Managing eating disorders in 2015 - Gold Coast Primary ...
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Addressing eating disorders in Primary Care 3 April 2019
Transcript of Managing eating disorders in 2015 - Gold Coast Primary ...
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 - [email protected]
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 [email protected]• 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)
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
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?
