BJPsych Advances (2021), vol. 27, 9–19 doi: 10.1192/bja.2020.

24

An update on eating disorders ARTICLE

Jane Morris & Stephen Anderson

all psychiatric disorders (Franko 2013). Behavioural Jane Morris, MA, MB BChir
SUMMARY (Cantab), FRCPsych, is a consultant
and psychotherapeutic approaches are the mainstays
Eating disorders are heterogeneous disorders of treatment.
psychiatrist at the Royal Cornhill
characterised by a maladaptive drive to lose Hospital, Aberdeen, UK, and lead
This review summarises the current state of the clinician for the North of Scotland
weight and, for the most part, by extreme fear of
specialty, covering eating disorders characterised Managed Clinical Network in Eating
weight gain and overvaluation of thin body Disorders. Stephen Anderson, BSc
image. Calorie restriction, overexercise and pur- by preoccupation with weight, shape and calorie
(Hons), MB ChB, FRCPsych, is a con-
ging behaviours put some sufferers at high risk of balance. Disordered eating behaviour stemming sultant psychiatrist in eating disor-
physical morbidity and mortality. Mental preoccu- from autistic, affective or other underpinnings war- ders in the Eating Disorder Service,
pations interfere with social, professional and gen- rants a separate review. NHS Forth Valley, Stirling, UK, and
eral quality of life. Patients’ defensive secrecy and Chair of the Royal College of
Psychiatrists in Scotland’s Faculty of
compulsivity can make it hard to diagnose and
Contemporary models of eating disorders Eating Disorders.
treat such disorders despite the suffering they Correspondence Stephen Anderson.
involve. Integrated medical and psychiatric inter- Clinicians commonly hold an ‘illness model’ of Email: stephenanderson@nhs.net
vention can save life and safely improve nutrition. eating disorders, whereas lay people, journalists
Behavioural support – with family and carer and patients, particularly on social media, may First received 13 Jan 2020
involvement when appropriate – can counter the assume that eating disorders represent a lifestyle
Final revision 22 Mar 2020
Accepted 31 Mar 2020
dysregulation that leads to vicious cycles of
choice. Charland and colleagues proposed that anor-
restriction–binge–purge, helping patients develop
exia nervosa be considered a ‘passion’ – an overrid- Copyright and usage
new skills to regulate emotion without weight losing. © The Authors 2020
In the future, exciting developments in neuroima- ing affect-laden philosophical priority (Charland
ging, neurosurgery and pharmacology may lead to 2013). This notion is fruitful in suggesting that treat-
ways to make the brain more responsive to therapy. ment should ‘fight passion with passion’.
Insights into risk factors may also improve prevent- Others emphasise endemic ‘eating-disordered’
ive strategies in a climate of highly sophisticated symptoms in society, stressing the role of physio-
international electronic communication. logical dysregulation in perpetuating restriction–
binge–purge cycles. Proponents of family-based
LEARNING OBJECTIVES
treatment (FBT) (Lock 2015) observe that early
After reading this article you will be able to: refeeding alone treats many teenagers with anorexia
• identify and assess the different types of eating
nervosa. Such diverse opinion suggests heterogen-
disorder, and be aware of core clinical signs
eity despite many common features. Clinicians who
and symptoms
• confidently manage the physical and psycho- address only physical disruptions are unlikely to
logical consequences of eating disorders in engage their patients or provide alternative coping
accordance with current evidence-based strategies, whereas those who neglect physiological
guidelines maintaining factors may inadvertently perpetuate
• understand current controversies in the field chronicity.
and evolving research themes.

KEYWORDS Diagnostic classification

Anorexia nervosa; bulimia nervosa; cognitive– Eating disorders share features of preoccupations
behavioural therapies; comorbidity; eating disor- and behaviours aimed at weight loss (Table 1). Both
ders NOS. DSM-5 and ICD-11 (World Health Organization
2018) discriminate between anorexia nervosa and
bulimia nervosa on the basis of weight. The hallmark
Traditionally, the ‘eating disorders’ have been char- of anorexia nervosa is significant weight loss, whereas
acterised by intense fear of gaining weight, although those who are not underweight are diagnosed as
DSM-5, (American Psychiatric Association 2013) having bulimia nervosa if they purge (induce vomiting
omitted fear of weight gain from criteria for binge or use laxatives) but binge eating disorder if they
eating disorder and some childhood eating disorders. ‘binge’ without purging. Anorexia nervosa has
Far more than eating behaviour is disordered. existed for centuries, but bulimia nervosa appeared
Starvation, and consequences of purging and over- in the later 20th century. Binge eating disorder is an
exercise, cause psychosocial and physical damage. even more recent phenomenon. Adult eating disorder
Anorexia nervosa has the highest mortality rate of services specialise in disorders sharing the core

