Detection of anorexia nervosa in primary care

Abstract

In the years preceding diagnosis, individuals with anorexia nervosa (AN) attend more primary care appointments than their peers. Primary care physicians (PCPs) may be uniquely situated to detect AN in early manifestations. In this study, a sample of physicians was recruited online. Videotaped vignettes of a primary care appointment were shown to these participants, who were asked to diagnose the patient and could make a referral. 61.2% of participants identified an eating disorder (ED) diagnosis. However, of those, only 40% intended to refer for therapy. These findings suggest that the rate of referral to mental health is problematically low among PCPs.

Full text

Detection of anorexia nervosa in primary care
Ashley Higgins
a
and Stacey Cahn
b
a
Department of Psychology and Counseling, Immaculata University, Immaculata, PA, USA;
b
Clinical
Associate Professor of Psychology, Wellness Center, Rowan University, Glassboro, NJ, USA
ABSTRACT
In the years preceding diagnosis, individuals with anorexia
nervosa (AN) attend more primary care appointments than
their peers. Primary care physicians (PCPs) may be uniquely
situated to detect AN in early manifestations. In this study, a
sample of physicians was recruited online. Videotaped vign-
ettes of a primary care appointment were shown to these
participants, who were asked to diagnose the patient and
could make a referral. 61.2% of participants identified an eating
disorder (ED) diagnosis. However, of those, only 40% intended
to refer for therapy. These findings suggest that the rate of
referral to mental health is problematically low among PCPs
Clinical Implications
●While individuals with eating disorders are likely to seek treatment from
their primary care physician, these providers are ill-equipped to provide
adequate care.
●The rate of referral for eating disorders remains low among primary care
physicians who are aware of the eating disorder.
In the current edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), anorexia nervosa (AN) is defined as an intense fear of gaining
weight, a refusal to maintain a healthy bodyweight,andanoverevaluationofshape
and weight (APA, 2013). While AN is relatively rare, it is a serious condition with
the highest mortality of any psychological disorder (Hoek & Van Hoeken, 2003).
Clearly, individuals with AN represent a high-risk and high-needs population.
Unfortunately, these patients’needs often go unmet. Successful treatment of
AN can take as long as a decade (Zipfel, Lowe, Reas, Deter, & Herzog, 2000).
Current medication and psychotherapies have limited success in treating AN,
especially if treatment begins more than 3 years after the onset of symptoms
(Treasure & Russell, 2011). It is estimated that only half of individuals with AN
achieve full remission of symptoms, and even recovered patients typically have
CONTACT Ashley Higgins ahiggins@immaculata.edu Psychology and Counseling, Immaculata University
College of Graduate Studies, 294 Iven Avenue Apartment 2D Wayne, PA 19087, USA.
EATING DISORDERS
2018, VOL. 26, NO. 3, 213–228
https://doi.org/10.1080/10640266.2017.1397419
© 2018 Taylor & Francis

