Editor's Note:

Welcome to the fortieth edition of the NEDC e-Bulletin. Eating disorders are becoming increasingly prevalent within Australia. This month we explore the history of eating disorders treatment and seek insight into a new state-wide service being launched in Western Australia. We also clarify the difference between disordered eating and an eating disorder.

The NEDC are excited to announce the 2016 NEDC Members’ Meeting to be held on Friday 17th June 2016, at the Royal Brisbane and Women’s Hospital, Brisbane QLD. More details about the Members’ Meeting can be found in this e-Bulletin.

If you are interested in collaborating with the NEDC, we encourage you to join and become an NEDC member.

Contents:

1. History of Eating Disorders and Treatment
2. New Service: Western Australia Eating Disorders Outreach & Consultation Service
3. Q and A: What is the difference between disordered eating and an eating disorder?
4. New Event: 2016 NEDC Members’ Meeting

Eating disorders are sometimes represented as culturally-bound syndromes of the post-modern era, however research finds that eating patterns commonly associated with eating disorders, such as bingeing, purging and fasting, date back to Roman and Christian eras, respectively (Bemporad, 1997; Craighead, Martinz, & Klump; 2013; Lock & Kirz, 2013). It wasn’t until the late 17th Century that these eating behaviours were interpreted within a medical framework and acquired associated remedies (Bemporad, 1997).

The Medicalisation of Eating Disorders

Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED) have become recognised as psychiatric disorders at different times throughout the 19th and 20th Centuries.

Anorexia Nervosa

The first complete medical descriptions of AN were recorded separately in 1873 by French physician Charles Lasegue and British physician, Sir William Gull. Both physicians described an illness - ‘anorexia hysterica’ – as a condition primarily affecting girls and young women, who presented with significant weight loss, constipation, and restlessness but without an identifiable organic pathology (Lock & Kirz, 2013; Walsh, 2013). In the early 20th Century German pathologist Morris Simmonds conceptualised AN as an endocrine illness and the disorder was treated with endocrinological medications (Bemporad, 1997; Lock & Kirz, 2013; Walsh, 2013). During the post-War period, the medical model of AN was challenged by psychoanalytical interpretations which understood the patients’ refusal to eat as a defence mechanism against their dreaded, unconscious wish for oral impregnation (Bemporad, 1997; Theander, 2004). Subsequent treatment for AN was an individual psychoanalytic therapy.

Arguably, the most profound theorisation of AN was presented in the work of psychiatrist Hilde Bruch (1973; 1978). Coming primarily from a psychodynamic approach Bruch (1973) explained AN as resulting from patients’ inability to master the tasks of adolescence, such as individuation and separation from the family. From this perspective, the patient used disordered behaviour to gain a sense of control over his/her own body in an attempt to control the chaos in their life (Bemporad, 1997). The psychodynamic approach led to the development of individual psychodynamic psychotherapy (IPP) for the treatment of AN. At a similar time, the family systems model of psychotherapy emerged – which interpreted AN as the consequence of family psychopathology. Subsequent treatment involved family therapy which emphasised family processes, communication and the negotiation of adolescent development issues (Lock & Kirz, 2013). These latter conceptualisations of AN are significant because they contributed to a range of contemporary treatment approaches, such as individual psychodynamic psychotherapy (IPP), Family Based Therapy (FBT) and to a lesser extent, Cognitive Behavioural Therapy (CBT).

Bulimia Nervosa

Although records of bulimic symptoms, such as overeating and purging, pre-date symptoms associated with AN, BN was not recognised as a separate disorder until its addition to the Diagnostic Statistical Manual (DSM) III in 1987. Its recognition as a disorder can arguably be accredited to the work of feminist and cultural scholars of the 1970s (Boskind-Lodahl & White, 1973) who framed binge-purge behaviours among normal-weight women as ‘bulimarexia’. In these accounts, BN was conceptualised as a culture-bound syndrome resulting from the obsession with thinness in modern Western culture (Boskind-Lodahl & White, 1973). Although socio-cultural ideals around gender and body shape continue to be recognised in the aetiology of eating disorders, they are now seen as only one of several contributing factors (Heaner & Walsh, 2013).

