‘How disenchanting in the female character is a manifestation of relish for the pleasures of the table!’William Charles Macready
What causes eating disorders and how they are best treated remains the subject of much debate (Royal College of Psychiatrists, 1992; Ward et al, 1995; Shoebridge & Gowers, 2000; Gowers & Shore, 2001; Steinhausen, 2002; Gowers et al, 2007). However, referral to CAMHS continues and the need for an effective service remains. The NICE guidelines (National Collaborating Centre for Mental Health, 2004) recommend psychological interventions primarily in an out-patient setting, naming CBT for bulimia nervosa and family involvement including siblings in the treatment of young people with eating disorders. Specialist services for these young people are increasing, particularly in the independent in-patient sector. The establishment of a Tier 3 team within a CAMHS makes effective use of resources, in terms of both personnel and time (Roberts et al, 1998). The principles that underpin the workings of such a team are set out in Box 21.1.
Eating disorders can present in a number of forms: anorexia nervosa; bulimia nervosa; atypical variations of both; eating disorders not otherwise specified; and other feeding problems or disorders in childhood, described by Nicholls & Bryant-Waugh (2009) as food avoidance emotional disorder, selective eating, food phobias, functional dysphagia and food refusal. Obesity, ironically, remains the result of the major eating disorder of our time – eating too much and exercising too little, but its management is not usually the province of an eating disorder team.
Anorexia nervosa is characterised by a fear of fatness and a preoccupation with food, in which reduction of caloric intake (vomiting may be used) and increase in energy output via exercise and/or forms of purging results in serious weight loss. It may commence prior to puberty, although this is unusual, and affects up to 1% of 15- to 20-year-olds, of whom 10% are male.
Bulimia nervosa is characterised by a fear of loss of control with regard to eating. It results in episodes of binging and vomiting, and a preoccupation with weight and diet. It is more common than anorexia nervosa but tends to develop later in adolescence.