chronic medical and psychiatric complications (Novotney, 2009). Given that years
of treatment outcome studies have yielded lacklustre outcomes for patients with
AN, it has been recommended that, rather than conducting additional clinical
trials, research on prevention of AN should be a priority (DeSocio, O’Toole,
Nemirow, Lukack, & Magee, 2007; Halmi et al., 2005).
Early detection and intervention are key components to successful prevention
of an eating disorder (ED), in terms of ‘prevention of chronicity, with its
associated high morbidity and mortality’(Halmi et al., 2005,p.780).Early
detection/intervention of EDs can be associated with lasting positive outcomes,
even with relatively brief interventions (Becker, Bull, Schaumberg, Cauble, &
Franco, 2008; Fairburn, Walsh, Agras, Wilson, & Stice, 2004; McVey, Gusella,
Tweed, & Ferrari, 2008; Stice, Marti, Spoor, Presnell, & Shaw, 2008; Stice &
Shaw, 2004). While some eating detection/prevention efforts focus on schools or
the Internet, some writers have indicated that the primary care setting as be the
ideal place to detect AN (Keski-Rahkonen et al., 2007), as primary care physi-
cians (PCPs) often have access to long-term information about a patient’s weight
and general medical well-being. Individuals with AN attend more primary care
appointments in the 5 years prior to their diagnosis than the average patient,
which suggests that PCPs have opportunities to detect AN in a subclinical form
(Chamay Weber, Haller, & Narring, 2010).
However, detecting symptoms of AN in the primary care setting is difficult
duetolackoftime(seeKates&Craven,1998) and that patients do not readily
self-disclose their ED symptoms, while perhaps voicing vague complaints of
dizziness, constipation, and/or fatigue (Pritts & Susman, 2003;Williams,
Goodie, & Motsinger, 2008). Patients with AN often disguise their symptoms
so effectively that their eating pathology can go undetected for some time (Pritts
& Susman, 2003; Wein & Foord-May, 2009). Since patients with AN are unlikely
to spontaneously self-disclose eating problems (Vandereycken, 2006), effective
screening by PCPs is crucial. However, in a national survey of physicians
intended to examine self-perceived knowledge, skills, and needs around ED
screening and intervention strategies, the majority of surveyed physicians (68%)
reported that they do not screen for EDs unless the patient brings up eating/
weight as a presenting concern (Linville, Brown, & O’Neil, 2012); these physi-
cians indicated fears of patient defensiveness or being unsure what questions to
ask. When patients do not volunteer the information and physicians do not ask,
early diagnosis of AN in unlikely.
Another issue is that psychological, physical, and demographic variables influ-
ence the likelihood of diagnosing AN, such as race/ethnicity (Becker, Arrindell,
Perloe, Fay, & Striegel-Moore, 2010; Becker, Franko, Speck, & Herzog, 2003),
weight status (see Linville et al., 2012), and gender (Currin, Schmidt, & Waller,
2007;Hugo,Kendrick,Reid,&Lacey,2000). In terms of race/ethnicity, qualitative
research has found that, among actively symptomatic African–American indivi-
duals with EDs, their PCPs ‘had dismissed or disregarded symptoms of an eating
214 A. HIGGINS AND S. CAHN

disorder, apparently because they did not expect them in an African American
patient’(Becker et al., 2010, p. 641). Similarly, Latina adolescents with EDs
reported that they had infrequently or never been screened for eating pathology
by their PCPs (Becker et al., 2003). In terms of weight status, close to 60% of
surveyed PCP
S
indicated they would not think to assess for an ED unless the
patientwasunderweight(Linvilleetal.,2012); this would prevent early detection of
patients with AN. Gender of the patient can also impact the likelihood of an ED
diagnosis; researchers have developed vignettes of fictitious patients with AN and
otherEDsandsubmittedthemtoPCPs.Forinstance, a sample of family physicians
fromtheUnitedKingdomwereaskedtoreadtwovignettesdepictingEDsymp-
toms and make a diagnosis; the authors provided a list of mental health diagnoses
for the participants to select (see Currin et al., 2007). The authors also varied the
gender of the patient in the vignette. When the vignette patient was male, physi-
cians were more likely to assign a diagnosis of depression than an ED diagnosis.
EDs of any kind were diagnosed less than 70% of the time, but the ED diagnosis
was most often applied to a female vignette patient. Gender of the PCP may also
impact diagnosis, as female PCPs appear more attuned to the early symptoms of
AN (Hugo et al., 2000).
Finally, even when AN or other EDs are properly diagnosed in primary
care, rates of referral to mental health services remain problematically low, at
around 50% (Green, Johnston, Cabrini, Fornai, & Kendrick, 2008). Instead of
referring to mental health, PCPs tend to offer follow-up appointments to
patients, perhaps reflecting a ‘watchful waiting’approach (Currin, Waller, &
Schmidt, 2009). However, this approach is not nearly aggressive enough for
the majority of individuals with AN, who require more active management
from a multidisciplinary team (Linville, Benton, O’Neil, & Sturm, 2010).
Purpose of this study
Given the difficulty faced by many PCPs in assessing AN, vignette research has
been utilized in order to better understand how PCPs fail to detect AN (e.g. Currin
et al., 2007;Greenetal.,2008;Hugoetal.,2000). These studies, which have all used
written vignettes, have identified a number of patient demographic variables (e.g.
gender and race/ethnicity) and physician demographic variables (e.g. gender) that
affect the likelihood of diagnosing AN. This study aimed to expand upon these past
research findings with videotaped vignettes, and the use of a new format for the
vignettesisintendedtoprovidegreaterecologicalvalidityasthePCPswillbeable
to see the underweight status of the ‘patient’and ways in which the patient presents
as hesitant or anxious during the vignette. In addition, this study proposed two
new demographic variables that are expected to affect the likelihood of diagnosing
AN. These new variables include one participant variable (years of medical
experience) and one patient variable (history of treatment for an anxiety disorder).
EATING DISORDERS 215

