Public Health (FOPH). 2012. contract no. 09.006170/204.001/-675 and 10.005736/204.0001/-782.
- Hilbert A, et al: Eating Disorder Examination: German language version of the structured eating disorder interview. Diagnostica 2004. 50: 98-106.
- Paul T, Thiel A.: EDI-2. Eating Disorder Inventory-2. Göttingen Hogrefe, 2004.
- Fairburn CG.: Cognitive behavioral therapy and eating disorders. Schattauer Verlag, 2011.
- German Society for Psychosomatic Medicine and Psychotherapy. German College of Psychosomatic Medicine Guidelines for the diagnosis and treatment of eating disorders. 2010 www.awmf.org/uploads/tx_szleitlinien/051-026l_S3_Diagnostik_Therapie_Essstörungen.pdf.