Jaco Serfontein What are Eating Disorders Complex psychological disorders Serious Physical complications Mortality increased Psychiatric comorbidity People often ambivalent about treatment ID: 814747
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Slide1
Eating Disorder Primary Care Workshop
Jaco Serfontein
Slide2Slide3What are Eating Disorders?
Complex psychological disorders
Serious
Physical complications
Mortality increased
Psychiatric co-morbidity
People often ambivalent about treatment
Slide4AN in History
Holy AnorexicsSt Catherine of Siena (14th Century)
Slide5Victorian Fasting Girls
Sarah Jacob – The Welsh fasting girl (1857-1869)Mollie Fancher – The Brooklyn Enigma (1845-1916)Josephine Marie Bedard – The Tingwick
Girl
Therese Neumann (1898-1962) - Bavaria
Slide6Diagnostic Criteria - AN
DSM-5:Markedly low weight (Body weight < 85% of expected in DSM-IV)Intense fear of gaining weight or persistent behaviour to avoid weight gainWeight and shape disturbance
(Amenorrhea in DSM-IV)
Restricting type and binge-eating/purging type
Slide7BMI
20 - 25
Normal weight
17.5 - 20
Underweight
15 – 17.5
Anorexia nervosa
13.5 - 15
Severe Anorexia nervosa
12 – 13.5
Critical Anorexia nervosa
< 12
Life threatening anorexia nervosa
Slide8Bulimia Nervosa
Recurrent episodes of binge eating once per weekRecurrent inappropriate compensatory behaviour in order to prevent weight gainPresent for 3 monthsSelf-evaluation unduly influenced by body weight and shape (morbid fear of fatness)Two subtypes
Purging type
Non-purging type
Slide9NoS-FED or atypical
Disorders of eating or weight control: resembles AN or BN but do not reach their diagnostic criteriasubthreshold casespartial syndromes
Slide10Binge-Eating Disorder (DSM-5)
Binge eating (once per week for 3/12)Binges associated with 3 of:Eating rapidlyUncomfortably fullLarge amounts when not hungryAlone because embarrassedGuilty, depressed, disgustedMarked distressNo compensatory behaviour
Slide11AN
BN
ED-NOS
Fairburn & Harrison (2003). Lancet 361, 407-16.
Categories and movement between diagnoses
Slide12The patients
Anorexia nervosaweight/shape related psychopathology not always present culturally influenced
highly visible
reluctant patients who deny their problems
others concerned
outcome poor
mortality high (20% at 30
yrs
; 1/3 = suicide)
early-onset
shorter stature
Bulimia nervosa
weight/shape related psychopathology central
strongly culture-bound
invisible “shameful secret”
ambivalent patients
others unaware
outcome fair
mortality not raised
Slide13Clinical features
AN BN BEDSpecific psychopathologystrict dieting +++ +++ -
self-induced vomiting + ++ -
laxative misuse + ++ -
over exercising ++ + -
bulimic episodes + +++ +++
ritualistic eating habits ++ - -
anxiety when eating with others +++ +++ +
over-evaluation of shape &
wt
+++ +++ +
Slide14AN BN BEDGeneral psychopathologydepressive symptoms + +++ ++anxiety symptoms + ++ +obsessional symptoms ++ + -impaired concentration +++ +++ -
social withdrawal +++ + -
substance misuse - + -
Clinical features
Slide15Prognosis
Outpatient AN – 80% remission after 5 years Keel and Brown, 2010Inpatient AN – 48% remission after 12 years Fichter et al, 2006
Swedish adolescent females inpatients 9-14-year follow-up study
Anorexia nervosa
21.4%
dependent on society for income
8.7% persistent psychiatric problem requiring hospital care
mortality: 1.2%
Hjern et al (2006) B J Psych 189, 428-432
Slide16How common is ED?
AN prevalence 0.3 – 0.9, increasing in young womenBN 1-2BED 2?Turnbull et al., 1996; Currin et al., 2005
Slide17An average GP list
On an average GP list of 2000 people expect: 1-2 people with full AN 18 people with full BN 40 people with ED-NOS
Slide18Eating disorders in males
AN - 5-10% BN 10-15% (0.2%) of young malesBED ~20%symptomatology quite similar to femaleslater age of onset (18-26) vs (15-18)higher premorbid weightbody image dissatisfaction - lean tissue
athletic pursuits / job
sexuality
osteoporosis more rapid & severe
Slide19What causes AN?
