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The Royal College of Psychiatrists Improving the lives of people with mental illness

Eating disorders psychiatry

Background to eating disorders psychiatry

As eating disorders typically start in adolescence, eating disorder psychiatry can involve working with children and adolescents or with adults with anorexia nervosa, bulimia nervosa or binge eating disorder. Many eating disorder patients have other psychological difficulties or disorders such as anxiety, depression, obsessive compulsive disorder or personality disorders. Physical complications and disabilities are common.

The opportunities and challenges of working with eating disorder patients include:

  1. To be able to build a good therapeutic relationship with young people who, at the point of referral, may have little understanding of the serious nature of their condition and no desire to change. To help young people with eating disorders build motivation for change.
  2. To safely assess and manage medical risk and physical complications. This requires sound skills in physical medicine and expertise in nutritional health and medical aspects of starvation and refeeding. 
  3. To work with different psychological models and therapies (individual and family) appropriate to the development and needs of the person, given the nature of their eating disorder and any presenting comorbid disorders.
  4. To teach families skills for supporting loved ones with eating disorders. 
  5. To work with people with long-term impairments and disabilities to keep them safe, prevent decline, and support their quality of life.

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Personal perspective one

Imagine having a major argument with your skeletally thin child at every meal of every day over whether she will eat a minute portion of food. Imagine lying awake every night, wondering whether she will die, as she is so painfully thin, so pale and visibly cold with blue fingers, and getting weaker, with increasing difficulties in getting up the stairs.

Imagine feeling so bad about yourself that you simply want to disappear. You don’t deserve to eat, as you are weak, defective, inferior, worthless… and only when you starve you feel that you are doing something that is worthwhile, that gives you a sense of being in control, worthy or safe. You cannot understand at all why your parents are so worried.

If you can hold these diametrically opposed positions in your mind, you have a good idea of the challenge of working with eating disorders - helping young people and their families to turn round from a situation that seems to be progressing inexorably in the direction of death and destruction. This involves working with the young person towards overcoming anorexia and aiming for a bigger life and teaching the parents the skills to support their daughter’s recovery.

I went into eating disorders psychiatry by accident, having worked in general and liaison psychiatry for some years, but I immediately knew that I had finally found my niche. What I enjoy about working in eating disorders is that it requires knowledge and skills in many different areas (e.g. knowledge in child and adolescent development, nutritional medicine and the neurobiology of hunger, satiety and emotion, expertise in different psychological treatment modalities, and sound diagnostic skills.) Thus, you will never get bored and you are always on a steep learning curve. You have got to be very flexible and be able to switch between the different mindsets required for dealing energetically with acute medical or psychiatric emergencies, being reflective and conducting or supervising psychological therapy with individuals and families to enable recovery, and working at a slower pace with people with long-term impairments and disabilities to keep them safe, prevent decline and support their quality of life.

Early intervention is critical for good long-term outcome of eating disorders. So in this field, if you catch the problem early, you can make a real difference to patients’ lives, helping young people to overcome a devastating illness and fulfil their potential.

There is also a lot of advocacy, anti-stigma, educational work to be done in eating disorders. Sadly, even health professionals are not free from prejudice against eating disorders as ‘self-inflicted’ disorders, whereas the reality is that these are severe biologically driven disorders.

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Personal perspective two

I trained in Cape Town, South Africa, and worked as a house officer at Groote Schuur Hospital (the world’s very first heart transplant was undertaken there by Professor Christian Barnard in December 1967). I can still recall the look of horror on the face of my then consultant, Professor of Haematology, when he asked what I was planning to do with my career and I boldly informed him, standing within such an esteemed medical and surgical establishment, that I planned to study Psychiatry in England. That was 12 years ago and I certainly do not for one moment regret my decision. 

Psychiatry has allowed me to find fulfilment far beyond being able to correctly recite the exact anatomical position of the Flexor Digiti Minimi muscle. I feel privileged to be able to be of assistance to people in times of psychological distress and to be trusted by them to know their most intimate and private thoughts. It is immensely fulfilling to be able to empower people to overcome their difficulties and often this is achieved without any intervention other than truly listening to them, being empathic and providing support and guidance. I do not deny that at times it is an extremely challenging field in which to work. I was not-so-gently reminded of this as an inexperienced senior house officer when I was hit over the head by a walking stick-yielding little old lady with dementia who objected to taking the medication I had prescribed for her.   

Indeed, I do feel fulfilled currently working as a staff grade doctor at the Yorkshire Centre for Eating Disorders in Leeds. In addition to readily assuming increasing clinical responsibility, I am also passionate about medical education and teaching. I enjoy having weekly teaching sessions with the Leeds medical students during their psychiatric placements. Following obtaining my Masters in Clinical Psychiatry (Leeds), I find myself once again possessing a student card (the shop discounts are just so appealing!); this time though I am studying for a degree in Medical Education. Simultaneously, I am pursuing accreditation in a specific form of psychotherapy relevant to the field in which I work, and will soon be functioning as a therapist within the multidisciplinary team in addition to my current role,.

I truly believe that, despite being a doctor, it is possible to have a fulfilling career and having a good quality of life. It is after all one of the most important factors in maintaining one’s own mental health! I congratulate my consultant colleagues on their hard work and the burden of responsibility that they bear all day, every day. I, however, enjoy supporting the work undertaken by a multidisciplinary team, assuming appropriate clinical responsibility but also being able to go shopping without a care in the world in addition to my current role.

Monique Schelhase, staff grade in eating disorders,
Leeds Partnerships NHS Foundation Trust.

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