Addressing eating disorders in Primary Care

3 April 2019

Addressing Eating Disorders in Primary Care

Dr Kate Murphy

MBChB, MRCPsych, (CCT General Adult), FRANZCP

Consultant Psychiatrist, Queensland Health

On behalf of the National Eating Disorders Collaboration

• Thank you Gold Coast PHNQLD Health

• NEDC ResourcesFree MembershipEvaluation Forms

• KEY stakeholders Any professional providing health, social, education and welfare support to people in the community

• Who is in the room?

NEDC RESOURCES

www.nedc.com.auwww.eatingdisordersinfo.org.auwww.storiesfromexperience.com.au

Free, user friendly, downloadable:- Infographics/Posters- PDF/Booklets

GPs, Allied HealthCounselling & Nursing Midwives and PerinatalPharmacists & DentistsTeachers and SchoolsSporting professionals/coachesCaring for Someone with an Eating disorder

- National Standards, Frameworks, Publications- Research Database

Get in touch - info@nedc.com.au

Resources and Support

HELP FOR YOU & YOUR CLIENTS

ED National Helpline:• 1800 ED HOPE (1800 33 4673) • 8am – midnight 7 days (except national public holidays)• Email support@thebutterflyfoundation.org.au• Webchat www.thebutterflyfoundation.org.au• Online support groups• Online carer psychoeducation• Professional practitioner database • Referral pathways

Eating

Disorders in

Primary CareKATE MURPHY, PSYCHIATRIST

WITH HUGE THANKS TO WARREN WARD, DIRECTOR OF QUEDS

An Overview of Eating

Disorders

Eating Disorders -

classification

Anorexia Nervosa

Restricting type

Binge-eating/purging type

Bulimia Nervosa

Binge Eating Disorder

OSFED

ARFID

Purge Disorder

Unspecified eating disorder

Emily

24 year old

Presents to GP asking for

bloods and dietician

referral

Always had problems

with intolerances

Low weight – hasn’t

weighed herself recently

GP measures BMI at

12.7kg/m2

Working as a nanny

Eating Disorders are common,

and increasing in prevalence

1 in 20 Australians has an eating disorder*

Approximately 15% of Australian women experience an eating

disorder during their lifetime*

The number of people in Australia with ED behaviours doubled

in 10 years from 1995-2005^

*www.nedc.com.au

^Hay PJ, Mond J, Buttner P, Darby A (2008) Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE 3(2)

Many sufferers and families

mention unhelpful responses from

clinicians Parents get told:

‘It’s just a phase’

‘There’s nothing wrong with her’

‘You’re worrying too much’

She’ll be alright

Patients get told:

‘You just need to eat’

‘There’s nothing we/I can do for you’

Sufferer denial + Doctor denial

= A Lethal Combination

‘She’s medically stable’

‘Her bloods are fine’

‘Everything’s pretty

normal now’

‘We’ve corrected her

potassium’

‘She looks fine’

‘She’s an athlete so

you’d expect her pulse

to be low’

‘I’m fine’

‘There’s nothing wrong with

me’

‘I’ll eat’

‘See my blood’s are fine’

‘You worry too much’

‘I’m not dead yet’

‘Everyone in my family is thin’

5 common myths about eating

disorders

1. People choose to have eating disorders

2. Eating disorders are not life-threatening

3. Parents cause their children's eating disorder

4. You can tell someone has an eating disorder just by looking at them

5. You can never fully recover from an eating disorder

Myths about Eating Disorders

Serve to isolate sufferer and family even further

and hinder recovery

Often believed by those who don’t have much

knowledge about eating disorders

Even medical staff sometimes perpetuate these

myths

Myth 1: People

choose to have eating disorders

The Reality:

Eating disorders

are serious and

complex mental

illnesses that

deprive sufferers of

choice, decision-

making capacity

and control

Exercise – non-

dominant hand

A starved brain sees the

world differently…

Myth 2: Eating disorders are

not life-threatening

The realities:

Anorexia nervosa has the highest death rate of any

mental illness (up to 20%)

Starvation

Suicide

People with bulimia nervosa can and do die from

cardiac arrythmias due to hypokalemia caused by

vomiting

Anorexia Nervosa:

Mortality RatesAN SCZ BPAD Depression

Mortality

rate per

1000 person

years

5 2.8 2 1.6

12 times higher in AN than patients without AN

A fifth of deaths in AN due to suicide

Higher mortality associated with low BMI at presentation

Ref: Arcelus et al, Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders A Meta-analysis of 36 Studies, Arch Gen Psychiatry. 2011;68(7):724-731

Myth 3: Parents cause their

children's eating disorder

The reality: The most effective treatment available for Anorexia

Nervosa involves utilising the patient’s best resource: their parents

The causes of eating disorders are complex and include…

Genetic

Personality

Early attachment problems (trauma/abuse/neglect)

Obesity

Bullying and teasing

The culture and media/certain subcultures

Stressors

Dieting

Starvation syndrome

Ancel Keys

Minnesota Semi-starvation study

Starvation causes reversible

changes to the brain

36 men lost 25% body weight

Preoccupation with food; ritualised eating; hoarding; rigid thinking; social withdrawal; impaired mood and concentration

Reversed after re-feeding

Anorexia Nervosa can be triggered by weight loss due to physical illness or dieting

Eating Disorders are more prevalent

in Western cultures

Idealisation of thinness

Abhorrence of fat

We are told that to be

happy, successful and

desirable we need to

be thin

Many women therefore

base self-esteem on

their physical

appearance

The impact of TV on

teenage girls

Within 3 years of introduction of TV to area in Fiji:

Eating Disorder symptoms increased 5-fold

Vomiting to control weight increased from 3% to 15%

74% felt “too big or fat”

62% dieting in past month

Favourite programs included Melrose Place, ER, Xena: Warrior Princess.

Becker et al (2002) British Journal of Psychiatry, 180, 509-514

Is body image concern an

epidemic?

Mission Australia National Survey of Young Australians

29,000 11-24 year olds

Body image one of top concerns every year in males and females, and increasing

Myth 4: Most people with

eating disorders are thin

A recent Australian study showed:

2-5% of young women will have eating disorders

24 out of 25 of these women will have non-anorexic eating disorder

Purging behaviours (vomiting, laxatives, diuretics) most common in 35-44 year old women

Hay et al PLoS ONE 3(2)

Myth 5: You can never fully

recover from an eating

disorder The reality:

Treatment is effective

However, most eating disorders will not just ‘go away’

With good treatment, and hard work, full recovery is possible

Even with Anorexia Nervosa, the most difficult ED to treat, approx

70% recover after 5 years

Treatments are effective

For adolescents with Anorexia Nervosa

Maudsley-based Family Therapy (FBT)

For adults with Anorexia Nervosa

Stabilise medically

Get some nutrition to the brain, then…

CBT, SSCM, or MANTRA

For Bulimia Nervosa and Binge Eating Disorder

Cognitive Behaviour Therapy – enhanced (CBT-e)

SSRIs (Fluoxetine 60-80 mg titrated up slowly)

Lisdexamfetamine 50-70mg (for BED only)

http://www.guilford.com/pr/fairburn4.htm

Treatment phases for any eating

disorder

Therapeutic alliance

Medical stabilisation (weeks)

Restore weight/regular adequate nutrition/reverse

starvation syndrome (months)

Psychotherapy (6-12 months min)

Back to Emily…

What should your assessment

include?

History?

Examination?

Investigations?

Risk Assessment

The biggest risk is unintentional death due to the effects of starvation or purging

Person can feel great and have normal bloods just before sudden death due to arrhythmia

Best indicators of cardiac risk are easily assessed:

BMI < 14

No oral intake for a week

Always ask in detail about food intake

Purging several times daily

BP < 90mm systolic

HR < 50 bpm or > 110 bpm

Postural tachycardia/hypotension > 20 bpm/mm

Serum potassium, phosphate or glucose below normal range

ECG changes secondary to hypokalemia, prolonged QT interval

Medical History

• Ask…

o Have you had any medical or physical problems in last few months?

o Fainting*

o Lightheadedness

o Chest pain

o Palpitations

o Ankle Swelling

o Weakness

o Tiredness

o Regular periods? (doesn’t count if on the pill)

o Bone scan?