Similar to treatment for AN, current treatment for BN predominantly draws on CBT, FBT and/or IPP. Wilson, Grilo and Vitousek (2007) found that patients presenting with BN are particularly responsive to CBT as a first line of treatment, and that the efficacy of this treatment – at least initially – is sometimes enhanced by the adjunction of medication (Craighead et al., 2013). Recently, several other modifications of CBT have been developed to treat BN including integrative cognitive therapy and dialectal behaviour therapy (DBT), however, these treatment avenues require further evaluation (Craighead et al., 2013).

Binge Eating Disorder

Compared to AN and BN, BED is a newly recognised psychological condition, acknowledged for the first time as a separate category of eating disorder in the DSM V (APA, 2013). Previously, patterns of disordered eating that did not fit the criteria for an AN or BN – including binge eating without compensatory behaviours –were grouped under the ‘Eating Disorder Not Otherwise Specified (EDNOS) category (Craighead et al., 2013). Binge eating was predominantly recognised as a clinical problem within the context of obesity, since obesity was typically the presenting problem. Craighead et al (2013) note that distinguishing BED as a separate diagnosis is useful for drawing attention to treatments specific to this disorder.

Recent research finds that most treatments used for BN have also been successfully applied to BED, although no treatment for BED has yet to result in meaningful weight loss. In some studies variants of CBT (Allen & Craighead, 1999; Klein, Skinner & Hawley, 2012) were found to be helpful for reducing episodes of binge eating but have not had a significant impact on patients’ weight. Similar outcomes have been seen in the application of medication for binge eating (Craighead et al., 2013), although given the recency of BED as a diagnosis, these findings remain preliminary.

Latest developments in the treatment of eating disorders

A literature search on treatment models for eating disorders yields confusing results. Although much has been written about the different frameworks that historically, and currently, frame our conceptualisations of eating disorders, at present there appears to be no theoretical agreement about the best approach for treatment. This may speak, in part, to current understandings of eating disorders as complex, multi-faceted illnesses requiring targeted and unique treatment. Recently there has been a renewed interest in the contribution of neurobiological factors to the development and maintenance of eating disorders (Craighead et al., 2013), as well as the role that genetic variations may play in the illness (QIMR Berghofer Medical Research Institute, 2016). Both of these recent developments are likely to hold significant implications for the kinds of treatments put forward to patients affected by said disorders.

References

Allen, H.N. & Craighead, L.W. (1999). Appetite monitoring in the treatment of binge eating disorder. Behaviour Therapy, 30(2): 253 – 272.

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.

Bemporad, J.R. (1997). Cultural and historical aspects of eating disorders. Theoretical Medicine, 18: 401 – 420.

Boskind-Lodahl, M., & White, W.C. (1973). The definition and treatment of bulimarexia in college women – a pilot study. Journal of American Health Association, 27: 84 – 97.

Craighead, L.W., Martinz, M.A. & Klump, K.L. (2013). Bulimia Nervosa and Binge Eating Disorder (2013). In W.E. Craighead, D.J. Miklowitz & L.W. Craighead (Eds.), Psychopathology: History, Diagnosis and Empirical Foundations (pp. 445 – 481). Somerset, U.S: Wiley.

Heaner, M.K & Walsh, T. (2013). A history of the identification of eating disturbances of bulimia nervosa, binge eating disorder and anorexia nervosa, Appetite, 65: 185 – 188.

Klein, A.S., Skinner, J.B., & Hawley, K.M. (2012). Adapted group-based dialectal behaviour therapy for binge eating in a practicing clinic: Clinical outcomes and attrition. European Eating Disorders Review, 20(3): e148 – e153.

