Eating Disorders In Adult LifeDR ABDUL KHALID MOHD SANI

ST5 IN EATING DISORDER SERVICE TO DR JESSICA MORGAN

SEPT 2015

Learning Objectives

Awareness of aetiology and epidemiology

Understand the diagnostic classification of eating disorders

Exploring eating disorders psychological features

Assessment including psychiatric comorbidity, physical features, prognosis

Risk assessment of eating disorders

Management of eating disorders

BMI: From ‘normal’ to ‘disorder’BMI Classification

>40 Obese class 3

35-40 Obese class 2

30-35 Obese class 1

25-30 Pre-obese

20-25 Normal

17.5-20 Underweight

15-17.5 Low-Moderate Risk

13-15 Moderate Risk

<13 High Risk

<12 Very High Risk

Aetiology of eating disorders

Genetic factors

Physical risk factors: premorbid obesity, early menarche

Adverse life events and difficulties

Family factors

Socio-cultural factors

Perfectionism

Impulsivity

Incidence and prevalence of eating disorders

Incidence of AN in UK: 19/100000/year females. 2/100000/year males

Highest rates in female 13-19: 50.8/100000/year

Previously thought to be ‘Culture bound syndrome’

Prevalence of BN: 0.5-1% in young women. 90% diagnosed female

In UK, young Muslim Asian women may be at particularly high-risk of developing BN

Eating disorders: criteria

Weight

Biological consequences

Behaviours directed at weight manipulation

Psychological features of over-concern with weight and shape, fear and avoidance of normal weight.

ICD-10 Anorexia Nervosa F50.0

Body weight is maintained at least 15% below that expected or BMI is 17.5 or less

The weight loss is self-induced by avoidance of “fattening foods”. May also include self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics

Body-image distortion i.e. dread of fatness

Widespread endocrine disorder involving HPG axis. In postmenarchal females, this is amenorrhoea.

Types: “restricting” or “binge-purge”

Rate of weight loss is also important

ICD-10 Bulimia Nervosa F50.2

Persistent preoccupation with eating, and an irresistible craving for food; succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time

Attempts to counteract the “fattening” effects of food by self-indued vomiting, alternating periods of starvation or/and use of drugs

Morbid dread of fatness and sets her/himself a sharply defined weight threshold, well below the optimum or healthy weight

Types: “purging” and “non-purging”

ICD-10 other eating disorders

Atypical anorexia nervosa F50.1

Atypical bulimia nervosa F50.3

Overeating associated with other psychological disturbances F50.4

Vomiting associated with other psychological disturbances F50.5

Other eating disorders F50.8

Eating disorder, unspecified F50.9

Anorexia Nervosa: psychological features

Intense of weight gain/becoming ‘fat’

Preoccupation with weight/shape and body image to the exclusion of other thoughts and activities

Tendency to evaluate oneself exclusively in terms of weight/shape

Denial

Daily restriction directed to weight loss

Food assumes great importance

Anorexia Nervosa: comorbidity

Depression

Obsessive-compulsive disorder

Anxiety disorders

Self-harm

Impulsivity

The Minnesota experiment(Keys, 1950)

A series of male conscientious objectors were starved to around 75% of their normal weight.

They became preoccupied with food to the exclusion of other interests and activities.

Eating behaviours were observed, for example, hiding or hoarding food, eating in secret, eating rituals and extended duration of mealtimes.

They became more socially isolated. Emotional and psychological changes were seen such as irritability and mood disturbance.

Some developed depression. Obsessive-compulsive symptoms were also observed. Physical restlessness was also a feature.

Many of these phenomena are seen in anorexia nervosa, and are related to the effects of starvation.

Course and prognosis: Anorexia nervosa

Course is very variable

No good evidence on who do not access care

Steinhausen,1995: 43% recover, 36% improve, 20% chronic, 5% die

Overall mortality ranged from 0-21%: physical complications & suicide

Mortality 3 times higher than other psychiatric illnesses

A number progresses to other eating disorders

Anorexia: Katie’s story

Bulimia Nervosa: Background

Records were less than 50% in one UK study (Whitehouse et al, 1992) and in a Dutch study 11% were identified in primary care (Hoek, 2006).

Difficulty sharing due to feelings of shame, guilt and fear of not being taken seriously.

GP – difficult to treat(Hay et al 2005)

Increased rate of consultation but not with ED presentation(Ogg et al 1997)

‘Hidden’ in psychiatric settings(Kutcher et al 1985)

Bulimia Nervosa: Psychological features

Self-evaluation in terms of weight and shape

Attempts at extreme dieting to manipulate weight

Binge eating

Mood

Guilt, shame, disgust

Attempts to counteract the high calorie intake of the binge: compensatory behaviours

Compensatory behaviours reinforce binge eating

Binge eating

‘Forbidden' foods: high-calorie, fat- and carbohydrate-rich.

The range of binge foods varies with individual preference.

The amount consumed is always large however.

May consume 'marker' foods at the beginning of a binge.

Typically eaten rapidly(within 2 hours). There is loss of control of the type and amount of food eaten. High levels of distress and anxiety.