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 Morris & Anderson

TABLE 1 Main features of the eating disorders

Anorexia nervosa Bulimia nervosa Binge eating disorder

Restrictive Often extreme calorie restriction, As for anorexia nervosa, but less Sufferer is less able to practise
behaviours with many dietary ‘rules’, extreme than in the restrictive extreme food restriction
including adoption of restrictive form of anorexia nervosa
diets – extreme forms of
veganism or ‘clean eating’ are
common
Binges In the binge–purge subtype, binges The hallmark of bulimia nervosa is Binges are similar in quality to
occur. ‘Subjective binges’ the large-scale, out-of-control bulimia nervosa but usually
describe unintended eating that consumption of amounts of food less extreme in amount. The
is distressingly out of control definitely more than would be lack of control over such
though not objectively a large normally consumed in a single eating is experienced with
amount sitting, and often food of a type shame and distress
not usually served as a meal
(e.g. entire packets of biscuits,
tubs of ice cream)
Compensatory Binge–purge subtype of anorexia Binges are followed by such Such behaviours are less
behaviours nervosa involves purging by compensatory behaviours as prominent in binge eating
vomiting or laxatives. Restrictive self-induced vomiting, disorder
subtype does not always, but deliberate regurgitation or use
may, change to binge–purge of laxatives or diuretics.
subtype in time. Deliberate Deliberate overexercise to burn
overexercise to burn off calories off calories also occurs
is often a feature of restrictive
anorexia nervosa
Affect and feeling There is often pride in successful Extremely high levels of shame are Shame, depression and low self-
weight loss, with increasing common, usually focused on esteem are common
levels of shame, anxiety and low bodily shame
mood as the disorder persists.
Isolation and social avoidance
contribute to this
Body-checking and Many patients repeatedly check their Patients may engage in similar body- Patients, particularly those who
body image body weight and composition by checking behaviours to those in are overweight, are most
avoidance weighing, measuring, pinching anorexia nervosa, but many also likely to practise body image
their flesh, trying on garments to practise body image avoidance avoidance to avoid the
assess size, inspecting their and hide their bodies in public – distress and shame of
appearance in mirrors or ‘selfie’ being unable to wear exposure
photographs, and making swimwear, sportswear or other
comments about their weight tightly fitting clothes. They may
that are designed to elicit avoid being weighed out of
reassurance shame and distress
Communication Preoccupation with losing weight is As in anorexia nervosa, Body shame and low self-esteem
extreme and interferes with preoccupation with losing may lead sufferers to
other aspects of life. Web-based weight may be extreme, engage in unrewarding,
and social media activity is although social life and work are unduly deferential
focused on losing weight often maintained. Web-based relationships
and social media activity is
focused on losing weight

psychopathology of preoccupation with weight and prevalence of anorexia nervosa in the general popu-
shape. lation in Western countries is about 1% among
Psychiatric classifications are limited by reliance on women and 0.5% among men. Gender distribution
symptoms, whereas research is hampered by inaccurate is less skewed in children. Adolescents have higher
diagnostic groupings. Treatment evidence is inextric- rates of full recovery and lower mortality than
ably tied to existing categorisation. Clinicians should adults (mean mortality 2 v. 5%).
remember that a patient’s failure to precisely meet A recent Scandinavian register-based study (Reas
listed criteria does not automatically exclude an eating 2018) found that, for both genders aged 10–49
disorder. Moreover, patients’ diagnoses commonly years, incidence rates of anorexia nervosa were
migrate across categories during the course of illness. stable across the 7-year period to 2016, at 18.8–
20.4 per 100 000 for narrowly defined and 33.2–
Epidemiology 39.5 per 100 000 for broadly defined anorexia
Eating disorders typically begin in early to mid- nervosa. There was a significant annual increase in
adolescence, but can emerge at any age (Nicholls anorexia nervosa among 10- to 14-year-old girls.
2011; Steinhausen 2015; Micali 2017). Lifetime Overall rates of bulimia nervosa declined.

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 An update on eating disorders

