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Eating Disorder Primary Care Workshop

Eating Disorder Primary Care Workshop. Jaco Serfontein. What are Eating Disorders?. Complex psychological disorders Serious Physical complications Mortality increased Psychiatric co-morbidity People often ambivalent about treatment. AN in History. Holy Anorexics

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Eating Disorder Primary Care Workshop

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  1. Eating Disorder Primary Care Workshop Jaco Serfontein

  2. What are Eating Disorders? Complex psychological disorders Serious Physical complications Mortality increased Psychiatric co-morbidity People often ambivalent about treatment

  3. AN in History Holy Anorexics St Catherine of Siena (14th Century)

  4. Victorian Fasting Girls Sarah Jacob – The Welsh fasting girl (1857-1869) Mollie Fancher – The Brooklyn Enigma (1845-1916) Josephine Marie Bedard – The Tingwick Girl Therese Neumann (1898-1962) - Bavaria

  5. Diagnostic Criteria - AN • DSM-5: • Markedly low weight (Body weight < 85% of expected in DSM-IV) • Intense fear of gaining weight or persistent behaviour to avoid weight gain • Weight and shape disturbance • (Amenorrhea in DSM-IV) • Restricting type and binge-eating/purging type

  6. BMI

  7. Bulimia Nervosa • Recurrent episodes of binge eating once per week • Recurrent inappropriate compensatory behaviour in order to prevent weight gain • Present for 3 months • Self-evaluation unduly influenced by body weight and shape (morbid fear of fatness) • Two subtypes • Purging type • Non-purging type

  8. NoS-FED or atypical Disorders of eating or weight control: resembles AN or BN but do not reach their diagnostic criteria • subthresholdcases • partial syndromes

  9. Binge-Eating Disorder (DSM-5) • Binge eating (once per week for 3/12) • Binges associated with 3 of: • Eating rapidly • Uncomfortably full • Large amounts when not hungry • Alone because embarrassed • Guilty, depressed, disgusted • Marked distress • No compensatory behaviour

  10. AN BN ED-NOS Categories and movement between diagnoses Fairburn & Harrison (2003). Lancet 361, 407-16.

  11. The patients Anorexia nervosa weight/shape related psychopathology not always present culturally influenced highly visible reluctant patients who deny their problems others concerned outcome poor mortality high (20% at 30 yrs; 1/3 = suicide) early-onset  shorter stature Bulimia nervosa weight/shape related psychopathology central strongly culture-bound invisible “shameful secret” ambivalent patients others unaware outcome fair mortality not raised

  12. Clinical features AN BN BED Specific psychopathology strict dieting +++ +++ - self-induced vomiting + ++ - laxative misuse + ++ - over exercising ++ + - bulimic episodes + +++ +++ ritualistic eating habits ++ - - anxiety when eating with others +++ +++ + over-evaluation of shape & wt +++ +++ +

  13. Clinical features AN BN BED General psychopathology depressive symptoms + +++ ++ anxiety symptoms + ++ + obsessional symptoms ++ + - impaired concentration +++ +++ - social withdrawal +++ + - substance misuse - + -

  14. Prognosis Outpatient AN – 80% remission after 5 years Keel and Brown, 2010 Inpatient AN – 48% remission after 12 years Fichter et al, 2006 Swedish adolescent females inpatients 9-14-year follow-up study Anorexia nervosa • 21.4%dependent on society for income • 8.7% persistent psychiatric problem requiring hospital care • mortality: 1.2% Hjern et al (2006) B J Psych 189, 428-432

  15. How common is ED? • AN prevalence 0.3 – 0.9, increasing in young women • BN 1-2 • BED 2? • Turnbull et al., 1996; Currin et al., 2005

  16. An average GP list On an average GP list of 2000 people expect: • 1-2 people with full AN • 18 people with full BN • 40 people with ED-NOS

  17. Eating disorders in males AN - 5-10% BN 10-15% (0.2%) of young males BED ~20% symptomatology quite similar to females later age of onset (18-26) vs (15-18) higher premorbid weight body image dissatisfaction - lean tissue athletic pursuits / job sexuality osteoporosis more rapid & severe

  18. What causes AN? • Complex psychological illness with no single cause • Combination of biological, psychological and sociocultural factors • First degree relatives of AN have a ten-fold increased lifetime risk of developing AN (Pinheiro, 2009) • Anorexia – specific heritability • Bulimia – general heritability

  19. Medical complications

  20. Etiology Starvation Fluid and electrolyte disturbance Direct local damage due to eating disorder behaviour Endocrine changes Changes in liver function Refeeding

  21. Cardiac-related Eliana and Luisel Ramos

  22. Multiorgan Failure Christy Henrich Ana Restin

  23. Suicide Anna Westin

  24. Biochemical abnormalities • Could have any abnormality, hypo >> hyper • ↓K • ↓ Na • ↓Mg • ↓glucose

  25. Refeeding syndrome • Refeeding of severely malnourished AN (esp parenteral) and bingeing • Severe intracellular shifts in fluids and electrolytes, esp PO4 (also Mg, K, Thiamine) • PO4 nadir in first week • Decreased PO4 = decreased ATP • Very low PO4 directly cardiotoxic • Clinical • Muscle weakness • Cardiac - arrhythmias, failure, pericardial effusion • Neurological – delirium (can occur > 1week and after PO4 has recovered), coma, death • Haematological – leukocyte dysfunction, haemolytic anaemia, platelet dysfunction

  26. Osteoporosis (oestrogen, cortisol, GH, IGF-I) Early, frequent and serious complication of ED Increased resorption (as result of decreased oestrogen and increased glucocorticoids) and decreased deposition (low IGF-I) No correlation with calcium intake, exercise or HRT 40% of women with AN has osteoporosis (>2.5 SD) 92% of women with AN has osteopenia (>1 SD) (Vestegaard et al, 2002) 7x higher fracture rate than healthy women of same age • Treatment • Refeeding • Weight bearing exercise? • HRT? • Bisphophanates?

