Evidence and perspectives in eating disorders: a paradigm for a multidisciplinary approach
Authors: Alessio M. Monteleone, Fernando Fernandez‐Aranda, Ulrich Voderholzer
Journal: World Psychiatry (2019)

The WPA Section on Eating Disorders is primarily concerned with the prevention of these disorders, the assessment of their psychopathology and psychiatric and physical comorbidities, the identification of pathways to specialist care, the organization of integrated multidisciplinary approaches to their management, and the promotion of information on evidence-based treatments and strategies to support caregivers and to facilitate treatment adherence and effectiveness. Eating disorders are complex mental diseases growing on a psychopathological core, i.e. the overconcern with body weight and shape in determining self-esteem, as recently confirmed through network analyses1. This psychopathological core also includes maladaptive perfectionism, impulsive traits, dysfunctional emotion regulation strategies, and social cognitive deficits, which lead to a number of abnormal behaviors ranging from extreme diet restriction to uncontrolled overeating with or without purging, vomiting and laxative or diuretic misuse, as well as excessive exercising. Anorexia nervosa, bulimia nervosa and binge eating disorder are the most well-known eating disorders, although other disorders have been included in the DSM-5. Eating disorder types differ in terms of lifetime prevalence and age at onset, but the peak age at onset of both threshold and subthreshold anorexia and bulimia nervosa occurs during adolescence. In this period, eating disorders are recognized as being the third most common chronic illness2. Moreover, they often co-occur with other psychiatric disorders, particularly anxiety and depression, over the lifespan. Hence, they have a considerable impact on personal, family, working and social life. On the other hand, treatment may promote recovery in 40-50% of adult people and higher percentages of adolescents3. Eating disorders are marked by a high rate of physical comorbidity4, with anorexia nervosa reaching the highest mortality rate of all mental disorders. This highlights the need for multiple levels of treatment, including outpatient facilities as well as rehabilitation and hospital units, depending on the severity of the clinical picture. In addition, a multidisciplinary approach, which includes access to physical, nutritional, psychological and psychiatric interventions, is recommended in order to achieve full recovery5. Psychiatrists with adequate training and expertise are in the best position to build links with general practice, medical/emergency wards, mental health settings and specialist services. They play a key role in coordinating other clinicians in both diagnosis and treatment processes. Unfortunately, the current access rate to specialized services is unsatisfactory. Possible reasons for this are the complexity of the pathways to care and the patients' ambivalence towards change or denial of their illness, but also some deficiencies in the transition between adolescent and adult mental health care. The relevance of this issue is higher in eating disorders than in other mental diseases, as there is evidence that early intervention, i.e. in the first three years, yields more favorable outcomes6. Trained mental health professionals are essential in addressing these problems through the promotion of educational programs for health care practitioners, which may facilitate knowledge and identification of the disorders, and through support to patients in their therapeutic engagement. For the latter purpose, offering shared decision-making and creating supportive environments may be particularly effective. The application of evidence-based treatments for these disorders is a critical area that needs to be pursued7, but therapeutic alliance has been identified as a non-specific therapeutic factor that significantly contributes to promoting recovery8. The relevance of family involvement is unquestioned, especially in adolescents. Family members are important in identifying the disorder and facilitating access to specialist care, particularly in youth. Hence, it is essential that psychiatrists provide them with appropriate support and information, reducing the fear and stigma associated with eating disorders. Furthermore, there is a need to promote prevention programs such as school-based interventions and e-health projects, although the settings and the means of delivery need to be further explored. In accordance with the staging model of eating disorders6, the persistence of the illness is associated with neurofunctional changes (especially with respect to reward learning habits) and social exclusion, which may contribute to the disorder evolving into a severe and enduring stage. These processes, as well as variables such as body mass index, binge-purging behaviors, interpersonal functioning, psychiatric comorbidities, family problems and motivation to recovery, need to be taken into account by psychiatrists and specialized mental health professionals in order to tailor treatment to the individual patient9. Although treatment guidelines provide specific parameters to assess the level of medical risk and hospital admission requirements, psychiatrists are advised to consider the current definition of eating disorder severity still in development. The WPA Section on Eating Disorders was founded in 2002 and includes 172 members. It organizes symposia and section meetings at WPA conferences in order to provide a multidisciplinary discussion of the most relevant research topics and clinical advances in the field. It also promotes research activities aimed to assess differences among countries in pathways to specialist care, choice of specialist treatments and organization of inpatient and outpatient facilities. The Section aims to disseminate knowledge on the clinical management of eating disorders among psychiatrists as well as psychologists, other specialist physicians, general practitioners and nurses, highlighting the crucial role that psychiatrists must play in the multidisciplinary approach to these complex mental disorders.