Complex psychological illness with no single causeCombination of biological, psychological and sociocultural factorsFirst degree relatives of AN have a ten-fold increased lifetime risk of developing AN (Pinheiro, 2009)Anorexia – specific heritabilityBulimia – general heritability
Slide20Medical complications
Slide21StarvationFluid and electrolyte disturbance
Direct local damage due to eating disorder behaviourEndocrine changesChanges in liver functionRefeeding
Etiology
Slide22Cardiac-related
Eliana and Luisel Ramos
Slide23Multiorgan Failure
Christy Henrich
Ana Restin
Slide24Suicide
Anna Westin
Slide25Biochemical abnormalities
Could have any abnormality, hypo >> hyper↓K
↓ Na
↓Mg
↓glucose
Slide26Refeeding of severely malnourished AN (esp parenteral) and bingeing
Severe intracellular shifts in fluids and electrolytes, esp PO4 (also Mg, K, Thiamine)PO4 nadir in first weekDecreased PO4 = decreased ATPVery low PO4 directly cardiotoxicClinical
Muscle weakness
Cardiac - arrhythmias, failure, pericardial effusion
Neurological – delirium (can occur > 1week and after PO4 has recovered), coma, death
Haematological – leukocyte dysfunction, haemolytic anaemia, platelet dysfunction
Refeeding
syndrome
Slide27Osteoporosis
(oestrogen, cortisol, GH, IGF-I)
Early, frequent and serious complication of ED
Increased resorption (as result of decreased oestrogen and increased glucocorticoids) and decreased deposition (low IGF-I)
No correlation with calcium intake, exercise or HRT
40% of women with AN has osteoporosis (>2.5 SD)
92% of women with AN has osteopenia (>1 SD) (
Vestegaard
et al, 2002)
7x higher fracture rate than healthy women of same age
Treatment
Refeeding
Weight bearing exercise?
HRT?
Bisphophanates
?
Slide28Direct local damage related to
binge-eating and purging
Parotid swelling
Oesophageal damage
GER reflux
GI bleed
Post-binge pancreatitis
Acute gastric dilatation
Colonic volvulus
prolapse
Slide29Gastrointestinal system - chronic
Due to starvation
Abnormal oesophageal motility
Delayed gastric emptying
Increased colonic transit time
Laxative abuse -> colonic autonomic nerve degeneration
Liver
Fatty infiltration (lipogenesis > lipolysis)
Increased ALT (less than 4x), benign
Rarely can progress to
Nonalcoholic
steatohepatitis (higher risk in older, dual diagnosis, obesity and AST/ALT>1)
Slide30Cardiovascular System
1/3 of deaths in adults with eating disorders
Starvation related
Hypotension and bradycardia
Mitral valve prolapse
Fluid and electrolyte balance related (and severe starvation)
Arrhythmias (prolonged QTc)
Refeeding
Cardiac failure
Eating disorder behaviour related
Ipecac related cardiomyopathy
Slide31Endocrine System
Reproductive
Low FSH, LH, oestrogen, testosterone
Adrenal
High cortisol
Growth hormone axis
High GH, low IGF-I
Thyroid Axis
Low T3/T4, normal or reduced TSH ‘sick
euthyroid
’
Appetite
Low leptin, high ghrelin and peptide YY
Slide32Haematology
Anaemia
Mild leukopenia
Thrombocytopaenia
Decreased ESR
Slide33Nervous System
Starvation related:
Pseudoatrophy
, enlarged ventricles
Cognitive impairment
Peripheral neuropathy
Slide34Self-injuryDry skin
Skin breakdown, pressure soresCarotenemia Dry, brittle hairHair lossLanugo
Skin and Hair
Slide35Type IAN – no increase
BN – 3X increaseEDNOS – 2X increaseType IIBED most prevalent
Comorbidity with Diabetes
Slide36Insulin purging women > men
Poor glycaemic control
Early diabetic retinopathy
Medical complications of ED higher
Higher rate of other psychiatric diagnoses
Treatment similar
Diabetes
Slide37How would you recognise the following?