Register-based studies substantially underesti- In anorexia nervosa the observed rigid thinking,
mate true community prevalence, and it is reported poor central coherence and emotional avoidance
that half of those who meet diagnostic criteria in may improve, at least partially, with re-nutrition
the community do not access treatment. Not receiv- (refeeding), but may persist and may also be observed
ing treatment is even more likely in low- and middle- in unaffected relatives (Kanakam 2013; Lang 2014).
income countries, now seeing increased prevalence Different eating disorders show different abnor-
of formerly ‘Western’ disorders. malities of attentional bias. In bulimia nervosa and
binge eating disorder there is increased attentional
bias towards food-related cues, whereas individuals
Risk factors with anorexia nervosa have increased attentional
Genetics bias towards disliked aspects of body image
Early family studies, large twin-based studies and (Stojek 2018). This could guide specific interven-
smaller adoption studies demonstrate both a herit- tions for different disorders.
able component and significant influence of non-
shared environmental factors in eating disorders. Sociocultural factors
There is a strong familial component to anorexia A prospective study of healthy adolescent girls (Stice
nervosa, with estimates of heritability between 28 2017) found that impaired interpersonal functioning
and 74%. The genetic contribution is polygenic. and negative affect were transdiagnostic risk factors.
Large genome-wide association studies (GWAS) Pursuit of the thin ideal, body dissatisfaction,
highlight the need to consider psychiatric and meta- dieting and unhealthy weight-control behaviours
bolic mechanisms involved in anorexia nervosa increased risk for bingeing and purging disorders.
(Watson 2019). These studies, together with further Inherently lean girls, even if not pursuing the thin
research in the genetics of bulimia nervosa and ideal, were at risk for anorexia nervosa.
binge eating disorder, may help elucidate new avenues The increase in eating disorders in lower-income
of treatment. societies follows Western lifestyle aspirations, nutri-
Gene–environment interactions are complex. tional habits and internalisation of the thin ideal.
Recent work on gut microbiota has found reduced Sociocultural pressures appear more powerful in
gut microbial diversity in anorexia nervosa, signifi- triggering bulimia nervosa and binge eating disorder
cantly associated with depression, anxiety and than anorexia nervosa but may also trigger genetic-
eating disorder symptoms (Kleiman 2015). ally vulnerable individuals to try to lose weight.
Childhood deprivation and trauma are important
Structural and functional brain abnormalities risk factors for many mental disorders and appear to
be associated with increased risk of bulimia nervosa
Neuroimaging often disappoints in revealing struc-
and binge eating disorder, but not anorexia nervosa
tural and functional abnormalities (Frank 2018).
(Larsen 2017).
Studies in anorexia nervosa may reflect consequences
Anorexia nervosa and bulimia nervosa are more
of starvation rather than the psychiatric disorder. Re-
common among females than males (Hoek 2006)
scans at normal weight cannot assume that brain
and there are higher rates of disordered eating
nutrition is fully restored or that damage is reversible,
among sexual minorities, particularly transgender
although studies suggest that some brain tissue
people (Calzo 2017).
abnormalities recover with weight regain.
Social media use and competitiveness can maintain
Reward and satiety circuits in the orbitofrontal
and perhaps trigger eating disorders (Ferguson 2014;
cortex are important in both anorexia nervosa and
Mabe 2014). Treatment and prevention strategies
bulimia nervosa. Structural magnetic resonance
might benefit from identifying differences between
imaging has revealed that individuals with anorexia
helpful and harmful behaviour online and in social
nervosa had increased right insula grey matter
media.
compared with controls (Frank 2018). This area is
associated with self-recognition and interoceptive
awareness. Prospective studies may explore whether Prevention
these changes are biomarkers or sequelae. A large number of prevention programmes are under
Functional imaging, with symptom provocation, development and evaluation. The most promising
suggests abnormal responses in subcortical regions interventions use cognitive dissonance, cognitive–
associated with stimulus-driven responses, and in behavioural therapy (CBT) and media literacy.
prefrontal regions involved in evaluation and execu- Although prevention programmes generally improve
tive control (Kaye 2013). Abnormalities in reward participants’ knowledge, and sometimes reduce risk
circuit activation have also been found in anorexia factors, there is no evidence that they actually
nervosa (Monteleone 2018). reduce development of diagnosable eating disorders.

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 Morris & Anderson

Combined preventive approaches developed by Signs and symptoms

eating disorder and obesity experts might avoid Signs and symptoms of eating disorders should be
inadvertent triggering of disorders by focusing on positively elicited by sympathetic enquiry. Individuals
the dangers of either extreme. Parent and carer often present with physical symptoms – weight
groups regularly report onset of eating disorders fol- loss, weakness, fainting, constipation, nausea and
lowing anti-obesity campaigns in schools. amenorrhoea – or psychiatric symptoms such as
depression and anxiety. The need to exclude
Assessment of symptoms and risk organic causes should not delay assertive re-nutri-
Prompt referral and treatment is important. tion, particularly in younger patients. Any organ
Specialist intervention in the first 3 years gives the system may be affected, and Table 2 lists possible
best prognosis (Stice 2017) and evaluation of a signs and symptoms.
novel service in the UK – the First Episode and Psychosocial disorder may be assessed by asking
Rapid Early Intervention for Eating Disorders the patient, or better still a friend or relative, to
(FREED) service – suggests that early treatment of describe a typical day. The Eating Disorder
young adults reduces the need for later, more Examination Questionnaire (EDE-Q) (Fairburn
costly interventions (Fukutomi 2020). 1994) is the gold-standard validated self-report
questionnaire and is available free of charge.
TABLE 2 Possible signs and symptomsa Widely used standard measures may be used to
assess quality of life, anxiety and depression. The
Organ/system Signs and symptoms Clinical Impairment Assessment (CIA) question-
Cardiovascular Bradycardia naire (Bohn 2008) assesses clinical severity.
Hypotension
Mitral valve prolapse
Arrhythmia and sudden death
Chest pain Physical investigations
Dizziness and fainting
Blood tests may reveal the low white cell count of
Pulmonary Respiratory failure
Spontaneous pneumothorax starvation and deranged liver function (starvation
or substance use). At any weight there may be phys-
Metabolic Hypokalaemia
Dehydration ical evidence of purging (e.g. low potassium) or of
Nephropathy the ‘fluid loading’ in which many patients engage
Metabolic acidosis to fill their hungry bellies or to disguise their
Neuropsychiatric Depressed mood weight. Overhydration can cause low sodium levels
Anxiety and low gravity in urine samples. Electrolyte
bsessive and compulsive symptoms
Poor concentration and memory derangements may cause cardiovascular irregular-
ities, seizures and even permanent damage.
Haematological Low white cell count, particularly neutrophils
Pancytopaenia Asymptomatic low glucose levels in starved patients
are less worrying than often feared, since the body
Skin and hair Dry skin
Alopecia adapts to metabolise ketones. Thyroid and other
Lanugo hair endocrine changes are mostly adaptive, to optimise
Starvation-associated pruritis energy expenditure.
Russell’s sign (calluses on the back of hand from self-induced vomiting)
After initial screening, patients at normal weight
Neurological Cerebral atrophy may need no further investigation. Those at low or
Endocrine Amenorrhoea changing weight, or with abnormal findings,
Reduced sex drive require further monitoring.
Infertility
steopaenia and osteoporosis Abnormal electrolytes, dizziness, fainting, palpi-
Thyroid abnormalities such as sick euthyroid tations, drug use or heart conditions should trigger
Hypercortisolaemia electrocardiogram (ECG) investigation, looking for
Hypoglycaemia
prolonged QTc interval. Patients at low weight, par-
Gastrointestinal Dental erosion ticularly with amenorrhoea, should undergo a non-
Parotid gland swelling
Gastrointestinal reflux urgent dual-energy X-ray absorptiometry (DEXA)
Barrett’s oesophagus bone density scan because of the risk of osteopaenia
Mallory–Weiss tear and osteoporosis (Schorr 2017). This allows advice on
Constipation
Refeeding pancreatitis safe activity and provides a baseline to show response
Acute gastric dilatation to nutrition. Bone mineral density loss is mostly
Delayed gastric emptying, leading to pain and bloating reversible with healthy nutrition over several years.
Elevated liver enzymes
Patients may omit prescribed medication if they
a. Note that any organ system can be affected by an eating disorder and this list is not exhaustive. believe it causes weight gain. This can include

