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Eating Disorders In Adult LifeDR ABDUL KHALID MOHD SANI
ST5 IN EATING DISORDER SERVICE TO DR JESSICA MORGAN
SEPT 2015
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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
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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
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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
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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
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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.
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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
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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”
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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
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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
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Anorexia Nervosa: comorbidity
Depression
Obsessive-compulsive disorder
Anxiety disorders
Self-harm
Impulsivity
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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.
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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
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Anorexia: Katie’s story
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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)
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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
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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.
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Bulimia Nervosa: Comorbidity
Depression
Anxiety
Personality Disorder
Substance misuse
Deliberate self injury
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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
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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
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Bulimia: Steve’s story
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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?
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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.
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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.
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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
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Sit-up/Squat-Stand test
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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
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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
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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
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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
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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