We Need to Pay More Heed to Eating Disorders

I have noticed that over the past five years in my practice, I am seeing increasing numbers of patients who suffer from eating disorders, often comorbid with other serious psychiatric illness.

For most psychiatrists, unless they have chosen a specialty elective in this field, residency training addressing anorexia nervosa, bulimia nervosa, binge-eating disorder, or the nebulous eating disorder NOS is relatively spare. Though there are opportunities for postresidency training in the field of eating disorders, since formal ABPN certification does not exist as it does for geriatric or forensic specialization, for example, there are few fellowships available.

This is not surprising given the small number of DSM-IV-TR diagnoses available to psychiatrists in this category.

The new APA Practice Guideline for the Treatment of Patients With Eating Disorders, Third Edition, was released in July. It highlights the potential leadership role for psychiatrists “within a program or team that includes other physicians, psychologists, registered dietitians, and social workers.”

If the standing-room only crowd at Dr. Joel Yager's “Focus Live” session on eating disorders at this year's APA annual meeting in Toronto is any indication, I would deduce that many of my colleagues are already being called upon or are ready to offer leadership and expertise in this field. Yager chaired the work group that developed the eating disorders practice guideline.

Like many of us outside of academia, I practice in a variety of settings (outpatient, inpatient, residential). In the residential treatment setting for serious and persistent mental illness, I have discovered that close to 25 percent of my patients have a comorbid eating disorder, often with a complex presentation. For example, a woman with schizoaffective disorder, anorexia nervosa, and borderline personality disorder stopped purging, but proceeded to cut her abdomen in an attempt to “cut the ugly fat out” of her body.

In an article in May/June issue of Psychosomatic Medicine, Dr. Barton Blinder, founder and chair of the APA Caucus of Psychiatrists Treating Patients With Eating Disorders, reported that 97 percent of patients at an inpatient eating-disorders program had a comorbid Axis I diagnosis. In this sample there were more diagnoses of psychosis in patients with anorexia than those with bulimia.

Beyond the traditional eating-disorder diagnoses, we now have the epidemic of obesity with which to contend. The advent of second-generation antipsychotics has added not only an effective addition to our pharmacologic tool chest for both psychotic and bipolar spectrum disorders, but also an additional responsibility to monitor our patients for metabolic syndrome. This increased monitoring of our patients' weights, BMI, lipids, and glucose tolerance is helping us to identify and manage weight-related pathology more effectively. In fact, many, including Dr. Renu Kotwal, believe that obesity should be considered a psychiatric disorder. He found that 87.2 percent of bipolar patients treated at a weight-management program had an eating disorder, compared with 71.3 percent of patients without bipolar disorder. The relationship between obesity, binge-eating disorder, and severe and persistent mental illness is fertile ground for new research.

There are several excellent professional organizations that focus on eating disorders; however, they are primarily for either researchers or are interdisciplinary in nature. As the leaders of eating-disorder treatment teams, it is imperative that, as psychiatrists, we continue to organize around the issues of residency and fellowship training in this important area, encouraging and supporting psychiatrists in eating disorders research, access to care, diagnostic and treatment advances, clinical excellence, and advocacy for our patients.

The APA Caucus of Psychiatrists Treating Patients With Eating Disorders will meet at the 2006 Institute of Psychiatric Services on Saturday, October 7, from 1:30 p.m. to 3 p.m. in the Jolson Room on the ninth floor of the Marriott Marquis. Please join us. ▪