What is the role of psychiatry in eating disorders? I thought that was more or less talk/behavioral therapy plus close monitoring by internal medicine.
unfortunately, psychiatry in the US has largely abandoned eating disorders. The reasons for this are many:
1. there is a hierarchy of disorders in psychiatry, with "schizophrenia", autism, bipolar disorder and so on assuming special place, and eating disorders on the lowest rung
2. eating disorder patients are challenging to work with, have poor insight, and are help-rejecting
3. eating disorder patients are frightening to work with; anorexia carries the highest mortality of any psychiatric disorder
4. psychiatrists receive little to no training in eating disorder; in fact most residents receive none
5. eating disorders are seen as self-induced and the person's "fault"; even psychiatrists who should know better may harbor such biases
6. the treatments for eating disorders are not that great
7. eating disorders are often seen as less "biological" whatever the f that mean...; though there is likely a strong biological component and heritability to anorexia nervosa; certainly no less so than addictions which have successfully branded themselves as being diseases of brain (though they are not diseases at all)
8. eating disorders are seen as "western disorders"; in fact anorexia nervosa exists in some form in most cultures, including those not exposed to western culture
9. eating disorders have not the same parity as other mental disorders; in fact some insurances plans continue to exclude eating disorders
10. eating disorders are seen as disorders of affluence; yet they can be found across social strata
11. eating disorders are seen as disorders of modernity; anorexia nervosa has been described across history, it is an hysterical syndrome known in antiquity, though first described by william gull in its recent form
The most common role for psychiatrists in eating disorder treatment teams is relegated to drug pusher, such is the nature of contemporary psychiatry. Comorbidity is the rule, not the exception; and so treatment of depression, anxiety, PTSD, bipolar disorder etc will be managed by the psychiatrist. These comorbidities are often see as "low-hanging fruit" in the management of these complex patients. SSRIs can be effective in the treatment of bulimia, naltrexone in compulsive eating, and olanzapine may have a limited role in anorexia nervosa. topiramate has also been used in bulimia but i am no fan of topamax.
The second most common role for psychiatrists is leader of the multidisciplinary team (or at least medical director, if a psychologist is the leader). Because psychiatrists are physicians specializing in psychological medicine, they are best placed to integrate both medical and psychological aspects of care and to be the liaison with other medical doctors. They will manage risk (both physical risk and suicide risk), identify and treat other comorbidities, and ensure patients receive the appropriate care at the appropriate time (therapy is not going to be of much use in a patient with a BMI of 12 for example, food is the medicine they need first).
However there is no reason that psychiatrists could not take more of a role in psychological aspects of treatment. In fact, many of the treatments for eating disorders have been developed by psychiatrists. Christopher Fairburn is a psychiatrist at Oxford University who has pioneered the development of cognitive-behavioral treatments for eating disorders including bulimia, and binge-eating disorder. Janet Treasure is a psychiatrist involved in the development of maudsley based approach (a family therapy), as well as the use of motivational enhancement therapy for anorexia nervosa. Ulrike Schmidt is yet another psychiatrist who has developed psychological treatments for eating disorders, including self-help and online treatments to expand access to care. cognitive analytic therapy is yet another psychotherapy developed by a psychiatrist (anthony ryle) that has been used in treatment of anorexia.
oh and btw, as to your intimation that psychiatry has no role in (behavior) therapy: behavior therapy (systematic desensitization) was developed by Joseph Wolpe, a psychiatrist. Cognitive therapy was developed by Tim Beck, a psychiatrist. Mentalization-Based Treatment was developed by Anthony Bateman, a psychiatrist. Structural Family Therapy was developed Salvador Minuchin, a psychiatrist. Systemic Therapy was developed by Mara Palazzoli, a psychiatrist. Psychodrama was developed by Jacob Moreno, a psychiatrist. Interpersonal therapy was developed by Gerald Klerman, a psychiatrist (and a neo-Kraepelinian one at that). In fact, psychoanalysis is the only one of the major branches of psychotherapy (not counting third wave as its own branch) that was not developed by a psychiatrist. Freud was not a psychiatrist, but as Jung put it, "the neurologist who brought psychology to psychiatry."