In examining physician’s years of experience, very little is known about the
training on EDs provided during medical school, which likely varies from
school to school. It is possible that ‘most primary care doctors have had
minimal training in psychiatry, possibly no more than a few short weeks in
medical school’(Ruiz & Primm, 2009, p. 67); this refers to psychiatry as a
whole, leaving very little time for covering the specifics of ED treatment. At
the level of residency, a survey of 113 internal medicine programs found that
only three offered a scheduled rotation on EDs, with 13 additional programs
offering an elective rotation in EDs; in most cases, these rotations had a
duration of one month or less (Mahr et al., 2015); in addition, these internal
medicine programs offered an average of less than 2 hours of didactics on
EDs. Similarly, in a study of 150 internal medicine residency programs,
85.3% of respondents reported they had received 5 hours or less of training
on EDs (Girz, Robinson, & Tessier, 2014). Thus, if medical schools and
residency programs are not providing adequate training on EDs, it is more
likely that any proficiency in assessing and diagnosing EDs such as AN
would need to occur after residency. In addition, given the low prevalence
rate of AN, more experienced physicians, would be more likely to have
encountered multiple patients with AN in their practices.
In terms of the patient variable (history of anxiety disorder), many indi-
viduals with AN have a prior history of clinically significant anxiety (Halmi,
2009). Epidemiological research indicated that, among individuals with AN,
one or more anxiety disorders are present prior to the ED in the majority of
cases (Godart, Flament, Lecrubier, & Jeammet, 2000; Godart, Flament,
Perdereau, & Jeammet, 2002; Kaye, Bulik, Thornton, Barbarich, & Masters,
2004), with twin research suggesting a genetic link that accounts for vulner-
ability to both early anxiety and later eating pathology (Silberg & Bulik,
2005).
Data analysis was intended to address the following hypotheses. In keeping
with past research, it was expected that the demographics of the vignette
patient will impact the frequency of AN diagnosis. Specifically, it was
hypothesized that AN will be diagnosed less frequently in the Asian
American patient. Another patient variable that was expected to influence
the diagnosis of AN is whether the patient has a history of a psychological
disorder. In the current study, it was expected that a prior diagnosis of an
anxiety disorder would make a PCP more attuned to psychological disorders,
and thus be associated with a higher diagnosis rate for AN. Physician
demographics were also expected to affect the diagnosis of AN. Female
PCPs were expected to diagnose both EDs and other psychological disorders
at a higher rate than their male counterparts. Furthermore, experienced
physicians were expected to diagnose EDs and other psychological disorders
at a rate higher than that of less experienced physicians.
216 A. HIGGINS AND S. CAHN

Methods
Participants
Physicians and residents working in primary care were recruited as participants
(N= 181) for this research through social media, national listservs, recruitment
emails, and recruitment flyers posted at local medical schools in the Philadelphia
area; the combination of local flyers and online recruitment was intended to
promote greater external validity to the results, though, of note, we did not ask
participants to identify their location or current hospital affiliation. Due to missing
or incomplete data, the responses of 21 participants were eliminated from data
analysis, leaving a final N= 160; for instance, a participant watched the vignette but
did not respond to all survey questions such as the demographic questions, which
were not marked as required questions on SurveyMonkey. Most of the participants
were residents (n= 130) in their first 3 years of postdoctoral training (residency).
Among the physician participants, most had been working in primary care/family
medicine for at least 4 years (M=4.30, SD = 6.75). The average age of the sample
was 32.32 years (SD = 8.76). The racial/ethnic composition of the sample was
largely White/Caucasian. Participant demographics are outlined in Table 1.
Vignette development
The vignettes were designed to include pathophysiological and behavioural
indicators of AN that are consistent with the current evidence base,
Table 1. Demographic statistics.
Demographic Frequency Percent
Gender
Female 90 56.30
Male 69 43.10
Other 1 0.60
Age
24–29 89 55.60
30–39 48 30.00
40–49 13 8.10
50–59 5 3.10
60+ 5 3.10
Ethnicity
White/Caucasian 105 65.60
African–American 4 2.50
Hispanic 10 6.30
Asian American/Pacific Islander 27 16.90
Native American 1 0.60
Middle Eastern 5 3.10
Biracial 8 5.00
Resident
Post-graduate year 1 51 31.90
Post-graduate year 2 38 23.80
Post-graduate year 3 40 25.00
Post-graduate year 4 1 0.60
Physician 30 18.80
EATING DISORDERS 217

