Rethinking the way we approach eating disorders

Jones et al (2012) detail the clinical features of eating disorders, and emphasise the role of the general psychiatrist in their detection and management. Despite the increased interest of both psychiatry and the media in eating disorders over the past two decades, this appears to remain a neglected clinical area. The mainstay of treatment is largely psychological, a skills set not always well developed among psychiatrists. Junior trainee experience in this area is often limited, with specialist services not routinely offering placements.

Jones et al give a very good summary of the core and more general features of both anorexia nervosa and bulimia nervosa, but only briefly mention ‘eating disorders not otherwise specified’ (EDNOS), which include binge eating disorder. Although there tends to be more focus on anorexia and bulimia, it is increasingly recognised that a large proportion of eating disorders do not fit into these two categories, with EDNOS still the most common diagnosis. Importantly, Crow et al (2009) found increased mortality rates among people with EDNOS similar to those found among those with anorexia nervosa. It is also not uncommon for people to move between eating disorder diagnoses, with diagnostic cross-over from anorexia or bulimia to EDNOS in over a third of cases (Milos 2005).

It may therefore be helpful to think about eating disorders as dimensional or on a spectrum, rather than as specific categories. The transdiagnostic approach proposed by Fairburn and colleagues, and adopted by some specialist eating disorder services, is based on the recognition that most eating disorders share certain core features. These include an extreme concern about eating, weight and body shape and the ability to control them, over-evaluation of the self on the basis of weight and shape, and engagement in weight control behaviours as a consequence (Fairburn 2005). This is a potentially useful and pragmatic approach to the treatment of eating disorders that requires further exploration.