• An update on improving our community services
• An update on our improvements to inpatient services
• Details of the Schizophrenia Commission's visit to a Trust art and wellbeing service

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If you have any comments or questions please contact Peter Swift on 0161 882 1093 or peter.swift@mhsc.nhs.uk.

Here the Eating Disorders Service Clinical Lead Martin Gill (pictured right with colleagues from the team) gives an overview of eating disorders and the support available.

Recovering from eating disorders

According to leading eating disorder charity BEAT, eating disorders affect around 1.6 million people in the UK. Figures from national mental health charity Mind also suggest that around one woman in twenty will have eating habits which cause concern, while the Royal College of Psychiatrists believe that 1 in 150 fifteen year old girls and 1 in 1000 young men will suffer from Anorexia.

However, it is important to remember that support is available and with the right treatment people can recover from eating disorders and live a full and healthy life.

Types of eating disorder

There are broadly four types of eating disorders.

• Anorexia Nervosa is divided into two subtypes. However, the common feature of both is maintenance of body weight 15% below what is considered normal for the individual's age and height. People with the disorder also experience an intense fear of gaining weight, restriction of food intake, excessive exercising, a disturbance or distortion in the way the body is viewed and an over influence on the importance of weight or shape on self-evaluation. Another feature of anorexia is an absence of menstrual periods in postmenarcheal women.

There are two sub-types of anorexia: binge eating/purging type (vomiting, laxative use or diuretics) and restricting type.

• Bulimia Nervosa typically involves individuals attempting to control their food intake but not managing to do this successfully leading to episodes of binge eating followed by vomiting and/or laxative use. Some sufferers also use diuretics. People with the condition exercise excessively and are preoccupied with concerns about weight and shape. Patients with the condition are typically a normal weight.
• Binge Eating Disorder is described typically as frequent episodes of uncontrollable binge eating, but without the compensatory behaviours associated with Bulimia. Often patients who suffer from binge eating difficulties will be overweight or even morbidly overweight, which seriously affects their physical health.

• EDNOS or Eating Disorder Not Otherwise Specified is a broad category of patients who may have some but not all diagnostic features of Anorexia or Bulimia, a kind of "sub-clinical" category. An example may be someone who has infrequent episodes of binge eating and vomiting but has serious over-valued concerned about their weight and shape.

People most likely to suffer from eating disorders

The Royal College of Psychiatrists' state that girls are ten times more likely than boys to suffer from an eating disorder and although eating disorders most commonly develop in adolescence they can affect both younger children and older adults. In the Trust's Eating Disorder Service, we certainly have more female patients than male and although we are an adult service (taking patients from the age of 16) many who are referred to the service are not the stereotypical picture of an underweight adolescent girl. Patients are typically aged 18-40 although eating disorders can affect people across all ages.

Causes of eating disorders

 It is unlikely that there will be a single reason why someone has developed an eating disorder and it is more likely to be a combination of factors. These can include any of the following, although this list is not exhaustive by any means:

• Depression/low-self esteem
• Peer/social pressure
• Control
• Family difficulties
• Emotional/psychological distress
• Biological factors

Eating disorders are serious mental illnesses that affect a large number of people and can have serious consequences. They often develop in adolescence and do not have a single cause. Consistent with this picture is the fact that they have a high incident of "co-morbidity", which is when there are other psychiatric or psychological problems present. These can include depression, anxiety disorder or personality disorder.

Treatment available

The type of treatment offered depends on the particular kind of eating disorder, and takes into account the severity, timeline, patients' age and other potentially complicating factors. For most patients this begins with their GP, who will make a referral to a specialist or specialist service where appropriate. This is likely to be a psychiatrist, psychotherapist, psychological therapist/psychologist, counsellor or other health care professional skilled in the treatment of eating disorders.

Generally speaking, treatment falls into two areas; in-patient care (in some circumstances day care may be offered as an alternative to in-patient care) and out-patient care.

For example, a patient diagnosed with anorexia may need to be admitted to a specialist hospital in order to receive specialist care to stabilise and address physical factors such as low weight. This will be a specialist hospital or department with a team of staff who are skilled in the treatment and management of patients with Anorexia. The team may typically include: a psychiatrist, psychologist/psychological therapist, dietician and nursing staff. The aim of treatment is to help the patient begin to address their anorexia, including supervised and monitored eating managed by a dietician, and possibly use of medication to treat any depression or anxiety. Psychological therapy is also offered to begin to tackle the reasons for the eating disorder developing and address the features that maintain the illness.

In-patient treatment is normally for the most severely ill patients.

Most patients suffering from eating disorders would not receive such intensive treatment and are more likely to receive some form of psychotherapy or counselling. This may be in conjunction with specialist advice from a skilled and experienced dietician.

Psychotherapy and counselling

Psychotherapy and counselling are "umbrella" terms in that there are many different schools or types of psychotherapy and counselling. As not all patients with an eating disorder will access help through a specialist eating disorder service or even through the NHS, it is worth saying more about psychotherapy and counselling.

