1. Eating DisordersInformation for relatives and friends Dr Harry Millar

2. What are eating disorders? • What are the effects on families and friends? • What help is available?

3. What are Eating Disorders?

5. Anorexia Nervosa • Body weight < 15% below expected or BMI 17.5 or less • Self induced weight loss • Eating restraint • Self induced vomiting,laxative abuse, excessive exercise, abuse of appetite suppressants / diuretics • Body image distortion • Amenorrhoea (Loss of sexual libido in men)

6. Body Mass Index (BMI) Weight in Kilograms/Height in metres squared e.g. 70Kg weight 1.8Metre height 70/1.8x1.8 =70/3.24 =21.6 e.g 37 Kg weight 1.7 Metre height 37/1.7x1.7 =37/2.89 =12.8 Healthy range 20-25 approx

7. Anorexia Nervosa • Body weight < 15% below expected or BMI 17.5 or less • Self induced weight loss • Eating restraint • Self induced vomiting,laxative abuse, excessive exercise, abuse of appetite supressants / diuretics • Body image distortion • Amenorrhoea (Loss of sexual libido in men)

8. F50.2 Bulimia NervosaGreek: Bous=Ox Limos=Hunger

9. Bulimia Nervosa (F50.2) • Persistent food craving pre-occupation, and binge eating • At least one of • Self induced vomiting, laxative abuse, starvation, abuse of appetite suppressants, thyroid drugs, diuretics • Morbid dread of fatness

10. Other Eating Disorders “Atypical” or Eating Disorder Not Otherwise Specified (EDNOS) • One or more of key features absent • Otherwise can be typical picture • Includes Binge Eating Disorder • Overweight binge eaters • No compensatory behaviours Patients often move from one group to another

11. Fairburn CG and Harrison PJ. Lancet 2003

12. Symptoms • Fear of uncontrolled eating and weight gain • Binge eating and compensatory behaviours • Distorted body image perception, mirror gazing

13. Distorted Body Image

14. Symptoms • Fear of uncontrolled eating and weight gain • Binge eating and compensatory behaviours • Distorted body image perception, mirror gazing • Pursuit of thinness • Food preoccupation, avoidance, restricted choice • Anxiety eating in company • Guilt after eating • (True loss of appetite) • Overactivity

15. Non specific symptoms • Depression, low self esteem and self blame • Lack of assertiveness • Obsessional, rigid and inflexible thinking • Thinking slowed • Social withdrawal and irritability • Self harm

16. Anorexia nervosa Emaciation, Cold extremities, Lanugo Slow Pulse, low BP Anaemia/leucopaenia Hypothermia Osteoporosis Oedema Constipation Infertility Bulimia nervosa Electrolyte abnormalities Dehydration Parotid enlargement Hoarse voice Damaged tooth enamel Loss of bowel tone Vomiting blood Finger Scars - Russell’s sign Physical features

17. Effects on Families and Friends

18. Effects on families • Extreme level of burden – greater than schizophrenia • Perplexed about cause • Often self blame by parents • Frustration at other’s lack of understanding • Including professionals • Fear of long term effects • Physical, mental, and social • Helplessness and hopelessness • Uncertainty about how much daughter can help herself • Tried everything – nothing makes any difference • Feeling controlled by the illness • Interference with family life • Difficult to make plans

19. Responses in the family • Sadness up to severe depression • Extreme anxiety – fear she will die • Spending hours over meals, shopping etc. • Anger and hostility • Fear of stigma • Wishful thinking • Externalising the illness • The anorexia as an enemy or alien possession

20. Help for Eating Disorders • Community, voluntary and self help • Primary care • Specialist care

21. Community/self help • Books • Web sites • Support services • beat • NEEDS • NHS services • SEDIG

22. Books – See beat web siteclick on books from Amazon • Eating Disorders: helping your child recover • S Bloomfield, 2006, Eating Disorders Association • Understanding eating disorders • R Palmer, 2005, Family doctor publications • Anorexia nervosa. A survival guide for families friends and sufferers • J Treasure, 1997, Psychology Press • Skill based learning for caring with a loved one with an eating disorder : the new Maudsley method • J Treasure, G Smith and A Crane, 2007, Routledge • Anorexia and Bulimia in the family • G Smith, 2004, Wiley

23. NICE QIS NICE and QIS Guidance Eating disorders: anorexia nervosa, bulimia nervosa and related eating disorders Understanding NICE guidance: a guide for people with eating disorders, their advocates and carers, and the public Eating Disorders in Scotland A Patient’s Guide

