Saturday, 13 October 2012

Are GPs Failing to Diagnose and Treat Eating Disorders?

On page 13 of The Times dated the 12th October 2012 a report by Martin Barrow, Health Editor, claimed that GPs are ‘failing to spot early signs of eating disorders’ as number of sufferers soars. The article followed a typical format: identifying family doctors as being at the root of the problem through an inability to understand, assess and manage appropriately its various manifestations. I was not surprised to see that the views of the chief executive of ‘Beat’ – the eating disorders charity – featured prominently. She presented opinions as facts and portrayed the GP in a negative light.
No doubt the intention behind the publication of such material is – so far as the charity is concerned – to draw attention to their cause. I have no issue with this so long as demonstrable facts rather than hypotheses are presented. So far as the newspaper is concerned the intention is to sell copy – and any article that portrays doctors as lazy, ignorant, greedy or whatever is certainly going to do that.
No – the problem for sufferers from eating disorders is one of very limited resources for a condition that requires intensive, time consuming and costly intervention. And possibly – I cannot say certainly – a public that is much less sympathetic towards eating disorders than it would be, say, towards heart disease or breast cancer.
In my 40 years as a GP and a teacher of young doctors in training to become GPs I gained a considerable experience of people with eating disorders. I would emphatically counter any suggestion that GPs ignore the possibility of an eating disorder presenting even in its earliest stages. The problem for family doctors is not that they are ignorant or disinterested, but the perception that when they refer patients any number of barriers is put up. Not least one of long waiting lists. The other problems are those of denial and concealment on the part of sufferers and their families. On those occasions when I tactfully raised the possibility with patient and parents by far the commonest reaction was that of a refusal to accept it. But in the end the GP is trained and equipped to gain the confidence of patient and family so that the true nature of the problem is acknowledged and treatment plans initiated. I acknowledge that GPs may have failed in the past, but the present day vocationally trained doctor is far less likely to fail the patient.
Eating disorders present to GPs one of the greatest challenges in their day to day work. And, contrary to such misreporting as appeared in The Times on the 12th October, they will rise to it and do the best they possibly can. Knocking the GP will really not help the cause at all. It is the politicians who should be pressured to ensure that effective, adequate and local resources for treatment are put in place.
And perhaps a little more attention, too, should be paid to identifying the possible causes of eating disorders. Not just by the health professionals, but by the families as well.


  1. I have every sympathy with your view that knocking GPs is as easy way of selling copy for newspapers and a cheap and unhelpful way of highlighting a cause. It is indeed the politicians who should be pressured to ensure effective and adequate local resources for treatment are put in place for eating disorders as for any other serious health conditions. The willingness of certain politicians instead to help to spread doubt and fear about the NHS and all who work in it while simultaneously undermining the resources given to it is truly shocking.

    I wonder though what you mean but identifying the possible causes of eating disorders. More research is indeed needed to explore these complex diseases and although excellent work such as that being done by Walter Kaye in California is being done a lot more is needed. How do you feel families can contribute to this research?

  2. I think perhaps that I was wondering - this is pure hypothesis as I claim no expertise - if on occasions an eating disorder is not just a problem for the individual sufferer, but of the family as a whole. That is - does the disorder arise as a consequence of disrupted family dynamics (for example)? I am not suggesting that this applies to every case. But perhaps to some ...

  3. Eeek. There is much research and many experts who agree that parents do not cause eating disorders - unless you are going to blame passing on their genes. Many families of children with eating disorders do present with anxiety and other difficulties associated with caring for a mentally ill patient. This is also the case for parents of children with a myriad of other conditions - childhood cancer, other mental illness, diabetes, to name but a few.

    In my experience, only the families of eating disordered patients are still expected to shoulder the blame. The work done by the autism community and such wonderful organisations as Rethink have shifted the blame from the (now discredited in the main?) family dynamic as a cause of mental illness and have moved it on to a more biological/genetic/environmental contributing factors. The credibility of "refrigerator" mothers in autism and schizophrenia is laughable now, but still seems to be an overwhelming prejudice against mothers of children with eating disorders. Why?

    Whilst blaming GPs is harsh and I agree about the long wait lists and the paucity of decent evidence based treatment in Tiers 1, 2 and 3 of the NHS, there is a lot of information and help on the internet for parents of children with eating disorders.

    The best evidence base for teenagers and young children (and there are Clinicial Trials in place for young adults) is Family Based Treatment, the Maudsley Method as manualised by Lock and Le Grange. This is NOT Family Therapy, remains agnostic as to cause and places treatment (in the form of normalising nutrition, restoring weight whilst being overseen by a qualified therapist) AT HOME as having the best outcome for full remission. The problem that seems to happen here is that there are not enough trained therapists and, without fully understanding the concept, parents are put under undue pressure to keep their children at home, without proper back-up from CAMHS and AMHS teams and without any kind of training.

    Those of us in the eating disorder advocacy world have often found that late diagnosis, blaming of the parents for something which is not their fault, the "Bruch" concepts hangover of looking for a "cause" and pointing the finger at parents for abuse (firstly) and then a whole heap of other psychological factors, rather than moving straight into treatment of the eating disorders and reversal of the effects of malnutrition (see Minnesota Starvation Experiment) are the biggest barriers to effective treatment.

