I know you are busy, with time pressures, targets and a never ending onslaught of patients and tasks. I know your day is 12 hours long, lunch breaks are rare and expectations high. I suspect that often, in the pecking order, mental health isn’t always up there as the most important (or deserving) of your time and attention. Eating disorders are not that common, and if we’re honest, often viewed as self induced or self indulgent. And do you really have time to learn about something you’ll encounter infrequently and that will only create more work if you do recognise it? So, as someone who received an eating disorder diagnosis (and treatment) ten years later than I should have, here are my thoughts on how valuable you are, and how you can help:
Treat the person with with genuine respect (even if you’re frustrated). People with eating disorders often present frequently in primary care with vague complaints. This can be frustrating. Try to keep in mind that they are often careful, caring people who may well be spending huge effort masking symptoms in order to prevent others from worrying. They may be functioning to a high degree at work or home, in spite of extreme tiredness and intrusive thoughts that frequently leave them feel rubbish and undeserving.
See the person, not the diagnosis. Don’t dismiss physical symptoms and assume these are automatically related to low weight or purging. If you do think this is the case, explain this carefully. Sometimes someone may see you several times with the same symptom, and yes, it’s irritating, but (respectful) repetition of the facts might be slowly chipping away at someone’s denial until one day, something clicks. You might have played a bit part in that process.
Give them a diagnosis if they need one. Don’t do what my GP did in the 1990’s, and send a fourteen year old girl with a BMI matching her age away with the message that she needs to “eat more cream cakes”. I hope things have moved on since then. Sometimes, diagnosis means access to treatment which can be life saving or at the very least life changing. It can be validating to have thoughts and behaviour which feel confusing taken seriously and named.
Monitor weight – but ASK before you share the numbers. Weight is a sensitive issue, however it needs to be faced, and if it’s falling, this needs to be noticed. BUT – being asked whether or not I wanted to know my weight, helped me to feel that my GP sort of ‘got’ how stressful I found the process of being weighed. And that made me more willing to share other things I felt ashamed of.
Know the referral criteria for local services. And have the compassion and tenacity to fight for someone to be assessed, if in your clinical judgement, they need it. Knowing how to identify eating disorders, particularly in ‘non-stereotypical’ groups (men, older women) and helping a person to access help fast, might make the difference between catching a problem early and full recovery, or the condition becoming entrenched and chronic. And being cold and hard about it, chronic eating disorders bring a myriad of other health issues, which mean a higher burden on your budget in the long term.
Take the person seriously. Patients with eating disorders have often had experiences of being repeatedly dismissed by others. If all you are able to do, is avoid repeating that cycle, you will have done something valuable. Eating disorders come with real health risks, and low weight isn’t the only marker of this. Purging is dangerous. Laxative abuse is dangerous. Mood can be low. There is a heightened risk of suicide for this group, and they aren’t necessarily going to volunteer relevant information without being asked. Refer on, where possible and give the person the opportunity to have their needs more fully assessed.
Don’t make subjective comments about weight or appearance. Not at ANY point. The eating disorder mindset can twist absolutely anything. Even ‘you look well’ can be misconstrued. Even if someone has gained weight and looks ‘better’, a comment is unlikely to be received positively. Instead, you could recognise effort, motivation, determination. It sounds petty but it is a powerful thing and fear over ‘weight comments’ can definitely be a barrier to engagement.
My experience with one particular GP prompted me to write this. She referred me quickly, was encouraging and highly respectful, and managed to convey a sense that she was rooting for me. It helped. A lot. As GP’s, you are valuable, you matter, and you can make a real difference. For those of you who already do, thank you!
See here for a GP’s guide to eating disorders. It’s only short, please read it.