Eating disorders continue to have a stigma attached to them. As such, remote therapies, based on e-mail, text messaging, or online cognitive behavioural therapy, could increase engagement with health services and improve recovery rates. These and other issues around these debilitating conditions are discussed in a Seminar published Online First and in an upcoming edition of the Lancet, written by Professor Janet Treasure, Institute of Psychiatry, King's College London, UK, and colleagues.
Anorexia nervosa is characterised by extremely low bodyweight and a fear of its increase; bulimia nervosa comprises repeated binge eating, followed by behaviours to counteract it (eg, vomiting, laxative abuse). The category of eating disorder not otherwise specified encompasses variants of these disorders, but with subthreshold symptoms; binge eating disorder is currently a subcategory of eating disorder not otherwise specified, and is defined as frequent binge eating distinguished from bulimia nervosa by the absence of recurrent inappropriate compensatory behaviours.
The lifetime prevalence of eating disorders in adults is about 0•6% for anorexia nervosa, 1% for bulimia nervosa, and 3% for binge eating disorder. Women are more affected than are men, and the sex differences in lifetime prevalence in adults could be less substantial than that quoted in standard texts: 0•9% for anorexia nervosa, 1•5% for bulimia nervosa, and 3•5% for binge eating disorder in women; and 0•3%, 0•5%, and 2•0%, respectively, in men.
The authors say: "The diagnostic criteria are in the process of review, and the probable four new categories are: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. These categories will also be broader than they were previously, which will affect the population prevalence; the present lifetime prevalence of all eating disorders is about 5%."
Eating disorders can be associated with profound and protracted physical and psychosocial disease. For example, the fertility and maternity rate of women with anorexia nervosa is reduced; a Swedish study suggested that the rate of fertility was 70% of that in the general population. Infant birthweight is lower in mothers with anorexia nervosa but higher in those with bulimia nervosa. The miscarriage rate for women with bulimia nervosa is higher than for healthy women—those with bulimia nervosa were twice as likely to have two or more miscarriages compared with the general population.
Practice recommendations emphasise the importance of specialised care for the treatment of eating disorders, but such care is not often accessible. Hence, new forms of service delivery (eg, e-mailing, text-messaging) with use of treatment directed via mobile phones, the internet, or telemedicine (eg, cognitive behavioural therapy [CBT] delivered by a therapist via the internet) are being assessed. A systematic review of self-help interventions (computerised or manual) concluded that with professional oversight (guided self-help) these interventions could have benefit in bulimia nervosa and binge eating disorder, although some uncertainty still remains.
For anorexia nervosa, family/individual counselling plus nutritional therapy aimed at gradual weight gain are the mainstays of treatment. Both bulimia and binge-eating disorder respond to treatments such as cognitive behavioural therapy, psychotherapy, and, in some cases, antidepressants or anti-obesity drugs such as orlistat. Recovery from anorexia nervosa becomes much less likely the longer that the illness has persisted. This finding contrasts with that of bulimia nervosa, for which the chance of recovery becomes higher the longer the illness duration.
The authors say: "The diagnostic criteria for anorexia nervosa and bulimia nervosa are under consideration and could be broadened...reducing the size of the population in the category for eating disorders not otherwise specified. Binge eating disorders will probably be accepted as an additional form of eating disorder."
They conclude: "Overall, apart from studies reporting pharmacological treatments for binge eating disorder, advances in treatment for adults have been scarce, other than interest in new forms of treatment delivery."
Professor Janet Treasure, Institute of Psychiatry, King's College London, UK. T) +44 (0) 7949531961 / +44 (0) 207 1880186 E) janet.treasure@kcl.ac.uk
For full Seminar, see: http://press.thelancet.com/eatdisord.pdf
Journal
The Lancet