• eating too much   or

• eating too little    and/or

• using harmful ways to get rid of calories.
   

For further information please read the leaflet below from The Royal College of Psychiatrists

Source: Royal College of Psychiatrists

The Royal College of Psychiatrists is the professional and educational body for psychiatrists in the United Kingdom and the Republic of Ireland.

Address: 17, Belgrave Square, London, SW1X 8PG

Website: www.rcpsych.ac.uk

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There are three main types of eating disorder;

• anorexia nervosa

• bulimia nervosa

• binge-eating disorder (a slightly controversial diagnosis).

There are several others as well, charmingly called “Eating Disorders Not Otherwise Specified” (EDNOS).

The main symptoms of “anorexia nervosa” are:

• Not eating enough to keep weight up

• Refusing to keep to the minimum normal weight for that person's age and height.

• Intense fear of gaining weight or becoming fat

• Lack of periods in females (missing three menstrual cycles or periods in a row)

• Not understanding what you look like e.g. feeling fat even when painfully thin.

Anorexia nervosa usually starts in the late teens, with continuous dieting. People may avoid carbohydrates, make themselves sick, abuse laxatives, take excess exercise, binge eat (eating huge amounts in a single session) and suffer depression and social withdrawal. It may occur in up to 1 in 50 schoolgirls and up to one in 25,000 of the general population

The main symptoms of bulimia nervosa are:

• Recurrent binge eating (eating huge amounts in a single session), including lack of control (ie not being able to stop)

• An urge to overeat (including lack of control of eating during binges).

• Always being worried about body shape and weight

• Making themselves vomit and taking lots of laxatives

• Strict dieting or fasting.

There must be at least two binge episodes per week for at least three months. Weight and periods are usually normal.

The main symptoms of binge-eating disorder are:

• Binge-eating of large amounts of food at separate time

• Not followed by actions to reverse this, such as taking laxative or vomiting

Many (but not all) sufferers of Binge-Eating Disorder are overweight and have depression.

One of the best places to go for further advice is BEAT (Beating Eating Disorders), the home of the British Eating Disorders Association, here in sunny Norwich, England.  (OK, so it probably isn’t sunny, but we live in hope).

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of eating disorders. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms need to be treated anyway, no matter what causes them.

Firstly, there are different types of eating disorders:

• Anorexia nervosa

• Bulimia nervosa

• Binge-eating disorder

• Selective eating disorder

Some causes include:

• Brain tumours affecting appetite

• Selective eating or food fads

• "Pervasive refusal syndrome"

• Zinc deficiency - where food doesn't taste

• OCD (Obsessive Compulsive Disorder)

• Social anxiety

• Seasonal Affective Disorder - which can increase binge eating in winter

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression

• OCD (Obsessive Compulsive Disorder)

• bipolar mood disorder - which is slightly more common than expected

• Social anxiety

• Seasonal Affective Disorder - there can be marked seasonal variations

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Basically, anyone can get an eating disorder. However, there are some "risk factors" that make it more likely that someone will get the symptoms of an eating disorder. This is not a complete list but some of the main ones include:

• Disturbed relationship with parent or parents (although one study showed no connection with this at all) e.g. the child feeling over-controlled, not being able to talk properly to his/her parents, or with critical or unaffectionate parents
• Being female - slightly more common in females, although the symptoms may show differently in males
• Media influence - the "thin is good" message, with younger people trying to become thin to match this
• Biological factors e.g. perhaps low serotonin in the brain may lead to a weakness towards having an eating disorder
• Trauma in childhood 
• Having mild depression as a child (3 times more likely)

^{Updated 12.11}

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Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful. The list here includes most of the main options but does not say what works and doesn’t. Many may be used in combination.

Self-help

• Controlling food intake (not too much or not too little), controlling eating and weight (attitudes to food, intake). Sometimes this may need admission to hospital if the person is really unwell
• Personal help (such as not abusing laxatives, extra dental care)
• Taking any medicines regularly and reliably
• Taking feeding supplements and vitamins to keep your body in shape
• Taking exercise  (“exercise to energise”) or being active, regular sleep patterns

Help from others

• Cognitive Behavioural Therapy (CBT) is the main and most effective treatment at the moment for eating disorders, especially bulimia nervosa and binge-eating disorder. Other psychotherapies include Cognitive Analytical Therapy and Interpersonal Therapy. There are variations of CBT aimed at anorexia, bulimia and binge-eating.On-line CBT, with support, has been shown to help ^{(Pretorius 2009)} 
• Family therapy - involving the whole family. The 13 studies published to 2010 showed it is probably the most effective treatment for anorexia nervosa ^{(Fisher 2010)}
• Hypnotherapy may help some people
• Alternative therapies such as  aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good, especially for eating disorders. All of these can be used with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Serotonin boosters, such as fluoxetine, a Specific Serotonin Reuptake Inhibitor (SSRI). These are probably of little use (except fluoxetine in bulimia) but might help with other sytmptoms e.g. anxiety and depression.

^{Updated 10.11}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines

• Fluoxetine, an SSRI - this can help bulimia nervosa and possibly binge-eating, but does not really help anorexia

Others:

• Antipsychotics (such as olanzapine, which may sometimes help anorexia over 4-6 weeks, but this isn’t definite)

• Other serotonin boosters (such as paroxetine), and some perhaps some tricyclics

• Topiramate can help binge-eating disorder

• Vitamins can help when the person needs more nutrients to maintain a functioning body

Medication is not generally very helpful for eating disorders, but can be used to help any depression, anxiety and other symptoms the person may have. Medicines may help reduce these symptoms enough for the person to be able to regain control.

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Not really. We'll try to do a handy chart in due course but there might not be much on it.

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For eating disorders that’s probably true. Medicines are probably at best just helpful, although sometimes they are very useful in treating other symptoms e.g. depression and anxiety. CBT and family therapy are the most effective treatments. They may be more effective if used with antidepressants ^{(CDSR 2001)}.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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If a medicine is helping, it should probably be taken for several months or years. It should be a personal decision as there is little or no evidence to guide us. You should consider the risk of the eating disorder getting out of hand again.

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

The important thing with fluoxetine is to make sure you get the right dose. Most studies show an effect from higher doses (i.e. fluoxetine 60mg a day) taken for 8 weeks but this isn’t entirely clear so you might need to give it longer if symptoms are beginning to get better. The effect from fluoxetine in bulimia is different to the antidepressant effect. In binge-eating disorder or bulimia, people who take fluoxetine who do not have at least a 60% drop in binge-eating or vomiting after 3 weeks are unlikely to improve ^{(Sysko 2010)}.

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

If you are taking medicines, one should usually be enough (excluding vitamins).

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the eating disorders guidelines)

• Scottish Intercollegiate Guidelines Network (SIGN)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

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Use the resources below to find out more information about eating disorders. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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