Eating disorders presentations and assessment in the primary care setting

Eating disorders are considered serious and complex mental illnesses.

The mortality rate in one particular subtype - anorexia nervosa - is as high as 20% in cases of a prolonged illness of 20 years or more.

Although information regarding the epidemiology of eating disorders in Ireland is limited, it is estimated that approximately 200,000 people experience some form of an eating disorder, with 80 new cases presenting each year.

Some 5% to 11% of people presenting with an eating disorder are reported to be male; however, similarities of core psychopathology and comorbid illnesses have been identified in both genders.

The Diagnostic and Statistical Manual of Mental Disorders-5 (American Psychiatric Association 2013) distinguishes between the subgroups of eating disorders to include anorexia nervosa, bulimia nervosa, binge eating disorder and other specified feeding and eating disorders.

Eating disorders and their characteristics

In brief, anorexia nervosa is characterised by an intense fear of weight gain, body image distortion and weight controlling behaviours that result in significant weight loss.

Bulimia nervosa is characterised by episodes of binge eating, followed by compensatory behaviours such as vomiting or laxative abuse.

Binge eating disorder is similar to bulimia nervosa, but the binge episodes are not followed by compensatory behaviours and, therefore, the person gains significant weight.

The term 'other specified feeding and eating disorders' applies to those individuals whose eating disorders behaviours or cognitions do not fully meet the criteria for anorexia nervosa, bulimia nervosa or binge eating disorder.

Despite the different manifestations in each of the subtypes, the underlying core symptoms of food and weight preoccupation, coupled with body dissatisfaction, are considered relevant to them all. In addition, and adding to the complexity of eating disorders, is the high prevalence of psychiatric comorbidity including anxiety, depression, substance misuse and obsessional compulsive disorders. There is no consensus regarding the aetiology of eating disorders; rather, multifactorial influences for its onset and development to include biological, psychosocial, family, childhood development and personality development have been identified.

Presentations to the GP and assessment

First presentation for many people with eating disorders will be in the primary care setting. Assessment and diagnosis, however, can be complicated because of complex histories, incomplete descriptions due to inability or reluctance of the person to share their information, symptoms being secondary to other psychiatric/medical conditions or symptoms failing to meet full criteria for anorexia nervosa, bulimia nervosa and binge eating disorder.

The SCOFF questionnaire (Morgan et al. 1999), below, is a useful brief screening tool that can assist the clinician to identify the presence of an eating disorder.

SCOFF questionnaire

• Do you make yourself SICK because you feel uncomfortably full?
• Do you worry that you have lost CONTROL over how much you eat?
• Have you recently lost more than ONE stone in a three month period?
• Do you believe yourself to be FAT when others say you are too thin?
• Would you say that FOOD dominates your life?

A more detailed assessment should include:

• History and current presenting problem
• Food and eating patterns
  • Quantity of food, restricting or bingeing, compensatory behaviours, attitudes to food and eating
• Medical assessment
  • Past medical and weight history, current weight and height; Body Mass Index (BMI) centiles, pubertal development, biochemistry, vital signs, electrocardiogram (ECG)
• Family history and attitudes
• Risk (medical, psychological and psychosocial risk).

Prognosis

Prognosis for recovery from eating disorders is linked to the severity of the disorder. Severity is measured, among other things, by the length of time the person has the eating disorder, the number of hospital admissions, other co-existing psychological difficulties and illness-specific markers such as the amount of weight lost.

Treatment

Treatment and outcome is often associated with a protracted recovery trajectory where outcome studies report that at least 30% of people with anorexia nervosa continue to have eating disorder symptoms after 10 years; however, early recognition and intervention are key to improving outcomes.

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