Termination comes about when the individual experiences uncomfortable or even painful fullness.

Bulimia Nervosa: Comorbidity

Depression

Anxiety

Personality Disorder

Substance misuse

Deliberate self injury

Course and prognosis: Bulimia Nervosa

Many are not receiving any form of help- chronicity or relapsing course

With the most effective treatments

-50% can be expected to be asymptomatic 2-10 years after assessment

-20% No change

-30% Remitting/relapsing or subdiagnostic

Poor prognostic factors:

Longer duration of illness

Previous treatment

Lower minimum weight

Personality and social difficulties

Distorted family relationships

Purging subtype

Later age of onset

Comorbidity

Bulimia: Steve’s story

The SCOFF questions- screening tool

1. Do you ever make yourself Sick because you feel uncomfortably full?

2. Do you worry that you have lost Control over how much you eat?

3. Have you recently lost more than One stone in a three month period?

4. Do you believe yourself to be Fat when others say you are too thin?

5. Would you say that Food dominates your life?

Assessment: components

assessment of physical (including diet history) + psychological factors

the family: strengths and difficulties

wider context including social and educational factors

risks: short term and long term

maintaining factors

motivational issues

engagement (both person and family)

consent to treatment

confidentiality issues.

Assessment: Improving motivation

Taking time to listen to the person’s perspective – reflective listening

Eliciting concerns that the young person might have about: social functioning, physical health, psychological functioning, educational/work progress

Helping to clarify the person’s short-term and long-term goals

Providing information in a form that the person can understand about their eating disorder and its consequences

Avoiding confrontation, arguing or lecturing.

Risk assessment: Nutritional status

weight and height, premorbid weight, speed of weight loss

cardiovascular functioning: BP, pulse, postural drop, peripheral circulation

skin: temperature, colour, turgor, lanugo, subcutaneous fat tissue, bruising

endocrine system: thyroid, periods

gastrointestinal system: constipation

musculoskeletal system: muscle atrophy/preservation, muscle strength (sit-up and squat tests)

nervous system: peripheral neuropathy.

Blood tests, ECG, bone densitometry

Sit-up/Squat-Stand test

GUIDANCE NOTES FOR ASSESSING MEDICAL

RISKS IN PATIENTS WITH ANOREXIA NERVOSA

SYSTEM TEST* OR INVESTIGATION CONCERN ALERT

Nutrition BMI 14 12

Weight loss/week 0.5kg 1.0kg

Skin Breakdown 0.1cm 0.2cm

Purpuric rash +

Circulation Systolic BP 90 80

Postural drop (sit-stand) 10 20

Pulse rate 50 40

Musculo-Skeletal(Squat Test and Sit Up Test)

Unable to get up without using arms for balance (yellow)

+

Unable to sit up without using arms as leverage (red)

+

Unable to sit up without using arms as leverage

+

Unable to sit up at all +

Temperature 35C98.0F

34.5C97.0F

Bone Marrow WCC 4.0 2.0

Neutrophil count 1.5 1.0

Hb 11 9.0

Acute Hb drop(MCV and MCH raised – no acute risk)

+

Platelets 130 110

SYSTEM TEST* OR INVESTIGATION CONCERN ALERT

Salt/Water Balance K+ 3.5 3.0

2. Na+ 135 130

3. Mg++ 0.5-0.7 0.5

4. PO4- 0.5-0.8 0.5

5. Urea 7 10

Liver Bilirubin 20 40

Alkpase 110 200

AST 40 80

ALT 45 90

GGT 45 90

Nutrition Albumin 35 32

Creatinine Kinase 170 250

Glucose 3.5 2.5

Differential Diagnosis

TFT, ESR

ECG Pulse rate 50 40

Corrected QT interval (QTC) 450msec

Arrhythmias +

*The baselines for these tests vary between labs. Any abnormal resultis an indication for concern and monitoring.

GUIDANCE NOTES FOR ASSESSING MEDICAL RISKS IN PATIENTS WITH ANOREXIA NERVOSA

(continued)

Risk assessment:

Physical risks :

short term: electrolyte imbalance (including low potassium, phosphate or sodium, cardiac abnormalities, hypoglycaemia, GI bleeding, infection, sudden death

long term: poor physical development, osteoporosis, infertility

Psychological risks

short term: self-harm, suicide

long term: depression, anxiety, obsessive symptoms, substance misuse, suicide

Social risks

short term: conflict in the family, alienation from friends, loss of peer group

long term: chronic social disability and isolation

Educational/Employment risks

short term: worsening performance or excessive (obsessional) focus on work

long term: inability to achieve educational/work potential

Management:

Outpatient vs Inpatient

Multidisciplinary

Psychological interventions: CAT, CBT, IPT, FT

Pharmacological interventions

Physical management: Managing weight gain, risk , feeding against the will

Refeeding syndrome

References:

RCPsych CPD online: Introducing eating disorders. Dr Clare Price & Dr John Morgan

NCCMH: Eating disorders- Core Interventions in the treatment and management of AN, BN and related eating disorders

Eating disorders and Obesity, Fairburn & Brownell