including: (a) rapid weight loss and current underweight status (a diagnostic
criterion for AN; American Psychiatric Association, 2013), with a reported
weight of 102 pounds/46 kg, which is underweight at any height equal to or
above 63 inches/160 cm (b) low blood pressure and pulse (Beers & Berkow,
2011), (c) hesitation before being weighed (Pritts & Susman, 2003), (d) low
body temperature (Buckelew, 2007), (e) long-term participation in sports
(Sanford-Martens, Davidson, Yakushko, Martens, & Hinton, 2005), (f) irre-
gular menstruation (American Psychiatric Association, 2013), (g) constipa-
tion (Zipfel et al., 2006), (h) not wanting to be touched on the stomach
(Espeset, Gulliksen, Nordbø, Skårderud, & Holte, 2012), and (i) cold extre-
mities (Buckelew, 2007). The vignettes were reviewed by three independent,
doctoral-level psychologists with specialty training and expertise in EDs.
Four vignette conditions were filmed. In all four conditions, the patient was
female. Vignette 1 featured a White/Caucasian patient with no mental health
history, and Vignette 2 featured an Asian American patient with no mental
health history. Vignette 3 featured a White/Caucasian patient with a pre-existing
anxiety disorder, and Vignette 4 featured an Asian American patient with a pre-
existing anxiety disorder. To ensure consistency in delivery and portrayal across
vignettes, the same three doctoral-level psychologists with specialty training in
EDs reviewed the vignettes prior to the start of data collection.
CBC and lipid panel values
This study is also unique in providing the participants with the ‘patient’s’results
from a complete blood count (CBC) and lipid panel. The inclusion of blood
work results was intended to enhance ecological validity by offering participants
a more complete picture of the patient’s general health. The blood work pre-
sented to participants did not vary across conditions. The CBC results presented
in this study were based on values obtained from two previous research studies
investigating patients who had been engaging in disordered eating for
10–17 months (Karczewska-Kupczewska et al., 2010; Misra et al., 2004). The
participants across the two studies were similar in age, BMI, and duration of
illness, so the lab results were integrated for this study.
Vignette actors
Individuals were recruited from the Philadelphia College of Osteopathic Medicine
campus to participate as actors in the vignettes. The same ‘PCP’actor and ‘nurse’
actress appeared in all four vignettes. The PCP actor and nurse actress self-
reported normal body weights. The same Caucasian actress was featured in
Vignettes 1 and 3. Similarly, the same Asian American actress was featured in
Vignettes 2 and 4. Both actresses playing the patient in the vignettes had body
weights consistent with what was reported in the vignette (102 pounds/46 kg,
218 A. HIGGINS AND S. CAHN

which is underweight at most adult heights) and appeared very slender in build.
All actors followed a script, which, as mentioned previously, was reviewed for
consensual validity by a panel of three psychologists with expertise in treating EDs.
All actors were compensated for their time. The vignettes were filmed in an
academic building on the Philadelphia College of Osteopathic Medicine, with
care taken to replicate the appearance of a doctor’s office.
Procedure
After reading the recruitment flyer, interested participants followed the pro-
vided link, which brought them to the study materials on SurveyMonkey.com.
All study procedures were conducted online, and were approved by the
Institutional Review Board at Philadelphia College of Osteopathic Medicine.
Participants completed the consent procedure and then watched a vignette.
SurveyMonkey.com has a random assignment feature, so each participant had
an equal chance of viewing each of the four vignettes, thus creating four
groups. While having participants watch multiple vignettes could be illuminat-
ing in examining within-subject differences in responses, it was the intention
of the authors to limit the time needed to participate in this study to less than
15 minutes, due to concerns about fatigue/incomplete data. After watching the
vignette, participants viewed a report of the patient’s blood work.
After reviewing this information, the participants were asked to diagnose
the patient in a free-response format, such that participants could type in one
or multiple diagnoses; since it can be difficult to diagnose a patient through a
vignette, the intent of the free-response format was to give the participants an
open format to hypothesize and indicate rule-outs, since they do not have the
opportunity to ask the patient questions to obtain more information. Next,
participants had the option of making a referral to another specialist. Finally,
participants entered their demographic information, including their email
addresses. Participants had the option of providing their email addresses so
that they could be entered into a $150 Amazon gift card raffle. Please see
Figure 1 for a summary of the procedure.
Data analysis plan
For this study, the ideal correct participant response would have been a
stand-alone diagnosis of AN. Participants were presented with the question
of diagnosis in a free-response format; thus, their responses would need to be
coded as ‘AN’(meaning an accurate diagnosis) or ‘MissedDx’(an incorrect
diagnosis). After reviewing the data, responses indicating an ED (but not
specifying which one) and responses indicating ‘female athlete triad’were
also considered correct responses (‘AN’). In addition, if the participants listed
multiple diagnostic possibilities within the free-response textbox and one of
EATING DISORDERS 219