Firstly, within the NHS and specialist eating disorder services psychotherapy is likely to be offered by a psychologist/psychotherapist or specially trained psychological therapist. The types of therapy available are usually Cognitive Behavioural Therapy (CBT), Psychodynamic Therapy, and Cognitive Analytic Therapy (CAT).

CBT is a type of therapy commonly offered by NHS eating disorder services, both for in-patients and out-patients. There is a good evidence base for its use, particularly for patients with certain Bulimic presentations, and it helps patients to understand unhelpful ways of thinking and how these trigger and maintain eating disorders. For example, a patient's belief that they are fat can lead to them restricting and controlling their diet and when this becomes unsustainable can lead to binge eating and vomiting.

Courses of CBT usually last six months and certain types have been developed to be particularly effective for helping some people with their Bulimia. CBT uses diaries and homework exercises to begin to understand and challenge the unhelpful thoughts and feelings that can maintain an eating disorder.

Psychodynamic psychotherapy is concerned with the understanding of the dynamics at play within our relationships. These may include elements of one's difficulties which may be unconscious or outside of our awareness. The aim is to develop greater understanding of these difficulties or defences and the way in which they negatively impact on our lives. This type of therapy can be longer term and is based on an understanding that relationship difficulties, including difficulties in the patient's relationship with food, will be played out with the therapy and in the relationship with the therapist. For instance, a patient with anorexia who rigidly controls their food intake may similarly attempt to control the therapy.

Here the therapists' task is to help to slowly and carefully support the patient in understanding this pattern and exploring what this may mean in order to lessen the need for rigid defences.

CAT is a brief therapy usually lasting 16 sessions, making use of both psychodynamic and cognitive principles in order to develop a shared understanding of the patient's difficulties. It is also an active therapy where the patient and therapist work together to understand how difficulties have emerged and developed over time and how they can then be better adapted and less damaging. Through this patients develop the skills and understanding to challenge and change unhelpful patterns.

Some patients may choose to access help outside of the NHS, for example through student counselling services or private therapists. Within these settings psychotherapy or counselling may not be of the above types, although due to the complex nature of eating disorders there may still be a need for ongoing medical monitoring. For example a patient with bulimia who vomits quite frequently may need regular blood monitoring, which could be supervised by their GP.

Psychotherapy and counselling are interventions that aim to help an individual (or if in a group setting) help the person develop insight. This means that during therapy the patients learn to understand themselves and their difficulties better. For instance, CBT can be effective in helping understand the thoughts and feelings which lead to the episodes of binge eating and vomiting, and thus begin to break the cycle of bulimia.

Psychodynamic psychotherapy helps the patient to gain a greater understanding of themselves, particularly the way they form and maintain relationships. This includes understanding the unconscious patterns which are present in relationships. For example, patterns of relating that emerge within childhood can be played out during later life without any awareness. Difficult or abusive relationships in early life can manifest themselves later as difficulties with food. It is possible to begin to understand that if someone had little or no control over what happened to them they may in adolescence or adulthood begin to exert control over their relationship with food.

I would suggest that all patients with a severe eating disorder should be under the care of a specialist service who will be able to manage any potential physical risks that the eating disorder may create. 

Carers

Learning that a son, daughter, partner or friend is suffering from an eating disorder can be very difficult. It can also be very confusing to understand why someone may vomit after eating or refuse to eat full stop. It can also be very frightening to see someone lose weight and feel like you are unable to help.

It is important to remember that an eating disorder is a mental illness and that vomiting or starving are symptoms of the illness. Carers may feel anxious, guilty, helpless or even angry and want their friend, daughter or partner to be given help to make them change straight away. An especially useful resource is the BEAT website, which has helpful and sensible information for carers and partners.

In-patient care will include families and partners in treatment, including being invited to ward rounds and care meetings or taking part in family therapy. This is especially the case for younger people under the age of 16.

Out-patient care and in particular psychotherapy or counselling may not necessarily include partners or family members, as treatment is confidential. However, it is usually possible for carers to have a discussion with the therapist to consider their worries during the assessment phase.

Useful resources

• BEAT: BEAT is the leading UK charity for people with eating disorders and their families. There are a range of services available including an excellent website (type BEAT into your search engine), support lines for young people and carers and a service directory which includes both NHS eating disorder services and individual therapists. BEAT also does extensive lobbying to raise awareness of eating disorders.
• The British Association for Behavioural and Cognitive Psychotherapy (BABCP). The BABCP website is a useful place to gain more information and Behavioural and Cognitive Psychotherapies. This would include a list of trained CBT therapist available in your local area.
• United Kingdom Council for Psychotherapy (UKCP). The UKCP website is helpful in understanding better the different types of psychotherapy available and help you find a suitably qualified therapist in your local area.
• The British Association for Counselling and Psychotherapy (BACP): The BACP website will give a better understanding of counselling and help you find a suitably qualified local counsellor.
• The Royal College of Psychiatrists has an excellent feature on eating disorders on its website (type Royal College of Psychiatrists into your search engine and then navigate to the appropriate section).