*Admit

Psychiatric history

Weight history

Daily oral intake

B

MT

L

AT

D

S

Vomiting/Exercise/Laxative use

Body image

Mood

Suicidality

Physical examination

Weight*

Height*

BP/HR-lying & standing

*BMI=Wt(kg)÷Ht(m)÷Ht(m)

Investigations

Serum biochemistry

Full Blood Count

ECG

FBC

U+Es

LFTs

Phosphate, Magnesium

American Journal of Clinical Pathology > Hematopathology

Bone Marrow Changes in Anorexia Nervosa…

E. Abella, et al Am J Clin Pathol. 2002;118(4)

After weight loss

After re-feeding

Emily’s results

HR 36 lying 72 standing

BP 85/60 lying 80/50 st

ECG 36 bpm

Neutrophils 1.2

Na 129

Cl 95 mmol/l (96 – 109)

K 3.2

HC03 35 mmol/L (25-33)

RANZCP criteria for

admission* BMI < 14

Rapid weight loss

BP < 90mm systolic (< 80 mm for children and adolescents)

HR ≤ 40 bpm (< 50 for children and adolsecents) or > 120 bpm

Postural tachycardia/hypotension >20bpm/mm

Serum potassium, phosphate, Mg or glucose below normal range

Neutrophils < 1.5 x 109/L

Prolonged QT interval on ECG

*Hay P, Chinn P, Forbes D, Madden S, Newton R, Sugenor L, Touyz S and Ward W

RANZCP clinical practice guidelines for the treatment of eating disorders

Australian & New Zealand Journal of Psychiatry 2014, Vol. 48(11) 977–1008

What would you do if

Emily declined admission

Therapeutic alliance

Express your concern about the risk

Try not to be swayed by their promises to put

weight on

Act fast – these investigation findings can indicate

very short period to cardiac death

Ask about supports and try to get them on board

Try to call MH services together

MHA might need to be used

ACT team

Treating medical complications

Complication Treatment

Cardiac decompensation Nutrition* + cardiac monitoring if

HR <40 adults, <50 in kids

Neutropenia Nutrition*

Raised LFTs Nutrition*

Amenorrhea Nutrition* + Bone Scan

Constipation Nutrition*

Depression/Insomnia/Anxiety/Te

rror of gaining weight

Nutrition*

Hypoglycemia Nutrition*

*Always give thiamine before nutrition

Refeeding Syndrome

Seen in POW survivors when they started eating

Starvation followed by rapid intake of excessive calories

Insulin levels increase quickly

Extracellular levels of Phospate, Magnesium and Potassium

Cardiac death

Treatment = careful refeeding of approx. 1500kcals/day

Monitor bloods daily

Thiamine

What should be offered to

Emily after she leaves

hospital?

Maudsley-based Family

Therapy (FBT)

Externalises the illness

Supports parents to take over nutrition until child can safely manage

Most effective treatment available

6-12 months duration

Towards end of treatment adolescent supported back to independence

What about adults with

AN?

SSCM

CBT-e

MANTRA

Specialist Supportive

Clinical Management

(SSCM) Evidence-based

40 weekly 1-hour sessions

Psychoeducation

Address symptoms

Weight

Medical complications

Dietary restriction

Purging/exercise

Body image

Support with emotions/relationships/life

Ethical & legal considerations

Autonomy

Beneficence

Competence

Reversibility of starvation syndrome

Legal framework

Countertransference

Intense reactions in family/you are normal

‘Splitting’ is common

Such reactions reflect patient’s own intense ambivalence/internal division

Helpful strategies include:

Externalising the illness

Team decision-making

Consultation

See c/t as guide to patient’s unspoken feelings

What about Bulimia

Nervosa (and Binge

Eating Disorder)?

Guided self help

CBT-e

CBT made simple

Restrict

Binge

(Purge)

Further Training/Resources

Queensland Eating Disorders Service, RBWH

Ph: 07 3114 0809

Queds@health.qld.gov.au

Google ‘QUEDS’

Eating Disorders Queensland (EDQ). Peak NGO in Qld. Carer resources etc

eda.org.au

Centre for Clinical Interventions. For fact sheets.

cci.health.wa.gov.au

RANZCP Clinical Practice Guidelines for Eating Disorders

NEDC

nedc.com.au

Butterfly Foundation support service

1800 ED HOPE / 1800 33 4673

Thank You

Questions?

Comments?