MRCPsych Course – Across the ages session

CAMHS – Prognosis of eating disorders

Sarah Stansfeld ST4 CAMHS

Aims of the presentation• Risk factors for the development of eating disorders• Diagnostic Stability• Comorbidity• Factors which predict a poor prognosis in eating

disorders• Prognosis• Junior Marzipan Guidelines.

Risk factors for the development of eating disorders – Anorexia Nervosa

• Female• History of infant feeding problems• Maternal depressive symptoms• History of under eating • Family History• Adverse life events can often precipitate illness• childhood sexual abuse - evidence suggests this is likely

to predispose to many forms of mental illness and is not specific to anorexia– if this is present there is a higher likelihood of psychiatric comorbidity

• Obsessional personality traits and perfectionism• ASD like personality traits

Risk factors for the development of eating disorders – Bulimia Nervosa

• Female• Elevated premorbid poor impulse control• Family environment with a high degree of

interest in weight, body shape and eating• Parental and/or childhood obesity• Family history of psychiatric disorder• Early menarche

Premenarchal presentation of Anorexia nervosa

• Initially would present with failure to gain the weight which should accompany growth then later would present with weight loss

• Delay or arrest of puberty (notable by amenorrhoea and delay in secondary sexual characteristics such as breast development)

• Growth arrest (monitor weight and height on growth charts)

• Adolescence is a crucial period for establishing lifetime bone density. Prolonged periods of starvation can lead to a osteopenia and osteoporosis in this age group

Diagnostic Stability

• There is a high level of diagnostic instability in the earlier stages of an eating disorder.

• 20–40% transition from anorexia into Bulimia• The cross-over from restrictive type AN to binge/purge

disorders usually occurs after a relatively short period of time between 12 and 36 months.

• Estimates of transition from Bulimia to Anorexia are lower at 20–30%

• This is likely to represent the inadequacy of a categorical diagnostic system in capturing the progression of symptomatology over time

Comorbidity

• Ulfvebrand 2015 in a large Swedish study of a database of 11588 of women and men with eating disorders found that

– 71% had at least one comorbid axis 1 disorder (DSM IV)– Anxiety disorders were the most common at 53%– Generalised anxiety disorder was the most common

comorbid diagnosis

Comorbidity in Adolescents• Rojo-Moreno 2015 in a community study of 933 adolescents

ED prevalence was 3.6%. 62.9% of individuals with an ED had a comorbid disorder

- anxiety disorders (51.4%)- Attention Deficit Hyperactivity Disorder (31.4%)

- oppositional defiant disorder (11.4%)- obsessive compulsive disorder (8.6%).

• ED incidence rate of 2.76% over the course of 2 years. 22.2% of new cases had received previous psychiatric diagnoses, of which all were anxiety disorders.

• ED exhibited a high comorbidity rate among adolescent populations and anxiety disorders were the most common comorbid diagnosis.

Poor Prognostic Factors

• Later age of onset• Longer duration of illness• History of comorbid personality disturbance• Disturbed relationships in the family• Psychiatric comorbidity• Loss of social and educational and

occupational function

Prognosis - AN• Ratnasuriya et al, a 41 patient, 20 year follow up study of AN found

that 30% of patients had a ‘good’ outcome, 32% had an ‘intermediate’ outcome and 38% had a ‘poor’ outcome. – 20 year outcome was predicted by outcome at 5 years. – 15% had died from causes related to anorexia nervosa – 15% had developed Bulimia nervosa.

• Sullivan carried out a meta-analysis of mortality rates in anorexia found the aggregate mortality rate to be 5.6% per 10 years (total patients 3006). This is substantially higher than both female psychiatric patients and the general population. Cause of death: was – complications of Anorexia in 54%, – suicide 27% and – other causes 19%.

Adolescents with AN

• Follow up studies of younger patients with AN show consistently better outcomes than adults

• Wenz et al – community sample of adolescent onset AN followed up for 10 years (51 patients)

– 1 in 4 had a persisting ED at 10 years– Outcome was ranked as poor in 27%, intermediate in 29% and

good in 43%– Half the AN group had poor psychosocial functioning at 10

years– Poor ongoing psychosocial functioning was accounted for by

ongoing ED or chronic obsessive compulsive behaviour or problems with social interaction

Prognosis of Binge eating disorder and Bulimia Nervosa (purging type)

• Fichter et al 2008 – 12 year follow up study of patients who had been admitted to hospital for treatment of an eating disorder– 36% of BED and 28.2% of BN still had a diagnosis of an

eating disorder at 12 years– Psychiatric comorbidity was the predominant predictor of

poor outcome in both diagnoses. – Predictors for poor BED outcome were body

dissatisfaction, history of sexual abuse, and impulsivity.

Mortality following hospital discharge- UK

• (SMR = standardised mortality ratio –> an SMR of 1.0 would mean the same likelihood of dying as the general age matched population. An SMR of 10.0 would mean a 10x greater chance of dying than the general age matched population)

• Hoang et al 2014 found that the standardized mortality ratio (SMR) for adolescents and young adults (aged 15-24) with a diagnosis of ED was 7.8 (95% confidence interval: 4.4–11.2) within the first year post discharge from any NHS hospital

- for anorexia nervosa (AN) was 11.5 (6.0–17.0- for bulimia nervosa (BN) was 4.1 (0–8.7)- for ED NOS was 1.4 (0–4.0)

• SMR for people of the same age with schizophrenia was 10.2 (8.3–12.2), with bipolar disorder was 3.6 (1.1–6.1) and with depression of 4.5 (3.6–5.3)

Mortality following hospital discharge- UK

• For older adults aged 25–44 years, the SMR for ED was 10.7 (7.7–13.6)