Consented and
randomized
(n = 180)
Assigned to
Vignette 1:
White/Caucasia
n patient with
no mental
health history
Viewed blood
work
Diagnose and
refer (optional)
Demographics
questionnaire
Assigned to
Vignette 2:
Asian American
patient with no
mental health
history
Viewed blood
work
Diagnose and
refer (optional)
Demographics
questionnaire
Assigned to
Vignette 3:
White/Caucasia
n patient with
history of
mental health
treatment
Viewed blood
work
Diagnose and
refer (optional)
Demographics
questionnaire
Assigned to
Vignette 4:
Asian American
patient with
history of
mental health
treatment
Viewed blood
work
Diagnose and
refer (optional)
Demographics
questionnaire
Figure 1. Procedure and randomization.
220 A. HIGGINS AND S. CAHN

their listed diagnoses was an ED, this was coded as ‘AN+.’Responses of
participants who did not identify an ED concern were coded as MissedDX.
These diagnoses were examined to discern whether they were reasonable
given the symptoms portrayed in the vignette, and all of the diagnoses
provided by the MissedDx group were consistent with one or more of the
nine pathophysiological and behavioural indicators; this served as a validity
check, to ensure that the participants were listening carefully while watching
the vignettes and were not randomly responding. This coding created cate-
gorical variables that can be analysed via chi-square analyses. For examples of
responses that were coded as AN, AN+, and MissedDx, refer to Table 2.
Results
One of the ‘correct’possible responses for the ‘AN diagnosis’was listed as a sole
diagnosis by 40.60% of the sample. An additional 20.60% of participants listed one
of these three correct responses but also listed one or more accompanying medical
diagnoses, such as hypothyroidism or irritable bowel syndrome (AN+ diagnosis).
The remaining 38.75% of the sample assigned non-ED-related medical diagnoses
to the vignette patient, including hypothyroidism, irritable bowel syndrome, celiac
disease, amenorrhea, and pregnancy (MissedDx). Therefore, 61.30% correctly
detected AN/AN+.
Effect of patient ethnicity and anxiety disorder history
A chi-square analysis was run to determine whether patient ethnicity or
history of an anxiety disorder impacted the likelihood of receiving a diag-
nosis of AN/AN+. There was no difference found across the four vignettes, χ
2
(3) = 2.20, p= .53.
Table 2. Examples of coding for AN/AN+.
Coding Examples of Acceptable Responses
“AN”anorexia nervosa
eating disorder
some sort of eating disorder
female athlete triad
“AN+”eating disorder plus irritable bowel
anorexia nervosa plus thyroid problem
eating disorder plus chronic constipation
anorexia nervosa plus gastrointestinal distress
“Missed Dx”possible pregnancy
amenorrhea
chronic constipation
thyroid problem
irritable bowel
EATING DISORDERS 221