Lock, J. & Kirz, N. (2013). Anorexia nervosa. In W.E. Craighead, D.J. Miklowitz & L.W. Craighead (Eds.), Psychopathology: History, Diagnosis and Empirical Foundations (pp. 482 - 510). Somerset, U.S: Wiley

Theander (2004). Trends in the Literature on Eating Disorders over 36 Years (1965 – 2000): Terminology, interpretation and treatment, European Eating Disorders Review, 12: 4 – 17.

QIMR Berghofer, Medical Research Institute (2016). The Anorexia Nervosa Genetics Initiative (ANGI). Retrieved from: https://angi.qimr.edu.au/News/AboutAngiResearchStudy

Walsh, B.T. (2013). The enigmatic persistence of anorexia nervosa, American Journal of Psychiatry, 170: 477 -484.

Wilson, G.T., Wifley, D.E., Agras, W.S. & Bryson, S.W. (2010). Psychological treatments of ginge eating disorder. Clinical Psychology Review, 32(4): 343 – 357.

Ziolko, H.U. (1996). Bulimia: a historical outline, International Journal of Eating Disorders, 20(4): 345 – 358.

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Dr. Anthea Fursland, Director of the new Western Australia Eating Disorders Outreach & Consultation Service (WAEDOCS), provides insight into this exciting state-wide service being launched in May. Dr Fursland is also a Consultant Clinical Psychologist and A/Director of the Centre for Clinical Interventions (CCI). In addition to her clinical work, Dr Fursland is involved in applied clinical research, service development, supervision, consultation, training and education.

The Western Australia Eating Disorders Outreach & Consultation Service (WAEDOCS) has been created to facilitate the provision of standardised, best-practice, compassionate care for youth and adults with eating disorders in WA.

In the WA public sector, Princess Margaret Hospital has a well-developed service, providing outpatient, day patient and inpatient treatment for children and adolescents. However, for youth aged 16+ and adults, the only treatment available is specialist outpatient psychological treatment at the Centre for Clinical Interventions in the Perth metropolitan area.

There is a strong need for upskilling clinicians working in inpatient settings. WAEDOCS’ focus is on inpatient care, since this offers the greatest challenges. We will be available for consulting, mentoring, supporting and educating clinicians throughout the state in all settings: metropolitan and rural, public and private, community and hospital-based, mental and physical health.

WAEDOCS has been funded by the WA Mental Health Commission and North Metropolitan Mental Health Services as a state-wide service. We are a multi-disciplinary group (psychiatrist, physician, dietitian, nurse practitioner, mental health nurse, peer support worker, clinical psychologist) and will be launching our service in May.

Currently we are creating a detailed set of guidelines, for use throughout the state by clinicians of varying levels of expertise. These are based on current best practice principles, which emphasise that early intervention and optimisation of nutrition are fundamental to improving outcomes for people with eating disorders. It is also based on the understanding that eating disorders are serious mental disorders and that treatment needs to be conducted in a compassionate manner, working with the patient not against them.

We are very excited to be involved in this new and innovative service, and hope that it will benefit clinicians and, ultimately, people with eating disorders.

Keep watch for the launch of the Western Australian Eating Disorders Outreach and Consultation Service in May.

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Distinguishing disordered eating from an eating disorder can be difficult. Primarily, disordered eating and eating disorders differ according to the frequency and severity of associated behaviours, with eating disorders sitting at the extreme end of the spectrum (Muazzam & Khalid, 2011; Pereira & Alvarenga, 2007).

Disordered eating is a disturbed and unhealthy eating pattern that can include restrictive dieting, compulsive eating, skipping meals and compensatory weight-loss methods (Pereira & Alvarenga, 2007). Disordered eating has been linked with adverse health outcomes and a reduced ability to cope with stressful situations. An individual engaged in disordered eating may not meet the full criteria for a clinical eating disorder, however their behaviours may be problematic and affect several aspects of their everyday life (Muazzam & Khalid, 2011; Pereira & Alvarenga, 2007).

An eating disorder is a serious mental illness where obsessive behaviours and beliefs around food, exercise and appearance are symptomatic of deeper psychological issues (Pereira & Alvarenga, 2007). The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) identifies four clinical eating disorders; Bulimia Nervosa, Binge Eating Disorder, Anorexia Nervosa and Other Specified Feeding and Eating Disorders.