• AN was 14.0 (9.2–18.8)• BN was 7.7 (3.5– 11.9)• ED NOS was 4.7 (1.4–8.0)

Junior Marzipan Guidelines

• Produced by RCPsych - For the management of really sick patients under 18 with Anorexia Nervosa

• Available free online at;• http://www.rcpsych.ac.uk/usefulresources/pu

blications/collegereports/cr/cr168.aspx• (or type Junior Marzipan guidelines into a

search engine)

The Junior MARSIPAN report provides guidance on:

• risk assessment, physical examination and associated action• location of care and transition between services• compulsory treatment• paediatric admission and local protocols• management of re-feeding• management of compensatory behaviours associated with an

eating• disorder in a paediatric setting• management in primary care and paediatric out-patient

settings• discharge from paediatric settings• management in specialist CAMHS in-patient settings.

Risk Stratification - Weight

Red (high risk) Amber (alert to high concern)

Green (moderate risk)

Blue (low risk)

Percentage median BMI <70% (approx below 0.4th BMI centile) Recent loss of weight of 1 kg or more/week for 2 consecutive weeks

Percentage median BMI 70–80% (approx between 2nd and 0.4th BMI centile) Recent loss of weight of 500– 999g/week for 2 consecutive weeks

Percentage median BMI 80–85% (approx 9th–2nd BMI centile) Recent loss of weight of up to 500g/week for 2 consecutive weeks

Percentage median BMI>85% (approx. above 9th BMI centile) No weight loss over past 2 weeks

Risk Stratification - CardiovascularRed (high risk) Amber (alert to

high concern) Green (moderate risk)

Blue (low risk)

Heart rate (awake) <40 bpm History of recurrent syncope; fall in systolic blood pressure on standing of 20 mmHg or more, or increase in heart rate of >30 bpm) Irregular heart rhythm (does not include sinus arrhythmia)

Heart rate (awake) 40–50 bpm Sitting blood pressure: systolic <0.4th centile 84–98 mmHg diastolic <0.4th centile 35–40 mmHg Occasional syncope; fall in systolic blood pressure of 15 mmHg or more, or diastolic blood pressure fall of 10 mmHg or more

Heart rate (awake) 50–60 bpm Sitting blood pressure: systolic <2nd centile (98–105 mmHg diastolic <2nd centile 40–45 mmHg Pre-syncopal symptoms but normal orthostatic cardiovascular changes prolonged peripheral capillary refill time (normal central capillary refill time)

Heart rate (awake) >60 bpm Normal sitting blood pressure for age and gender Normal orthostatic cardiovascular changes Normal heart rhythm

Calculating Percentage BMI

Percentage BMI = Actual BMI × 100___________ Median BMI (50th percentile) for age and gender

Median BMI is obtained from the relevant growth charts

Assessment of the unwell patient with anorexia would also include…

• ECG (arrhythmias, heart rate, QTc)• Hydration status• Temperature (hypothermia indicates physiological instability)• Bloods including FBC, U&Es, LFTs, Bone Profile, Mg2+, glucose• Assessment of muscular weakness (sit up and stand or hand grip

strength)• History of food and fluid intake• Assessment of level of Engagement with management plan• Level of current exercise• Self harm and suicidality• Mental state/psychiatric assessment• Full physical examination• Collateral History!

References

• Anorexia nervosa: outcome and prognostic factors after 20 years.R H Ratnasuriya, I Eisler, G I Szmukler, G F RussellThe British Journal of Psychiatry Apr 1991, 158 (4) 495-502; DOI: 10.1192/bjp.158.4.495

• Mortality in anorexia nervosa.Authors:Sullivan PF; University Department of Psychological Medicine, Christchurch School of Medicine, New Zealand.Source:The American Journal Of Psychiatry [Am J Psychiatry] 1995 Jul; Vol. 152 (7), pp. 1073-4

• HOANG, U; GOLDACRE, M; JAMES, A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001-2009. The International Journal Of Eating Disorders. United States, 47, 5, 507-515, July 2014. ISSN: 1098-108X.

• Wentz, E., Gillberg, C., Gillberg, I. C. and Råstam, M. (2001), Ten-year Follow-up of Adolescent-onset Anorexia Nervosa: Psychiatric Disorders and Overall Functioning Scales. Journal of Child Psychology and Psychiatry, 42: 613–622. doi: 10.1111/1469-7610.00757

• Gelder, Michael G. New Oxford Textbook Of Psychiatry. Oxford: Oxford University Press, 2012. Print.• FICHTER, MM; QUADFLIEG, N; HEDLUND, S. Long-term course of binge eating disorder and bulimia nervosa: relevance for

nosology and diagnostic criteria. The International Journal Of Eating Disorders. United States, 41, 7, 577-586, Nov. 2008. ISSN: 1098-108X.

• CR168. JUNIOR MARSIPAN: MANAGEMENT OF REALLY SICK PATIENTS UNDER 18 WITH ANOREXIA NERVOSA, Royal College of Psychiatrists available at http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr168.aspx

• ULFVEBRAND, S; et al. Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research. Sept. 6, 2015. ISSN: 0165-1781.

• TREASURE, J; STEIN, D; MAGUIRE, S. Has the time come for a staging model to map the course of eating disorders from high risk to severe enduring illness? An examination of the evidence. Early Intervention in Psychiatry. 9, 3, 173-184, June 2015. ISSN: 17517885.

• ROJO-MORENO, L; et al. Prevalence and comorbidity of eating disorders among a community sample of adolescents: 2-year follow-up. Psychiatry Research. 227, 52-57, May 30, 2015. ISSN: 0165-1781.