Helping People with Eating Disorders
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Helping People with Eating Disorders

A Clinical Guide to Assessment and Treatment

Bob Palmer

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eBook - ePub

Helping People with Eating Disorders

A Clinical Guide to Assessment and Treatment

Bob Palmer

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About This Book

Up-to-date and accessible, the second edition of Helping People with Eating Disorders is a comprehensive guide to understanding, assessing, and treating eating disorders.

  • Focuses on evidence-based practice with references to the latest research and new DSM-V classifications
  • Discusses the types of eating disorders and their causes, reviews treatment methods and their outcomes, and provides guidance on dealing with challenging cases
  • Illustrates concepts and methods using several case studies that run throughout the book, as well as many examples from the author's clinical work
  • Written in clear and concise language by an expert with over 40 years' experience in the field

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It is safe to assume that most people starting to read this book will already know a fair amount about what the eating disorders are and about how they affect those who suffer from them. Indeed, a majority of the public at large have heard of both anorexia nervosa (AN) and bulimia nervosa (BN) and know something about them. However, this was not the case until fairly recently. Before 1979, the term BN had not been coined, and very few people were aware of the condition it names. AN had been described for well over a century, but it was thought of as a rarity. However, what had, until the 1950s and 1960s, been the subject of brief entries in medical textbooks has now become the stuff of dozens of books and countless articles in magazines and newspapers. The increased prominence – and probably the increased prevalence – of the eating disorders was a phenomenon of the late twentieth century.
This chapter is concerned with defining and describing the main eating disorders. It will outline the history of the development of the concept of the eating disorders and will then describe the key features of these disorders as they are presently defined. The classification used is the fifth version of the Diagnostic and Statistical Manual of the American Psychiatric Association, DSM-5, which was published in the summer of 2013 (American Psychiatric Association [APA], 2013).1 This chapter will be long on description and short on attempts at explanation or understanding. That will come later. ‘What’ comes before ‘why’.


The new version of the American system (DSM-5) will be used in the rest of this chapter and indeed in the rest of this book. It helps to have a system as an anchor for discussion. However, it is important to remember that even the broad and well-established diagnostic categories, such as AN, are themselves best thought of conceptual tools. They have value and are ‘true’ inasmuch as they are useful in organising our thinking and clinical practice. But they are inventions and should be thought of as provisional. Only if they were to survive criticism and be bolstered by more and more evidence of their utility, integrity and mechanism should they be accorded the kind of status enjoyed by a disease like syphilis where symptoms, signs, aetiology and pathogenesis can all be wrapped up together into some kind of convincing whole.2 Indeed, there would be those who would suggest that finding such a disease concept is unlikely when considering a psychological disorder or, perhaps, that the very idea is incoherent even as a goal. In practice with the eating disorders, such theoretical considerations are hardly an issue since the present entities are so clearly provisional and the subject of much tinkering. They are renewed and usually changed every few years. Indeed, DSM-5, which was published in 2013, defined two ‘new’ eating disorder diagnoses. Binge eating disorder (BED) had a long gestation but fully emerged and was added to the canon only with DSM-5. And a further disorder – avoidant/restrictive food intake disorder (ARFID) – was created.
In principle, a classification should comprise a set of categories that are distinct and mutually exclusive and which together cover every case. In practice, an important proportion of people presenting to clinicians with significant eating and weight problems do not have disorders, which fulfil criteria for any of the main syndromes. Most systems can provide a slot for every case only by including a residual ‘rag bag’ category to cater for these diagnostic non-conformists, and DSM-5 is no exception. (See later sections.) The previous version – DSM-4 – was notorious for having a residual category, which was the most common diagnosis in many series of eating-disordered subjects.3