Although there are marked differences between disordered eating and eating disorders, it is important to understand that disordered eating behaviours sit on a continuum, where problematic beliefs and behaviours around eating can ultimately progress into an eating disorder (NEDC, 2012). The figure below displays a continuum of eating behaviours, with unrestrained and healthy eating on one end of the spectrum and clinically diagnosed eating disorders on the other.

Examples of Disordered Eating may include, but are not limited to:

• Dieting
• Fasting or chronic restrained eating
• Skipping meals
• Binge eating
• Self-induced vomiting
• Unbalanced eating (e.g. restricting a major food groups)
• Laxative, diuretic, enema misuse
• Steroid and creatine use – supplements designed to enhance athletic performance and alter physical appearance
• Using diet pills
• Obsessive calorie counting

An individual with disordered eating may engage in some of the above behaviours, but generally at a lesser frequency and lower severity than that of clinically diagnosed eating disorders. Dieting has become a common form of disordered eating within Australia. As a result, confusion can arise around what defines healthy or ‘normal’ eating behaviours and problematic eating behaviours. According to Dr Anthea Fursland, ‘normal’ eating is flexible, without the presence of rigid rules, but working with healthy guidelines.

Not all those who diet will develop an eating disorder, however research indicates that individuals who engage in disordered eating behaviours, specifically dieting, are at an increased risk of developing a clinical eating disorder (Loth et al., 2014).

The thoughts and behaviours associated with dieting are cyclical. Severely restricting the amount of food you eat can be a very dangerous practice. When the body is starved of food it responds by reducing the rate at which it burns energy (basal metabolic rate), this can result in overeating and binge eating behaviours (Dellava, Policastro, & Hoffman, 2009). Feelings of guilt and failure are common in people who engage in disordered eating. These feelings can arise as a result of binge eating, ‘breaking’ a diet/ rule or weight gain. A person with disordered eating behaviours may isolate themselves for fear of socialising in situations where people will be eating. This can contribute to low self-esteem and significant emotional impairment (NEDC, 2012).

To put simply, disordered eating can develop into an eating disorder when there is an increase in the severity and frequency of associated behaviours and the complete criteria for diagnosis is met. Regardless of whether an individual has a clinically diagnosed eating disorder or exhibits patterns of disordered eating, both can have adverse health effects (Liechty & Lee, 2013; Muazzam & Khalid, 2011). Recognising the differences, but also understanding the connection between disordered eating and eating disorders can assist with the prevention and early intervention of eating disorders.

Further Information: For more information on disordered eating click here.

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Please note, the answers provided in Q and A are based on current research findings. They are not conclusive answers.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Association.

Dellava, J. E., Policastro, P., & Hoffman, D. J. (2009). Energy Metabolism and Body Composition in Long-Term Recovery from Anorexia Nervosa. International Journal of Eating Disorders, 42, 415–421.

Liechty, J. M., & Lee, M. (2013). Longitudinal Predictors of Dieting and Disordered Eating Among Young Adults in the U . S . International Journal of Eating Disorders, 46(8), 790–800.

Loth, K. A., Ph, D., D, R., Maclehose, R., Ph, D., Bucchianeri, M., … D, R. (2014). Predictors of Dieting and Disordered Eating Behaviors From Adolescence to Young Adulthood. Journal of Adolescent Health, 55(5), 705–712.

Muazzam, A., & Khalid, R. (2011). Development and Validation of Disordered Eating Behavior Scale : Identification , Prevalence , and Difference with Clinically Diagnosed Eating Disorders. Pakistan Journal of Psychological Research, 26(2), 127–148.

National Eating Disorders Collaboration. (2012). An Integrated Response to Complexity National Eating Disorders Framework. NSW, Australia.

Pereira, R. F., & Alvarenga, M. (2007). Disordered Eating : Identifying, Treating, Preventing, and Differentiating It From Eating Disorders. Diabetes Spectrum, 20(3), 141–148.

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