Eating Disorders: Much Progress but Still Far to Go

Psychiatry has seen a transition from art to science in the past century and, largely because of 2 developments in the past several decades, this has also been the case for the field of eating disorders. The first development is the increased awareness that eating disorders are epidemic in economically advantaged parts of the world, which has sparked increasing interest in research and yielded a growing body of literature.

The second development is the recent technological advances in genetics, neurobiology, and neuroimaging, which have yielded a growing understanding of the biological aspects of these complex biopsychosocial illnesses. This has facilitated the shift in public opinion, from viewing eating disorders as lifestyle choices to recognizing them as serious mental illnesses. There has also been an important shift, from blaming families to recruiting them as agents of change.

However, there is much work to be done, and we still have more questions than answers. For one thing, we have limited evidence to support the effectiveness of our current therapeutic armamentarium, especially in psychopharmacology. Other questions remain as well, including the optimal management of medical complications such as osteoporosis, how to assess severity of illness, and how to individualize levels of care and therapeutic options as the course of illness progresses (which often involves changes in eating disorder behaviors that cross over among the current diagnostic criteria).

To date, we have been mostly guided by clinical experience with limited evidence to support best practices. Other important hurdles for those seeking care include the disparity of availability of professional resources (especially in less densely populated areas) and the financial burden imposed on individuals and families. These constraints also impact the treating professional and add to the challenge of navigating through the day-to-day realities of clinical practice.

Another issue is the paucity of data related to most common eating disorder diagnoses. There are no studies on the pharmacological treatments of eating disorder "not otherwise specified," which leaves clinical decisions to be extrapolated from what we know about anorexia nervosa and bulimia nervosa.

How do we define recovery?
Of all these issues, perhaps the most important is the lack of consensus in defining recovery.

We have been able to identify predisposing, precipitating, and perpetuating factors and are continuing to move forward in our understanding of predictors of outcome, but the wide variability in how recovery has been defined makes it difficult to pool available research data in order to draw sound conclusions. The question of defining recovery becomes even more difficult to answer if we consider from whose point of view recovery should be defined. Should it be defined from the point of view of patients, families, treating professionals, third-party payers, or other stakeholders? This may be a particularly sensitive issue given that there are likely to be different expectations of what constitutes recovery among these groups.

The time to resolution of different eating disorder symptoms among treatment responders can be quite varied. This needs to be taken into consideration as we define recovery. A study by Clausen¹ in 2004 found that symptoms such as restriction or purging may improve or resolve within a few months after the onset of treatment, while other symptoms, such as body dissatisfaction or nonpurging compensatory behaviors, may take years to resolve. In order to effectively look at long-term treatment outcomes we need to establish a consensus in the definition of recovery, at least from a research perspective.

Other developments are also worthy of note. There has been an increasing understanding of the distinct and important roles that different organizations have in representing the interests of persons with eating disorders. A number of regional and national groups have furthered and will continue to further the agenda for eating disorders. But perhaps the most important development is the spirit of collaboration among these organizations that has allowed them to gather strength with their collective voices.

Funding research on eating disorders
Last but not least, we need to make more headway in funding the research necessary to answer the questions that we still have. The NIMH is currently funding several important studies on eating disorders, including 2 multicenter studies on anorexia nervosa. One is on genetics and the other is on the Maudsley (family empowerment) approach. However, funding for research on eating disorders is still quite limited and far behind that for other psychiatric illnesses (eg, schizophrenia or Alzheimer disease), which have significantly lower prevalences than those of eating disorders.

There is great opportunity for discovery and room for important contributions to the field. The articles presented in this Special Report cover some major aspects of the topic as well as some lesser-known areas. I hope that these articles spark your interest in the subject and bring to your attention some of the challenges and opportunities that lie ahead as we continue to work towards eradicating eating disorders.

Articles in this Special Report:
 

• Family Therapy for Adolescents With Anorexia Nervosa
  James D. Lock, MD, PhD
• Pharmacological Treatment of Bulimia Nervosa
  Mary Ellen Trunko, MD and Walter H. Kaye, MD
• Purging Disorder
  Pamela K. Keel, PhD
• The Links Between PTSD and Eating Disorders: Diagnostic and Treatment Implications
  Timothy D. Brewerton, MD
• An Update on Pica: Prevalence, Contributing Causes, and Treatment
  Barton J. Blinder, MD, PhD and Christina Salama

References:

Reference

1. Clausen L. Time course of symptom remission in eating disorders. Int J Eat Disord. 2004;36:296-306.