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 An update on eating disorders

insulin, steroids or anticonvulsants, with cata-

strophic results. BOX 1 Checklist to guide fitness to drive of people with eating disorders
‘Compensatory behaviours’ that may be hidden or
1. Is the patient suicidal or insufficiently normal blood glucose (above 4) in the last
subtly disguised include purging by self-induced
caring of whether they live or die? four blood glucose tests (>4 using venous
vomiting, taking diuretics or laxatives, overuse of pre-
2. What medication is prescribed and blood, >5 on blood glucose test strips)?
scribed or acquired drugs associated with weight loss
taken? Might it interfere with driving? 11. Does the patient induce vomiting on the
and compulsive overactivity. These may be prioritised
3. Does the patient use alcohol, other over- same days as driving? If so, how long
over pleasurable and useful experiences. elapses after vomiting before driving,
the-counter, online-purchased or street
Body-checking, reassurance-seeking and ‘coach- and does the patient eat/drink again
drugs (including painkillers, diuretics,
ing’ in ways to lose weight maintain the preoccupa- laxatives, etc.)? before driving? Frequent vomiting is
tion with eating, shape and weight. Compulsive likely to result in unstable electrolytes
4. Are there comorbid physical or psychi-
accessing of social media sites is a powerful main- atric conditions that may be inadequately and fluctuating concentration.
taining factor (Mabe 2014). managed, e.g. diabetes, epilepsy. 12. Is the patient so preoccupied by obses-
5. Has the patient had any episodes of sional thoughts, ruminations and calcu-
collapse, faints, falls? lations that they cannot prioritise road
Risk safety? Sometimes their behaviour in
6. On examination of heart and brain, is
Management of the acute physical risks of eating dis- therapy will reveal preoccupations.
there risk of collapse?
orders is addressed further below (in the section 13. What about impulsivity and rage?
7. Is the patient stable at their current
‘Acute medical treatment’). Risk of self-harm and Patients who have to satisfy their binges
weight or have there been fluctuations
suicide should be considered and monitored – dis- at all costs (e.g. shoplifting) may not be
(in both directions)?
able to show the patience needed e.g. at
tress sometimes worsens as weight increases. 8. In particular, has the patient had a recent traffic or pedestrian lights.
Physical compromise increases the lethality of self- increase in their weight so that there will
14. Does the patient eat while driving or
harm that is not necessarily intended to end life. be increased metabolism without corre-
engage in compensatory behaviours such
Risk assessment is particularly delicate when suf- sponding replenishment of glycogen
as purging while driving?
ferers have social responsibilities such as parenting, stores?
15. Do ‘checking behaviours’ occur in the car,
nursing, medicine and teaching. Patients sometimes 9. Does the patient have adequate physical
such as using mirrors to check appear-
coerce others to eat, or neglect children to engage in strength to do an emergency stop etc. if
ance rather than for traffic, or using
compulsive exercise. Witnessing purging and self- necessary?
phones or calculators to add up calories
harm is traumatic. Clinicians are also responsible 10. Has the patient ever had a recorded low while at the wheel?
for giving advice on safety to drive (Box 1). blood glucose? If so, has there been

