The effects of an acquired brain injury (“ABI”) are truly multi-faceted, ranging from dysexecutive syndrome, neuro-behavioural issues, to more obvious physical disabilities. It is well known t hat mental health issues and conditions can arise from acquired brain injuries; the well-known ones being depression and anxiety. However, what about Eating Disorders arising from ABI; is that possible and are they linked? Whilst there have been massive strides in the neurological sciences over the past half century or so, there is still much more we do not understand fully.

Eating disorders (which encompass conditions such as anorexia, bulimia, amongst others) are yet to be truly understood; it is still difficult amongst clinicians treating in this area what is often the best method to treat sufferers. The clinical studies and clinical treatment of eating disorders is still evolving; so what does one do when presented with an individual who has an ABI and has thereafter developed an eating disorder? The short answer is: it’s complicated. Treating eating disorders per se is phenomenally tricky and if it is compounded with someone who has an ABI, which can bring with it other co-morbidities associated with that, it makes for a very convoluted clinical mix and a huge challenge for those clinicians trying to treat the individual affected.

This article is not an attempt to go into ‘chapter and verse’ about ABI and eating disorders (primarily because the writer is not clinically trained) but is an attempt to bring more awareness and insight. The below shall provide a summary of what eating disorders are, with a focus on anorexia. There shall then be some brief insight into the interplay between ABI and eating disorders

What is an eating disorder?

An eating disorder is when an individual adopts an unhealthy attitude towards food. It does not necessarily mean eating too little, it can also involve eating too much, or being obsessive with one’s weight and body shape.

The goal of any intervention towards an eating disorder is to essentially[1] :

• Restore physical health
• Develop normal patterns of eating habits/attitudes;
• Reduce the impact of illness and day to day functioning.

The goal is fairly obvious but achieving it is not. For a start there a number of differing disorders[2] :

• Anorexia Nervosa – this condition involves where one tries to keep their weight as low as possible. Sufferers do this through not eating enough, excessive exercise or a combination of both.
• Bulimia – with this condition, sufferers lose control and binge eat before then being deliberately sick or using laxatives.
• Binge eating disorder – losing control of your eating by consuming large portions of food at once which leads to feelings of guilt
• Other specified feeding or eating disorder (OSEED) – this is where a sufferer does not have what classically fall under the above conditions but nonetheless have an issue.

The above conditions have differing approaches ranging from pharmacological to the psychological, or a combined approach of the two. The environment and setting of how such treatment is delivered can differ too and depends largely on the sufferer’s wishes, the availability of specialist services and the clinical presentation of the sufferer.

The impact of eating disorders should not be underestimated. As well as the personal impact on the individual and their families, it has wider social and economic connotations as well. PwC recently conducted research and prepared a report on the commission of the eating disorder charity, “BEAT”. That report estimated that the cost to UK society of eating disorders was circa £15 billion per annum, which is simply staggering.[3]

Eating disorders tend to affect the younger population and young females are the more prevalent group. One study found that there was mean incidence for anorexia, as an example, of 4 to every 100,000 in people aged 10-39 years.[4]  What is more disturbing, using anorexia again as a graphic illustration, is that anorexia is often reported to have the highest mortality rate amongst all of the psychiatric disorders.[5]

Focus on: Anorexia Nervosa

‘Anorexia Nervosa’ (or as it is commonly referred to with the general public, “Anorexia”) is a serious and debilitating condition.  Without effective and early intervention, it is widely reported and accepted that the condition can take root within the individual and they can suffer for many years.

To try and beat anorexia, it is important to understand what it is defined as. The World Health Organisation say that it involves: “A disorder characterized by deliberate weight loss, induced and sustained by the patient. It occurs most commonly in adolescent girls and young women, but adolescent boys and young men may also be affected, as may children approaching puberty and older women up to the menopause. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves. There is usually undernutrition of varying severity with secondary endocrine and metabolic changes and disturbances of bodily function. The symptoms include restricted dietary choice, excessive exercise, induced vomiting and purgation, and use of appetite suppressants and diuretics .” [6]

As one can see, this is not a simple definition which only demonstrates the complicated nature of the condition and in treating it.

Clinicians in this field accept that there is no strong research to suggest which treatment is the most effective. Treatments such as ‘re-feeding’ might be necessary and effective but isn’t proven to help beat it long term. The evidence on psychotherapy intervention and its benefits are also unclear.[7]  There is also debate as to what is a more appropriate environment to combat it: outpatient vs inpatient. Studies and outcomes have varied on the setting of treatment. One study reported that people with a longer duration of illness had a better chance of good outcome with longer duration of inpatient treatment.[8]  Whereas a different study found that continued inpatient treatment is no more effective and no safer than a short inpatient stay followed by outpatient appointments/treatment.[9]

What is evident though amongst the research studies and scholarly articles on this topic is the need for early intervention. Early intervention has been shown to be the most effective in limiting the impact of anorexia on the sufferer.[10]  It is also reported that extended follow up with the sufferer is essential to improving the outcome for the sufferer.[11]