Over the centuries, there have been people who have starved themselves. Some could be interpreted from a modern perspective as having had AN or something akin to it. However, AN is a state with psychological aspects which cannot easily be detected in the minds of those who are long dead unless they have themselves written about their inner lives and done so in a way that can be translated into modern terms. In the absence of such accounts, we are left to make rather tenuous inferences about these early ‘cases’ (Habermas, 1989, 1992; Parry-Jones, 1991; Parry-Jones & Parry-Jones, 1995). It is thus difficult to make confident judgements about the fasting saints and others – interestingly often young women – who were noted and sometimes exploited because of their apparent ability to live without eating (Vanderycken & van Deth, 1994). Likewise, there must remain a deal of uncertainty about the nature of the maladies in the very earliest clinical descriptions, such as the famous and often quoted ‘nervous consumption’ described by Thomas Morton in 1689 (Silverman, 1995). Different times may construe similar states in different ways (Brumberg, 1988).
The earliest ‘modern’ accounts of what came to be called AN were made more or less simultaneously – although it seems independently – by physicians Charles Lasegue in France (1874) and Sir William Gull (1874) in England. Both accounts are worth reading, although they are different in style.4 Lasegue was more concerned with the psychological aspects of the patients he describes. He invoked the then prominent but protean concept of hysteria and called the illness anorexie hysterique – hysterical anorexia. Gull’s paper is more straightforward and descriptive, and it was Gull who invented the name that was to stick – anorexia nervosa.
There was a steady trickle of publications on AN in the last decades of the nineteenth century and the first half of the twentieth century (Mount Sinai, 1965; Silverman, 1997). There was debate as to its nature. It is said that there was a degree of muddling of AN and hypopituitarism (Simmond’s disease) after that disorder was described in 1913. Furthermore, even when AN was construed as a psychiatric disorder, there was continuing debate as to whether it was better thought of as an entity of itself or merely as a variant of some other condition such as obsessional neurosis or schizophrenia (Bliss & Branch, 1960). From the 1960s onwards, the utility of assigning AN to a diagnostic category all of its own became increasingly established. The modern concept of AN had reached maturity (Bruch, 1973; Crisp, 1967; Russell, 1970) However, as sometimes happens to people, no sooner had a measure of maturity been achieved then things began to fall apart. AN started to undergo a nosological mid-life crisis.
Firstly, there were attempts to produce a useful sub-categorisation of the disorder. The most significant split was that between sufferers who maintained a low weight solely by restraining their eating and those who resorted to vomiting (Beumont, George, & Smart, 1976). Many, but not all, of the latter also showed bingeing behaviour (Casper, Eckert, Halmi, Goldberg, & Davis, 1980). The two groups were shown to differ on a number of characteristics of their background and current clinical picture, the latter seeming to be on average more likely to show a wider variety of troubled or troubling behaviour.
Secondly, a group of people was recognised as suffering from eating disorders which closely resembled this second bingeing and vomiting group of AN sufferers except that they were of normal or high body weight (Russell, 1997; Vanderycken, 1994). With the publication of Gerald Russell’s classic paper (Russell, 1979), BN had emerged. The wider concept of ‘bulimia’ was included in the DSM-3 (APA, 1980), but Russell’s term and, broadly speaking, his concept came to be included in later revisions of the main classificatory systems. The broad outline of the syndrome seems to have unequivocal utility, although there is still room for doubt about the detailed criteria (Sullivan, Bulik, & Kendler, 1998).
The next sections will be concerned with the definition description and discussion of the three main eating disorders: AN, BN and BED. Each disorder will be illustrated by a case history.5


The most prominent feature of AN is low weight. This is almost always the result of weight loss. (The exception is when a child comes to be at a lower than average weight because he or she has failed to gain weight in the expected way.) In general, it is best to discuss body weight using an index which takes height into account, usually the body mass index (BMI).6 Some sets of diagnostic criteria specify a level below which a low body weight is thought to be significant even though weight is a continuous variable, and a line is being drawn in order to define a category for practical use.
The weight loss of AN is attained and maintained by inadequate eating. Typically, this is because of motivated eating restraint rather than loss of appetite or of any reduction in the drive to eat. Indeed, the sufferer may feel that her urge to eat is very strong and potentially out of control. She nevertheless attempts to eat little, less than she would normally do and less than is required to maintain a normal weight. She sits on top of her hunger. Of course, for many sufferers the issue of their drive to eat is a touchy topic and their account of it to others – perhaps even to themselves – is variable and may be evasive. Some will acknowledge an urge to eat but will deny being hungry because that word has too positive a connotation for them. Other sufferers will deny having any drive to eat at all. However, whilst it seems that some sufferers do come to experience true anorexia in the sense of loss of appetite, this is not the case for the majority. Of course, ‘anorexia’ means lack of appetite and the inclusion of the word in the name AN is strictly a misnomer. However, after well over a century of use, it is probably too late to change it now.
Some sufferers will give in to their urge to eat more than they intend and may then seek to thwart the effects of this by use of abnormal weight control methods such as inducing vomiting or taking laxatives or diuretics. Sometimes, sufferers will exercise excessively. This may be directly motivated by beliefs about ‘burning off calories’, although there also seems to be some biologically driven connection between food deprivation and overactivity.
Some anorexia sufferers will truly binge. They will have the symptom of bulimia. (The issues involved in what this means will be discussed in the section ‘The Features of Bulimia Nervosa’.) More often, the person will feel that she has binged even though objectively she has eaten only a little. She feels that she has binged because she has transgressed her own personal rules by having given in to her urge to eat. Such behaviour is described as subjective bingeing.
The motivation for the eating restraint of AN typically has something to do with the sufferer’s wish to keep her weight low. Indeed variants of this particular motivation are specified in most sets of diagnostic criteria. They set out attitudes and beliefs which are said to constitute the specific psychopathology of AN. The words used to capture these include ‘intense fear of gaining weight or becoming fat’ (DSM-5) or ‘a dread of fatness’ (International Classification of Diseases, 10th edition (ICD-10)). Of course, such motivation resembles that which underpins much ‘normal’ slimming, although the anorexia sufferer continues with her motivated eating restraint to a point way beyond that to which the typical slimmer aspires. The suf...

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