Acute medical treatment When MARSIPAN is enacted, medical rather

A thorough knowledge of medical complications can than psychiatric wards can be the safest setting,
be life-saving, if backed up by clinician and service meeting the need for frequent blood tests, intraven-
networks. The Management of Really Sick ous treatment, continuous ECGs and intensive care
Patients with Anorexia Nervosa (MARSIPAN) unit (ICU) availability. Keeping the individual
guideline, first published in 2010, was developed warm, rested, nourished and protected from infec-
in response to a number of avoidable deaths of tion is usually taken for granted with medical
patients with anorexia nervosa in medical units. patients, but compulsive eating disorder behaviours
The second edition (Royal College of Psychiatrists may sabotage this and alienate staff. Both psychi-
2014), as well as the Junior MARSIPAN guideline atric nursing skills and dietetic expertise are indis-
(Royal College of Psychiatrists 2012), are currently pensable in refeeding low-weight patients.
under review and readers should ensure that they The potentially fatal refeeding syndrome is caused
access the most up-to-date editions. General by the switch from fasting gluconeogenesis to carbo-
(family) practitioners and generalist health profes- hydrate-induced insulin release, inducing consider-
sionals should be aware of their local specialist able intracellular uptake of potassium, phosphate
eating disorder team, which will aim to work and magnesium from the bloodstream. Unfortunately,
closely with an identified physician or paediatrician avoidance of overfeeding can result in lethal underfeed-
to enact MARSIPAN. ing and MARSIPAN guidelines advise on this.
Psychological recovery from low-weight anorexia Continuing physical management involves balan-
nervosa must be supported by medical management cing the need to relieve constipation without fuelling
to prevent or mitigate lasting physical damage. an obsessive laxative habit, improving bone density
Death is preventable with timely, effective treat- without recourse to ineffective treatments, and fol-
ment. The key to safe management is for key clini- lowing up on emerging or relapsing instabilities
cians to have prepared and trained together, rather and abnormalities. Infections and hypothermia are
than improvise care plans in crisis. risks in winter. Regular dental assessment is

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 Morris & Anderson

helpful. Contraceptive discussions are important Binge eating disorder

even with low-weight patients. There is evidence that guided self-help and group
CBT-ED improve binge frequency and EDE total
Evidence-based psychological treatment score compared with waiting-list control (Vocks
When physical stability, with appropriate monitor- 2010), but there is no evidence that this treatment
ing, is assured, the most effective treatments for brings about weight loss.
eating disorders are psychological therapies specific-
ally adapted to target eating disorder pathology, as Pharmacological treatment
summarised in National Institute for Health and Anorexia nervosa
Care Excellence (NICE) guidelines (National
Many patients are prescribed psychotropic drugs for
Institute for Health and Care Excellence 2017).
associated symptoms of depression, anxiety and
obsessive–compulsive disorder (OCD), although
Anorexia nervosa there are scant data on effectiveness in the presence
Treatment for anorexia nervosa combines emotion of anorexia nervosa. The main medications directed
regulation, distress tolerance, body image acceptance at the eating disorder pathology are the atypical
and interpersonal interventions alongside weight gain. antipsychotics, particularly olanzapine, shown in
In effect, the patient is exposed to a normal healthy some studies to reduce illness preoccupations and
weight and learns to tolerate this without eating dis- anxiety during refeeding. Surprisingly, weight
order responses. In-patient or carer containment gains are not significant in pooled meta-analyses of
may be needed initially, followed by careful transition placebo-controlled trials. A recent out-patient RCT
to the patient taking back responsibility. showed modest benefit on weight gain for olanza-
Manualised FBT (Lock 2015) has the best evi- pine, but with no significant benefit on psychological
dence base for anorexia nervosa in the under-18s, symptoms (Attia 2019). Cannabinoid receptor
with individual eating disorder focused cognitive– agonist studies are at an early stage. A network
behavioural therapy (CBT-ED) as a second choice. meta-analysis is underway to build evidence for
Family-based models are being adapted for young both pharmacological and non-pharmacological
adults, and for adults and their partners (Bulik treatments for anorexia nervosa (Wade 2017).
2011; Wierenga 2018).
NICE acknowledged the ‘low- to very-low’ quality
Bulimia nervosa
of evidence for psychological treatments for adult
anorexia nervosa, but recommended CBT-ED, the High-dose antidepressant treatment has been shown
Maudsley Anorexia Nervosa Treatment for Adults to be of benefit in bulimia nervosa. CBT-based psy-
(MANTRA) and specialist supportive clinical man- chological therapies are more effective and longer
agement (SSCM). Randomised controlled trials lasting, but prescribing is an attractive choice if
(RCTs) are underpowered to show superiority for depressive symptoms are prominent, if CBT is
any specific therapy. Even the best current treat- unavailable or as adjunctive treatment.
ments bring about significant improvement in only
50% of patients (Brockmeyer 2018; Murray 2019). Binge eating disorder
A systematic review and meta-analysis of 35 treat-
A recent meta-analysis (Peat 2017) found that lis-
ment-outcome RCTs for anorexia nervosa generated
dexamfetamine (LDX) increased binge abstinence
concern about lack of effect (Murray 2019) and discon-
more than second-generation antidepressant drugs.
nect between weight gain and psychological improve-
LDX is not approved for the treatment of binge
ment. Clearly, further research is urgently needed.
eating disorder in the UK and European Union.
Bulimia nervosa
There is more evidence for the effectiveness of CBT- Mental health legislation
ED for bulimia nervosa than for anorexia nervosa. UK mental health legislation allows compulsory
Guided self-help appears beneficial and cost-effect- treatment when the illness is of a nature or degree
ive, and individual CBT-ED is effective for adoles- that warrants hospital treatment and there are
cents as well as adults (Slade 2018). Treatment risks to health or safety. Any fully registered
involves resetting dysregulated cycles of restric- medical practitioner can detain patients for brief
tion–binge–purge. Patients establish regular meal- periods. For longer periods, psychiatrists approved
times and stabilise electrolyte levels. As hunger under the relevant legislation must be involved.
comes under control, avoided foods are reintro- Clinicians should be aware of the relevant legislation
duced. Intrapsychic and interpersonal skills are where they work. Individuals with eating disorders
learned for coping with life stresses. also perceive high levels of ‘informal coercion’.