Effect of physician gender
A separate chi-square analysis was run to determine whether female
physicians were more likely to diagnose the patient with AN/AN+. The
resulting chi-square approached statistical significance, χ
2
(1) = 3.31,
p= .07. This result indicates a trend in which female PCPs were more
likely than male PCPs to diagnose the vignette patients with AN/AN+.
Finally, it was expected that more experienced physicians (i.e. post-resi-
dency physicians) would have a higher detection rate for AN/AN+. A chi-
square analysis comparing the residents and physicians was not signifi-
cant, χ
2
(1) = 0.23, p=.63.
Incorrect diagnoses
As stated previously, 38.75% of the participants (MissedDx) failed to
correctly diagnose the vignette patient. Within the MissedDx group
(n= 62), most of these participants diagnosed the patient with a repro-
ductive condition, such as amenorrhea, oligomenorrhoea, dysmenorrhea,
or pregnancy (n= 31, 19.40%). In addition, some participants diagnosed
the vignette patient with a thyroid condition (e.g. hypothyroidism;
n= 12, 7.50%), a gastrointestinal condition (e.g. irritable bowel syn-
drome or celiac disease; n=8,5%),abnormalvitals(e.g.lowblood
pressure or low body temperature; n= 6, 3.80%), psychiatric symptoms
(e.g. anxiety or anhedonia; n= 2, 1.30%), or stated that the patient was
healthy (n= 3, 1.90%). The incorrect diagnoses provided by the
MissedDx group appear in Table 3.
Referrals
Participants also had the opportunity to make a referral. Among the participants in
this study who diagnosed the patient with AN (n= 65), 44.60%, referred to
psychiatry/psychology. Among participants who diagnosed the patient with AN
+(n= 33), only 27.27%, referred to psychiatry/psychology. When the AN and AN
+ groups are combined, just 39.17% of the participants reported that they would
provide a referral to psychiatry/psychology. The rate of referral to mental health
Table 3. Frequency counts for diagnoses within MissedDx group (n=62).
Diagnosis Frequency Percent
Reproductive condition 31 19.40
Thyroid condition 12 7.50
Gastrointestinal condition 8 5.00
Abnormal vitals 6 3.80
No diagnosis –healthy patient 3 1.90
Psychiatric symptoms 2 1.30
222 A. HIGGINS AND S. CAHN

was the most frequent referral made, followed by referrals to OB/GYN (10%),
endocrinology (4.50%), and gastroenterology (3.60%).
Exploratory analyses
Exploratory analyses were conducted to determine what, if anything, was
associated with a diagnosis of AN/AN+ in the vignettes. First, a chi-square
analysis comparing the participants’ethnicity (dichotomized as White/
Caucasian vs. non-White) was run and was found to be statistically signifi-
cant, χ
2
(1) = 7.55, p< .01, φ= .21. White/Caucasian participants were more
likely to correctly diagnose the patient with AN/AN+ (45.0%) as compared to
non-White participants (16.3%).
Next, a chi-square analysis (a 3×2×2 crosstabulation) was used to compare
patient ethnicity in the vignettes (White/Caucasian vs. Asian American),
participant ethnicity (White/Caucasian vs. non-White) and diagnosis. This
analysis was statistically significant χ
2
(1) = 4.87, p< .05, φ= .23. In the two
vignettes which featured a White/Caucasian patient, a correct diagnosis of
AN/AN+ was significantly more likely if the participant was also White/
Caucasian (25.63%) as opposed to non-White/Caucasian (8.75%). These
results are displayed in Table 4.
Discussion
The results of this study are intended to discover how physicians might
diagnose and refer patients portraying the symptomatology of AN.
Physicians in this study correctly identified the AN/AN+ only 61.30% of
the time, with the remaining 38.75% incorrectly diagnosing the patient.
While these findings are consistent with past research using written vignettes,
it is problematic that close to 40% of participants could not identify any
eating pathology in the patient. If patients are not identified as having an ED,
this delays treatment, which then reduces the likelihood of success for that
treatment as the ED continues to become more and more entrenched over
time. The use of videotaped vignettes was intended to provide more ecolo-
gical validity and more visual information about the patient, which would
Table 4. Crosstabulation of physician ethnicity, patient ethnicity, and diagnosis.
Ethnicity AN/AN+ MissedDx χ
2
pΦ
Vignettes with White/Caucasian patient
White/Caucasian Physician 41 17 4.87 < 0.05 .23
Non-White Physician 14 16
Vignettes with Asian American Patient
White/Caucasian Physician 31 16 2.19 ns ns
Non-White Physician 12 13
EATING DISORDERS 223