  27. Direct local damage related to binge-eating and purging • Parotid swelling • Oesophageal damage • GER reflux • GI bleed • Post-binge pancreatitis • Acute gastric dilatation • Colonic volvulus • prolapse

  28. Gastrointestinal system - chronic • Due to starvation • Abnormal oesophageal motility • Delayed gastric emptying • Increased colonic transit time • Laxative abuse -> colonic autonomic nerve degeneration • Liver • Fatty infiltration (lipogenesis > lipolysis) • Increased ALT (less than 4x), benign • Rarely can progress to Nonalcoholic steatohepatitis (higher risk in older, dual diagnosis, obesity and AST/ALT>1)

  29. Cardiovascular System • 1/3 of deaths in adults with eating disorders • Starvation related • Hypotension and bradycardia • Mitral valve prolapse • Fluid and electrolyte balance related (and severe starvation) • Arrhythmias (prolonged QTc) • Refeeding • Cardiac failure • Eating disorder behaviour related • Ipecac related cardiomyopathy

  30. Endocrine System Reproductive Low FSH, LH, oestrogen, testosterone Adrenal High cortisol Growth hormone axis High GH, low IGF-I Thyroid Axis Low T3/T4, normal or reduced TSH ‘sick euthyroid’ Appetite Low leptin, high ghrelin and peptide YY

  31. Haematology Anaemia Mild leukopenia Thrombocytopaenia Decreased ESR

  32. Nervous System • Starvation related: • Pseudoatrophy, enlarged ventricles • Cognitive impairment • Peripheral neuropathy

  33. Skin and Hair Self-injury Dry skin Skin breakdown, pressure sores Carotenemia Dry, brittle hair Hair loss Lanugo

  34. Comorbidity with Diabetes • Type I • AN – no increase • BN – 3X increase • EDNOS – 2X increase • Type II • BED most prevalent

  35. Diabetes Insulin purging women > men Poor glycaemic control Early diabetic retinopathy Medical complications of ED higher Higher rate of other psychiatric diagnoses Treatment similar

  36. How would you recognise the following? • Vomiting • Water loading • Over exercise • Infection in low weight AN • Refeeding syndrome

  37. Treatment

  38. NICE OVERVIEW NICE guidelines (2017) recommend Support should include: Psychoeducation Regular physical health monitoring Multidisciplinary Involve family and carers

  39. Evidence based, disorder-specific psychological treatments • Anorexia Nervosa • Restricting EDNOS

  40. Evidence-based psychological treatments for anorexia • Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) • Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) • Specialist supportive clinical management (SSCM) Next step if unsuccessful or unacceptable • Eating-disorder-focused focal psychodynamic therapy (FPT) • Only 30% of adult cases are recovered at 1 year, 40-50% at 5 yrs • Limited evidence of fluoxetine in relapse prevention

  41. Children & adolescents Family interventions (first line or relapse prevention) produce recovery rates of 60-70% at 1 year, 70-90% at 5 yrs classical family therapy not necessary (Eisler et al. 2003)

  42. Evidence based, disorder-specific psychological treatments • Bulimia Nervosa • EDNOS • Binge Eating Disorder

  43. Stepped care approach • Explain that treatment limited effect on body weight • Bulimia-nervosa-focused guided self-help • Individual CBT-ED • Regularising eating • Reducing compensatory behaviours • Introducing emotional regulation skills • Problem solving skills • Addressing weight and shape concerns – anxieties, perceptual biases, attitudes etc • Medication should not be offered as sole treatment

  44. Treatment complications

  45. Maintaining Factors of AN Perpetuating consequences Predisposing traits Emotional avoidance Interpersonal Relationships Beliefs about The value of AN in the Person’s life Obsessive compulsive traits

  46. The Pros and Cons of anorexia nervosa (Serpell et al., 2002, 2003) 3 most important pro-anorexic beliefs were: Anorexia nervosa keeps me safe helps to communicate distress stifles emotion

  47. Iatrogenic Maintaining factors Treasure et al., 2011

  48. Difficulties • Secretiveness – highly functional, denial, difficult to detect • Ambivalence – engaging with services, about what recovery or treatment entails • Reactions of others (including services) – high expressed emotion, overly controlling, accommodating, dismissing • Physical & psychological complications of illness • Psychiatric and physical co-morbidity (e.g. PD / Diabetes)

  49. Treatment considerations • Collaborative and motivational approach vs MHA • Engagement and disengagement • Recovery and prognosis • Risk management • Shared care • Medication

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