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 An update on eating disorders

Ambivalence and the perception of coercion often secondary to the eating disorder – for instance, star-
fluctuate over the course of treatment. vation from any cause frequently causes depression.
Compulsory treatment may increase eating dis- Over 70% of people with anorexia nervosa report
order behaviours in an attempt to regain control. a lifetime mood disorder (Keski-Rahkonen 2016).
Clinicians may then impose yet more restriction, so Between 25 and 75% report a lifetime history of an
the vicious circle strengthens, unless this is anxiety disorder (Raney 2008), typically preceding
managed by working to engage the patient. Studies the anorexic illness. Bulimia nervosa is even more
have shown that compulsory treatment may robustly associated with affective and anxiety disor-
improve survival, even when detained patients had ders (Becker 2018). Around 80% of people with
poorer functioning before admission (Ward 2016). anorexia nervosa experience OCD symptoms at
Detention may retain people in treatment long some point. Prior OCD is associated with increased
enough to establish an effective therapeutic alliance risk of subsequent bulimia nervosa (Hofer 2018).
that will then be the basis for ongoing work towards Register-based studies confirm aggregation of
recovery. autism spectrum disorder in probands with anorexia
nervosa and their relatives (Koch 2015).
The prevalence of alcohol misuse in restrictive
Prognosis anorexia nervosa is similar to that in the general
The standardised mortality ratio for anorexia nervosa population. People with bulimic illnesses have a
is 5.9 – the highest mortality rate of all psychiatric dis- higher prevalence of substance misuse (Root
orders (Franko 2013). Most deaths result – shockingly 2010). Eating disorder sufferers use harmful sub-
– from starvation. Significant numbers are attributed stances to reduce appetite, trigger vomiting, burn
to suicide. With treatment, around 50% of people with off calories or permit overexercise despite pain.
anorexia nervosa recover fully (Murray 2019). Lower There is increased prevalence of other disorders of
body mass index (BMI) or higher age at admission, impulsivity and lack of control in people with
persistence of binge eating and purging behaviours, bulimia nervosa (Kim 2018; Sala 2018).
substance misuse and type 1 diabetes all predict
poor outcome. Motherhood is related to better
outcome, as is access to specialist eating disorder Insulin-dependent diabetes
services. Type 1 diabetes is a disease of insulin deficiency,
Recovery from bulimia nervosa is widely consid- resulting from destruction of pancreatic insulin-pro-
ered greater than from anorexia nervosa. At 9-year ducing cells. This causes hyperglycaemia, gluco-
follow-up, 68.2% of participants with bulimia suria, ketone production and weight loss. Diabetics
nervosa had recovered, compared with 31.4% of lose weight easily by omitting insulin rather than
those with anorexia nervosa; however, by 22-year by diet, overexercise and purging. Between 30 and
follow-up, 62.8% of participants with anorexia 40% of young people with diabetes omit or reduce
nervosa had recovered (the recovery rate for insulin with the intention of losing weight (Hasken
bulimia nervosa remained at 68.2%) (Eddy 2017). 2010). Longitudinal studies suggest an increase in
In contrast, despite optimistic long-term results eating disorders among young women with type 1
from centres of excellence (Franko 2018), other evi- diabetes (Larranaga 2011). The peak onset of type
dence suggests recovery rates from anorexia nervosa 1 diabetes is at age 10–14, unfortunately just as
decrease over time, particularly after 12 years puberty brings increased body image concerns.
(Papadopoulos 2009). The term ‘diabulimia’ (not recognised in official
There is disagreement about what constitutes diagnostic criteria) implies that causing calories to
‘recovery’ from eating disorders, with consequent be excreted in the form of glycosuria and high
variation in outcome figures. Qualitative meta-ana- blood glucose levels is analogous to purging. In
lysis finds that recovered individuals value self- type 1 diabetes conventional eating disorder beha-
acceptance, autonomy and interpersonal relation- viours are unlikely, so we recommend use of the
ships as much as reduced eating disorder symptoms Diabetes Eating Problem Survey – Revised
(de Vos 2017). (DEPS-R) screening tool (Markowitz 2010).
In addition to the serious but mostly reversible
Comorbidity complications of non-diabetic eating disorders, dia-
betic complications are cumulative and irreversible.
Psychiatric disorders They include retinopathy, kidney disease and per-
Behavioural symptoms of eating disorders often ipheral neuropathy. Insulin reduction increases
overlap with those of other psychiatric conditions, muscle breakdown, risk of dehydration, fatigue
although the meaning of such behaviours may be and risk of infection. The presence of an eating dis-
different. Some apparent comorbidity may be order significantly and greatly increases rates of