We do not live in a perfect world though, so the likelihood that timely and long standing treatment is provided is not great. To illustrate this a study found that 47% of people recover completely, 34% improve, 21% develop a chronic eating disorder and 5% die from the condition. This study ultimately arrived at the finding that there was only limited evidence that the outcome of anorexia has improved significantly over the last half a century.[12]

ABI with an eating disorder

It is uncommon to find individuals who have sustained an ABI, with no previous history or risk factor for eating disorders, to then develop one post-accident. However, whilst it is uncommon, suffice to say, it does not mean it does not occur. The clinical community are aware of the link between ABI and eating disorders but it is perhaps not as clearly agreed or understood amongst them is how best to tackle it. There have been some reports and studies but it is understood that these are not vast by any stretch of the imagination. There is little data that exists which concentrates on food behaviour patterns with this cohort of sufferers.[13]  In one particular case study, the authors found that the cases “all had a frontal subcortical syndrome, expressed by neuropsychologic dysfunction, neuroimaging (frontal and basal ganglia lesions) and also as personality changes .” They went onto discuss how patients with cognitive deficits might not be affected by behavioural strategies to combat their eating disorder. They ultimately concluded the following: “the eating disorders in patients with traumatic brain injury may be present from early phases and persist years after the lesion….Eating disorders in the TBI patient should be approached and treated in a different way to a typical anorexia and bulimia taking into account the cognitive impairment caused by traumatic brain injury. Prospective studies are required to determine the importance of the different factors influencing eating behaviour of these patients. Results enable us to understand the course and progression of these disorders over time and establish appropriate medication for their control.”

The future

What is evident from the above is that field of eating disorders faces its own battles in understanding and tackling the competing factors, be it clinically, socially or even politically (with respect to funding). The added layer of an ABI into the mix, convolutes the picture further, what with insight and cognitive deficits.

This will be to some therapists and clinicians in the ABI field relatively new ground to them; therefore, it is difficult to say (even if one was from a clinical background) how to approach this. What can be said though is that input is almost certainly required between specialist clinicians practising in treating patients/clients with atypical ABI symptoms and with those from the Eating Disorder field. It is therefore of the utmost importance that, for instance, a case manager presented with such a client, considers specialist input from psychiatrists and clinicians from the eating disorder field. They will need to work in conjunction with those treating the typical symptoms arising from the ABI; the priority of treatment will undoubtedly be the eating disorder and without tackling that firstly, it may not lead to progress in tackling other areas such as the client’s cognitive deficits and associated behavioural issues.

Case managers, therapists and even legal practitioners practising in the ABI field, need to act quickly if there is an inkling that their client could have an eating disorder. Regular contact/communication with your client and their family should allow you to be alive to such situations. If such a situation does occur, then the case manager/legal team should consider arranging urgent discussions with those concerned in the care of the client; individuals with Eating Disorders may not accept that they have a problem and added with possible insight issues arising from a ABI, then this needs a careful approach so as not to disengage the client.

Acknowledgements

The writer would like to thank Dr Matthew Cahill, Consultant Psychiatrist specialising in General Adult and Eating Disorder psychiatry, for his help in advising of the relevant literature to consult and input into the article.

[1]  Lock JD, Fitzpatrick K “Anorexia nervosa”. BMJ Clin Evid. 2009.

[2]  https://www.nhs.uk/conditions/eating-disorders/

[3]  “The costs of eating disorders; social, health and economic impacts” BEAT, February 2015

[4]  Currin L, Schmidt U, Treasure J, et al. Time trends in eating disorder incidence. Br J Psychiatry 2005; 186:132-135. [PubMed]

[5]  Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psychiatry. 1998; 173:11-53

[6]  https://apps.who.int/classifications/apps/icd/icd10online2005/fr-icd.htm?gf50.htm+

[7]  Lock JD, Fitzpatrick K “Anorexia nervosa”. BMJ Clin Evid. 2009.

[8]  Kachele H for the study group MZ-ESS. Eine multizentrische studie zu aufwand und erfolg bei psychodynamischer therapie von e storungen. Psychother Med Psychol (Stuttg) 1999; 49:100-108.

[9]  Herpertz-Dahlmann B, Schwarte R, Krei M, et al. Day-patient treatment after short inpatient care versus continued inpatient treatment in adolescents with anorexia nervos (ANDI): a multicentre, randomised, open label, non-inferiority trial. Lancet. 2014;383(9924):1222-1229

[10]  Espia J; Eister I; “Focus on anorexia nervosa: modern psychological treatment and guidelines for the adolescent patient” Adolesc Health Med Thr; 2015; 6; p.6-16;

[11]  Steinhausen H “The outcome of anorexia nervosa in the 20th Century” Am J Psychiatry 2002; 159: 1284-1293

[12]  Steinhausen H “The outcome of anorexia nervosa in the 20th Century” Am J Psychiatry 2002; 159: 1284-1293

[13]  Castano, B, Capdevila, E; “Eating disorders in patients with traumatic brain injury: A report of four cases.” Neurorehabilitation; 2010;vol.27 (no.2); p.113-116.

This article first appeared on the Brain Injury Group website.