increase the likelihood of receiving a primary AN diagnosis. PCPs may
struggle to detect AN whether they see the patient in person, watch the
patient in a video, or read about the patient.
In addition, physician demographic variables (e.g. gender and years of
experience) and patient characteristics (e.g. ethnicity and history of an
anxiety disorder) were expected to impact the rate of diagnosis for AN, but
this was also not supported by the data. Surprisingly, there was no
difference found in AN/AN+ diagnosis rates across the four vignettes,
meaning that physicians were equally likely to correctly diagnose the
patient whether the patient was White/Caucasian or Asian American,
with or without a history of an anxiety disorder. Thus, none of the
hypotheses received support.
In terms of physician gender, the results obtained revealed a slight trend
towards female physicians being somewhat more likely than male physicians
to diagnose AN, but this result only approached statistical significance. Since
a gender difference in diagnosing EDs has only been suggested by a small
number of studies (e.g. Hugo et al., 2000), whether female physicians are
truly more attuned than male physicians to patients’eating psychopathology
remains unclear. In terms of patient/physician ethnicity, White/Caucasian
physicians were more likely to diagnose the vignette patient with AN/AN+,
especially if the vignette patient was also White/Caucasian. For reasons of
statistical power, all African–American, Hispanic, Asian American, Native
American, and Middle Eastern participants were combined into a single
group of non-White participants. A larger sample may have been able to
make more nuanced comparisons among ethnic groups. No other studies
have reported a similar finding about physician ethnicity being related to AN
diagnosis. Given the sample size recruited for this study and the lack of
support for this finding from other studies, future research on physician
ethnicity and ED diagnosis is needed to replicate and establish the potential
external validity of this finding.
Participants were given the option to refer the vignette patient to another
specialty; one option provided was a referral for psychiatry/psychology.
Fewer than 40% of the participants who diagnosed the patient with AN/
AN+ made this referral. These findings are surprising, given the severity and
chronicity of symptoms in AN and how crucial timely treatment is in
predicting full recovery. We can only speculate as to why this was the case.
Perhaps the fact that most patients were not referred to another specialty
reflects the ‘watchful waiting’approach commonly cited in the research
literature on diagnosing mental illness in primary care (e.g. Currin et al.,
2009). Another possibility is that physicians may have wanted to try person-
ally treating the patient for anorexia, and then refer out only if unsuccessful.
It is also possible that some PCPs may not fully appreciate the importance of
early, comprehensive treatment in recovery from AN.
224 A. HIGGINS AND S. CAHN

The primary limitation of this study is common to all online research, in that
cannot know whether these findings will generalize to other samples. This issue
of generalizability in online research is especially pronounced when recruiting
physicians, as many studies have noted a problematically low response rate
among physicians (Cho, Johnson, & VanGeest, 2013). These results should be
interpreted with some caution, given that the sample favoured residents and
younger physicians. In addition, the way this study operationalized referral
behaviours is not ideal. Psychological research on numerous topics has repeat-
edly shown that a difference exists between an individual’s intended behaviours
and actual behaviours. Therefore, in this study, it is difficult to discern whether
the participants who indicated they would refer the vignette patient to mental
health services in the study would do so in real life. Past research has determined
that PCPs are hesitant to refer their patients to mental health services for AN
(e.g. Currin et al., 2007), but this research has not established why the rate of
referral is so low for this disorder. Future qualitative research could offer some
clarity on this issue.
Conclusions
Given the secrecy displayed by individuals with this illness and the disappoint-
ing efficacy of available treatments, many researchers have urged for greater
early detection. However, past vignette research, as well as the current study,
reveal disturbingly low detection rates for AN in primary care. The reasons for
the low detection and referral rates for AN remain poorly understood. In past
research studies (e.g. Linville et al., 2010), PCPs have indicated that they do not
receive much training in AN, which may contribute to this low detection rate.
However, demographic variables may also impact the detection rate, including
the gender and ethnicity of the physician and the ethnicity of the patient. Even
among the participants in this study who correctly diagnosed the patient with
AN, the reported rate of referral to mental health services was low. Future
research should explore what contingencies may be operating, both for the
physician and the patient, that serve to suppress or disincentivize the diagnosis
and referral of patients with EDs in primary care. Only when we can fully
understand these contingencies can we adequately determine the interventions,
trainings, or public policy changes that are needed to improve the diagnosis
and treatment of this disorder.
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