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 Morris & Anderson

ketoacidosis, hospital admissions, morbidity and some women become pregnant without having
mortality and there is an association between periods, so contraception is still relevant.
poorer glycaemic control and self-reported eating Body changes during pregnancy have various
disorder symptoms. effects. Some women ‘suspend’ their eating disorder,
There is a potential for preventive approaches in attributing the need for nutrition to a cherished
diabetes clinics. Clinicians need awareness of baby, but others report increased body image con-
eating disorder patients’ acute sensitivity to weight cerns and fear that weight will get out of control
and body image, and psychological ‘denial’ of the (Rocco 2005).
risks of diabetic complications. Such patients avoid A mother’s eating disorder can significantly affect
giving insulin, avoid monitoring their blood fetal development, especially neural development.
glucose to prevent being confronted with ‘bad’ Women with anorexia nervosa are more likely to
results and avoid clinic appointments for fear of have smaller-than-average babies and increased
being ‘told off’. risk of postnatal depression. Women with active
bulimia nervosa have increased risk of miscarriage
(Micali 2017).
Personality disorders
Around 30% of patients with an eating disorder meet
criteria for at least one personality disorder (Solmi Severe and enduring anorexia nervosa
2018). Many meet criteria for more than one. Definitions of ‘severe and enduring anorexia
Some features are common to both disorders, and nervosa’ (SE-AN) vary. The very concept is conten-
it is possible that some are consequences of the tious. ‘SE-AN’ is evoked when the eating disorder
eating disorder or its treatment, rather than does not appear to respond to our best available
primary features of a personality disorder. treatments or responds only with extreme distress.
The presence of a comorbid personality disorder A rehabilitation model, shifting away from weight
causes difficulties in terms of diagnosis and manage- recovery to focus on quality of life, may be more
ment. There are likely to be additional problems in appropriate, reducing adverse effects, achieving
engaging such patients, and increased risk of some symptom control and setting attainable goals
suicide and other mortality. The eating disorder (Bamford 2015).
may be used to manage the symptoms of the person- Recent studies suggest that CBT-ED is effective
ality disorder, or the personality disorder may predis- for people with long-standing anorexia nervosa in
pose to eating disorder behaviours. Individualised community or in-patient treatment (Raykos 2018),
formulation helps both patient and clinicians to but clinicians as well as patients may experience
understand these functions. Alternative emotional hopelessness. If this is not managed in supervision,
coping behaviours can help patients to give up less ‘therapeutic nihilism’ can blight patients’ chances.
adaptive behaviours. Patients may be considered ‘treatment resistant’
Treatment access is complicated by service when not all appropriate treatment approaches
boundaries. NICE recommends that people with have been attempted. A detailed independent
eating disorders are managed by specialists second opinion can suggest other avenues to follow.
(National Institute for Health and Care Excellence
2017). People with personality disorders tend to
be managed by community mental health services Emerging treatments
and may be referred between services according to Current research activity is most active in exploring
dominant symptoms, receiving inadequate treat- ever more powerful, more focused or novel psycho-
ment in each when the disorders are intertwined. logical therapies such as cognitive remediation
Eating disorder treatment focused on reducing therapy and exposure-based therapy, and third-
purging may lead to an increase in trauma-related wave behavioural therapies such as radically open
symptoms if purging was a way to cope with flash- dialectical behaviour therapy. There is also research
backs. Difficulty managing relationships with differ- into improved delivery of treatments in a range of
ent clinicians is a notorious aspect of personality web-based or electronic formats, both to exploit
disorder presentation, so joint working is essential. media that may be most acceptable to patients and
also to provide equitable delivery of care from
small specialist services across remote or low-
Fertility, pregnancy and the puerperium income populations.
The effects of starvation on the hypothalamic– One bold, and often controversial, approach to
pituitary–gonadal axis often cause amenorrhoea. both the understanding and treatment of eating dis-
Women attending infertility clinics have a high orders is the practice of neurosurgery and deep brain
prevalence of lifetime eating disorder. Conversely stimulation.

