Hidden eating disorders and the treatment gap

Abstract

The American Psychiatric Association' Diagnostic and Statistical Manual for Mental Disorders 2013 fifth edition (DSM-5 1) and the World Health Organisation' International Classification of Diseases 2019 eleventh edition (ICD-11 2) introduced two new feeding and eating disorders, namely Binge Eating Disorder (BED) and Avoidant/Restrictive Food Intake Disorder (ARFID). Neither are characterised by body image disturbance-a notable departure from the classic disorders, anorexia nervosa and bulimia nervosa. Two papers in this issue present reports on BED 3 and ARFID 4. The papers provide diverse and important new information and perspectives on the contemporary understanding of Eating Disorders. They reach from the community to the bedside and point to the importance of translational research. The analytic epidemiologic study by de Oliveira et al. 3 reported very high rates of restricted dieting (including fasting) and binge eating in university students. This is consistent with other international research which has found similarly alarming proportions of eating disorder symptoms in general population samples 5. These symptoms were also associated with a high body mass index (BMI), binge eating and, in particular, with poorer food choices 3. This association between problems of weight and of eating disorders is reflected in the known greater increase in both problems when they co-occur 6. The challenge for the future is how to develop appropriate interventions to prevent and to manage both problems. The second paper was a case study 4 that highlighted the newly described feeding and eating disorder, ARFID. ARFID is distinctive in that a fear of weight gain or body image disturbance is not merely not required, it is proscribed. The case is important as the misdiagnosis of anorexia nervosa lead to a delay in instituting appropriate therapy to address the anxiety around fear of swallowing. Both the papers thus highlight potentially severe physical health impacts of BED and ARFID, at respective "ends" of the BMI spectrum. Because of their recent recognition both may be mistaken for other problems or missed. The high prevalence of BED in particular is a concern as it is likely many people with BED do not realise they have a treatable eating disorder. Consequently, there is a large treatment gap with most people presenting for help over a decade after onset of symptoms or not presenting at all 7. The treatment gap had been extensively documented around the globe with many explanations proposed. These range from issues for people with disorders, such as poor access to care, poor eating disorder mental health literacy in those with problems and health care professionals, and pervasive stigma at all levels 7. A recent study 8 attempted to understand mechanisms behind the treatment gap and thus possible solutions. In a large general population study participants were asked a series of questions regarding their health care use and specific topics discussed during contemporaneous general practice consultations. In people with a