    Blaming and shaming - whether GPs or families - is, in my opinion and borne out by the latest research, a waste of time and can, in some cases, be fatal for the patient.

    What IS needed is better education at all levels of the NHS and within the wider community. This is something that Beat are trying to do.

    Charlotte Bevan
    C&M ED Productions
    Moderator, Around the Dinner Table Forum

  4. As someone who struggled severely with an eating disorder (restricting anorexia nervosa - AN) for many years, and who also has a PhD in the biomedical sciences, I will comment from the perspective of an eating disorder patient and a biomedical scientist.

    I can see why parents of offspring with an eating disorder (ED) are upset by what you have written above, because:

    a) there is little research evidence to suggest that family dynamics are the cause of EDs - and

    b) these parents have done their utmost to help and support their child, sometimes only to face misunderstanding or criticism by medical professionals.

    EDs are complex illnesses with a strong biological basis. That is to say that the disordered eating drives itself and the person gets stuck in a pattern of dangerous behaviours around eating, purging, exercising etc. Why some people are vulnerable to getting completely stuck in these behaviour patterns is unclear, but there is increasing evidence to suggest that this relates to inherent factors, such as information processing (i.e. neurological/brain factors) and resistance to behaviour change, as well as a somewhat atypical response to energy deprivation - especially in AN.

    My family did not cause my AN - which I developed at age 11 after many years of childhood OCD. Childhood OCD is now understand to be largely neurological and not caused by attachment issues or poor parenting in any shape or form. My AN was closely linked to OCD and certain traits on the autism spectrum. I did experience some severe traumatic stresses before the onset of AN, but these had nothing to do with my parents, who knew nothing of these stresses, because I was the type of kid who didn't talk about feelings.

    I experienced trauma before the onset of my AN, but research evidence suggests that most people with EDs have NOT suffered trauma. The triggers for EDs are many and varied - and no two individuals with an ED are the same. But one common denominator in almost all EDs is energy deprivation in one form or another (e.g. deliberate dieting, illness-induced weight loss, overtraining in sports with inadequate energy intake).

    There is little evidence that EDs can be prevented, and I for one despise attempts to run 'body image' classes in schools which are based upon the hypothesis that if a person likes their physical appearance then they are protected from developing an ED. I, for one, did not develop an ED because I didn't like the way my body looked.

    I recognise that the objective of your article is not to assign blame to families in the context of the aetiology of EDs, but I thought I'd just comment anyway..

  5. Guys - firstly I must apologise if I have caused hurt or offence. It was never my intention, but I can see how it might be construed so.
    In my years as a GP I often worked with families experiencing problems of one sort or another. I hope you can agree that, given that family problems are common, some people with eating disorders will belong to such families but that is NOT to suggest a causal relationship. And certainly I worked with wonderful families where a member had an eating disorder, and the sufferer was fully loved and supported. Am I making sense.
    If you've a problem with my post I would be happy to remove it. Let me know.

  6. Don't remove it. It is good to get these things in the open and to hear both sides of the discussion - and that's what it is - not an attack or an argument.

    Parsing out the details often offers the chance for us to help people who may be reading, but not commenting, come to a clearer understanding of eating disorders - a much neglected and under-resourced area of mental illness - on that we are ALL agreed.

    It also gives you a chance to explain what you are meaning to,

    The internet is a TERRIBLE place to communicate. We write without people being able to see our body language and I know I can come across as a bit of tiger - don't mean to.


  7. I agree totally with Charlotte. Please don't remove it. It has provided a good opportunity for discussion. More resources on the subject are available on the Kings College London website and, specifically geared towards families but with a section for professionals, from F.E.A.S.T.

  8. Dr Tegner,

    I agree with above comments in reference to keeping the post here. It provides an opportunity to open up discussions to gain an understanding of how, particularly a General Practitioner, work with families and eating disorder patients.

    As parent advocates, we work hard to find effective ways and means to dispel outdated myths which are firmly rooted in family blame. As Marcella stated above, FEAST are a world wide, non profit organisation which provides evidence based information regarding eating disorders; a forum for parent's and caregivers of those who have a loved one suffering from an eating disorder, and provide succinct information and resources for those in need of help and support. Very sadly, the forum threads and discussions centring around blame of parents who struggle to come to terms finding effective treatment and are more often than not given mis information or worse, their child is misdiagnosed.

    We stand united in our efforts to raise awareness, affect change in the way eating disorders are understood and treated. Strong, robust evidence now exists for Family Based Treatment/Maudsley and is considered the gold standard of treatment in the first instance. Family play a significant role not only for children, but also adults. When family are excluded as so often is the case, even today, it can cause significant harm and delay much needed care. We currently have a member of our advocacy group experiencing a type of active parentectomy in the treatment of her young adult daughter.

    Certainly an important objective and learning point, for me as well as other's within your profession who may read your posts, is to launch, quite urgently, a programme of education to update those in the medical profession on current and relevant treatment and early recognition of symptoms of eating disorders and disordered eating.

    I would like to direct you to a pamphlet, published by Families Empowered and Supporting Eating Disorders (F.E.A.S.T.) and the Academy of Eating Disorders (AED), entitled: Puzzling Symptoms: Eating Disorders and the Brain - A Family Guide to the Neurobiology of Eating Disorders.

    Best wishes,
    Gabriele Matthewman