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 An update on eating disorders

Controversies, uncertainties and preoccupations and emotions that interfere with

MCQ answers
outstanding research questions human experience and life achievements. Despite
1b 2d 3a 4a 5d
the appalling suffering, which also affects family
Evolving considerations about the nature and classi-
and friends, the obsessive fear of weight gain often
fication of the eating disorders affect the precision
obliges sufferers to avoid rather than seek effective
with which treatments can be researched. Most
treatment.
treatments involve biological, behavioural and psy-
Genetic research has identified a substantial,
chosocial elements, making it hard to dissect out
complex genetic contribution to causation and sug-
effects.
gests that anorexia nervosa and bulimia nervosa,
Psychological treatments rely crucially on thera-
though overlapping, may be somewhat differently
peutic attachments. Relationships may be repeat-
inherited. Adverse childhood experiences appear to
edly interrupted when treatment has to span child
have a non-specific relationship with all mental
and adult services, or local out-patient services
illness, but the body image competitiveness of
follow distant in-patient treatment. Management of
modern society and social media may be triggering
such crucial transitions is discussed in a recent
increased incidence in vulnerable young people,
report from the Royal College of Psychiatrists
and preventive strategies are addressing this, par-
(Crockett 2017).
ticularly in high-risk groups.
The role of social media in causation and mainten-
There is little evidence for psychotropic medica-
ance of the eating disorders is a contemporary field
tion as a stand-alone treatment, and most prescrib-
for exploration, as is the potential for the proper
ing addresses comorbid psychiatric conditions.
exploitation of new technology in prevention and
Meanwhile, integrated medical and psychiatric
treatment. A linked concern is whether obesity pre-
interventions save life and safely improve nutrition.
vention campaigns fuel eating disorders.
Integrated medical expertise is most challenged
Ignorance of the scale of the problem, and public
when the patient is pregnant or has type 1 diabetes.
perception of eating disorders as ‘self-imposed life-
At our present stage of understanding, psycho-
style choices’, mean that services struggle for
logical therapies are the mainstay of treatment.
adequate funding. Research suggests that even
The CBT model has been variously adapted so
within specialist services there is inadequate imple-
that both cognitive and behavioural exercises are
mentation of evidence-based treatments, and pro-
used to challenge and tolerate the emotional distress
blems of ‘therapeutic drift’. Clinicians need skills-
that accompanies acceptance of a normal body
based supervision to deliver the most effective inter-
weight. A strong, mutually respectful attachment
ventions rather than those with which they are most
to the therapist or therapeutic team is a crucial
comfortable. Meanwhile services need to collect data
element of therapy. In younger patients, family-
on both clinical activity and outcomes.
based models mobilise the strong attachment to
Modern neuroscience holds promise for develop-
parents to permit refeeding and toleration of the dis-
ing understanding and treatment approaches,
tress involved.
while psychotherapeutic, ethical and philosophical
work yield insights for overcoming obstacles to pro-
gress in these uniquely ego-syntonic disorders. We Author contributions
may learn how to amplify psychotherapeutic bene- The two authors contributed equally to the writing
fits by pretreating the brain with surgery, medica- and editing of the main text and preparation of the
tion or electrical stimulation. In this world of tables and the box.
endemic preoccupation with body image and valid
concerns about obesity, psychiatry is starved of Declaration of interest
good evidence and desperate to discover effective
None.
prevention and treatment.
ICMJE forms are in the supplementary material, avail-
able online at https://doi.org/10.1192/bja.2020.24.
Conclusions
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MCQs 3 Regarding assessment of patients with 5 Which of the following statements about
Select the single best option for each question stem probable eating disorders: comorbidities in eating disorders is not true?
a the Eating Disorder Examination Questionnaire a around 30% of patients with eating disorders
1 Lifetime prevalence of anorexia nervosa in (EDE-Q) is the gold-standard validated self-report meet criteria for at least one personality disorder
European women is estimated to be about: questionnaire for assessment of eating disorders b the most common cause of mortality in anorexia
a 0.05% is adults nervosa is starvation
b 1% b the MARSIPAN checklist assesses the psycho- c prior obsessive–compulsive disorder increases
c 5% social severity of an eating disorder the risk of subsequent bulimia nervosa
d 10% c the Clinical Impairment Assessment (CIA) ques- d in individuals with comorbid type 1 diabetes and
e 20%. tionnaire rates weight change in recovering eat- eating disorder, most diabetic complications are
ing disorders reversible
2 Current knowledge regarding the causation d doctors have a responsibility to consider patients’ e women attending infertility clinics have a high
of eating disorders suggests that: fitness to drive only if the patient is significantly prevalence of lifetime eating disorder.
a bulimia nervosa and binge eating disorder are underweight
inherited in a polygenic fashion, whereas anor- e all patients with anorexia nervosa require an
exia nervosa is now thought to show autosomal urgent DEXA scan of bone to screen for life-
recessive inheritance with partial penetrance threatening osteoporosis.
b a history of childhood sexual abuse is strongly
predictive of the development of anorexia ner- 4 There is evidence of at least moderate
vosa in the early teens effectiveness for:
c there is a strong familial component to binge a family-based treatments for individuals with
eating disorder, with estimates of heritability anorexia nervosa who are under the age of 18
between 28 and 74% b dialectical behaviour therapy for people with type
d scanning studies have shown that, compared 1 diabetes and an associated eating disorder
with controls, individuals with anorexia nervosa c psychodynamically informed multi-family groups
have increases in brain areas associated with for adults with binge eating disorder
self-recognition and interoceptive awareness d rebirthing therapies for teenagers with anorexia
e an ‘over-involved’ style of parenting, particularly nervosa
in the mother–daughter relationship, predisposes e single-session cognitive–behavioural therapy for
girls to develop eating disorders. bulimia nervosa in adults.

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