VomitingWater loadingOver exerciseInfection in low weight ANRefeeding syndrome
Slide38Treatment
Slide39NICE OVERVIEW
NICE guidelines (2017) recommendSupport should include:
Psychoeducation
Regular physical health monitoring
Multidisciplinary
Involve family and carers
Slide40Evidence based, disorder-specific psychological treatments
Anorexia Nervosa Restricting EDNOS
Slide41Evidence-based psychological treatments for anorexia
Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)Specialist supportive clinical management (SSCM)
Next step if unsuccessful or unacceptable
Eating-disorder-focused focal psychodynamic therapy (FPT)
Only 30% of adult cases are recovered at 1 year, 40-50% at 5 yrs
Limited evidence of
fluoxetine
in relapse prevention
Slide42Children & adolescents
Family interventions (first line or relapse prevention) produce recovery rates of 60-70% at 1 year, 70-90% at 5 yrs classical family therapy not necessary(Eisler et al. 2003)
Slide43Evidence based, disorder-specific psychological treatments
Bulimia Nervosa EDNOSBinge Eating Disorder
Slide44Stepped care approach
Explain that treatment limited effect on body weightBulimia-nervosa-focused guided self-helpIndividual CBT-EDRegularising eatingReducing compensatory behaviours Introducing emotional regulation skills Problem solving skillsAddressing weight and shape concerns – anxieties, perceptual biases, attitudes etc Medication should not be offered as sole treatment
Slide45Treatment complications
Slide46Maintaining Factors of AN
Predisposing
traits
Perpetuating
consequences
Emotional
avoidance
Obsessive compulsive traits
Interpersonal
Relationships
Beliefs about
The value of
AN in the
Person’s life
Slide47The Pros and Cons of anorexia nervosa (Serpell
et al., 2002, 2003)3 most important pro-anorexic beliefs were:
Anorexia nervosa
keeps me safe
helps to communicate distress
stifles emotion
Slide48Iatrogenic Maintaining factors
Overprotection
Over zealous use of inpatient treatment.
Excluding or disempowering the family.
Criticism or confrontation-coercive treatments
MHA
Use of loss of privilege systems
Accommodation
Use of treatment without nutritional direction/expectation of change.
Engaging in bargaining of treatment goals with the persuasive patient.
Enabling
Services palliating loneliness and isolation.
Providing the opportunity for further striving competing and calibrating against others.
Treasure et al., 2011
Slide49Difficulties
Secretiveness – highly functional, denial, difficult to detect Ambivalence – engaging with services, about what recovery or treatment entailsReactions of others (including services) – high expressed emotion, overly controlling, accommodating, dismissingPhysical & psychological complications of illnessPsychiatric and physical co-morbidity (e.g. PD / Diabetes)
Slide50Treatment considerations
Collaborative and motivational approach vs MHAEngagement and disengagementRecovery and prognosisRisk managementShared careMedication
Slide51Recognition and Initial Management of Eating Disorders
Screening
The King’s College Risk assessment
Slide52Screening – The SCOFF questionnaire
Do you make yourself Sick because you feel uncomfortably full?Do you worry you have lost Control over how much you eat?Have you recently lost more than One stone in a 3 month period?Do you believe yourself to be Fat when others say you are too thin?
Would you say that
F
ood dominates your life?
2 or more out of 5 predicts an ED with 100% sensitivity and 87.5% specificity
Morgan et al (1999)
Slide53King’s College Medical Risk Assessment
Medical Risk –Psychiatric RiskPsychosocial Risk
Insight/Capacity and motivation
Slide54Surgery: St Stephen’s Gate Medical Practice
NHS Number: XXXXXXXXXXXX
Medical monitoring request
This box is shared with commissioners and should not contain any identifying information
Frequency
FBC, u&e, LFT, Ca, PO4, Mg, muscle CK, random glucose
X
Every two weeks
Brief essential examination
(weight, pulse, lying/standing blood pressure, core temperature, squat test)
X
Every two weeks
Weight only
Additional requests:
Please do an ECG at
baseline
u&e
only
Slide55Medical Monitoring
Brief Essential Examination – BMI alone is not enough because it is not reliableSpecial Investigations – Bloods, ECG, Dexa Scan, etc
Slide56Brief Essential Examination
BMI (single layer of clothing, no shoes/mobiles/wallets/heavy jewelery etc
)
Sitting/standing blood pressure
Pulse rate
Peripheral circulation
Core temperature
A measure of muscle strength – squat test
Slide57Sit-up/Squat test
Slide58Investigations
FBC, u&e, bicarb, LFT, Ca, PO4, Mg, CK,
gluc
Bonescan
if >1 year amenorrhoea
ECG if BMI<14 or if on drugs that can affect
QTc
Any other physical investigation pertinent to physical state,
eg
, TFT