24. Some useful web sites • http://www.something-fishy.org – Full of excellent information including a chat room. • http://www.grrr.demon.co.uk/eat.html – Lucy Serpell’s eating disorder resource page has many links. • http://www.anred.com/toc.html - Information about anorexia nervosa, bulimia nervosa, binge eating disorder, and other less-well-known food and weight disorders. • www.anitt.org.uk/ - Click on downloads for care pathways for anorexia nervosa • http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=308 - Institute of Psychiatry • www.patient.co.uk – Links to information and other sites • http://www.rcpsych.ac.uk/Royal College of Psychiatrists

25. Sources of information, advice, support • Beat • Helplines, 01603 621 414 - under 18, 01603 765 050 • www.edauk.com • Local NEEDS Group – Meetings first Monday of month • 01224 557652 - Answering service • www.needs-scotland.org • North of Scotland Managed Clinical Network (MCN) • 01224 557858 • www.eatingdisorder.nhsgrampian.org • Grampian Eating Disorders Service • 01224 557392 • Scottish Eating Disorders Interest Group (SEDIG) • www.sedig.members.beeb.net

26. Primary care • Usual first point of contact for professional help • variable response • Have continuing responsibility even if patient is seeing a specialist • During normal hours your practice • Out of hours • NHS 24 – 08454 242424 • G-Meds • A and E • Can access psychiatric services via them

27. Specialist Care • Can be • General Medical if uncertain diagnosis or physically unwell • General Psychiatric if urgent or emergency worry about mental state e.g. depression and suicidality • Specialist Eating Disorders (Psychiatric) • For Advice • For Assessment and advice • For Treatment • Usually multiprofessional mental health team • Most patients will just see one or two team members but other team members may advise

28. Grampian Eating Disorder Service

29. Staffing • Consultant Psychiatrist 0.5 • Psychologist 0.8 • CBT therapists 3.0 • Nurses 1.6 • OT 0.4 • Psychologist 0.8 • Dietitian 1.0 • Secretaries 1.0 ?social work, general medical, junior psychiatrist

30. Referral to Triage Assessment • Referral received (usually from GP) ↓ • Referral documented ↓ • Clinical Meeting ↓ • Referral accepted / not accepted ↓ • Opt in procedure with standard letter and questionnaires ↓ • Scoring of questionnaires ↓ • Triage assessment clinic ↓ • Suitable / unsuitable for EDS ↓ • Waiting Lists for Treatment

31. Assessment • Opt in questionnaires • Risk assessment/prioritisation • But don’t do emergency/urgent • GP and General Medical/General Psychiatric Services • Triage Assessment • Extended assessment • In patient assessment • Therapy Assessment • Physical Assessment • In abeyance

32. Telelinks • Peripheral clinics • Orkney • Shetland, Lerwick and Unst • Peterhead • Fraserburgh • Aboyne • Stonehaven • Elgin • Turriff • Priory Hospital • Management meetings

33. Treatment/Management • Individual therapy • Maybe alongside group treatments e.g.Self esteem, body image • Group treatments • Bulimia group • Overeaters group • Video therapy • Dietetic input (alongside other therapy) • Nutritional education - 6 group sessions • Individual sessions • Medical • Medication • Monitoring • Family support

34. Specialist Treatment Strategies • Engage the patient Motivational Interviewing • Psychological treatments • Drug treatments • Hospital admission

35. Psychological TreatmentsAnorexia Nervosa • Individual Psychotherapy OP. • continuity of care with single therapist who can co-ordinate other aspects of treatment. • long term follow up. • Family therapy / counselling • Group therapy - usually an adjunct • psychoeducational /nutritional/cooking • psychodynamic / CBT

36. Psychological TreatmentsBulimia Nervosa • More effective than drug treatment • Cognitive Behavioural Therapy (CBT) • 10 to 18 sessions of one hour (Video?) • response rates of 60-80% • Other techniques eg Interpersonal therapy (IPT) but less available • Individual/Group treatments • Self help/Guided self help/Internet/CD/

37. Drug treatmentAnorexia Nervosa • No drugs affect the course of illness. • Some drugs may help particular symptoms: • Depression - antidepressants • obsessionality – anti–obsessional drugs i.e. clomipramine in low dose / Selective Serotonoin Reuptake Inhibitors (SSRIs) • dietary supplements eg. calcium / oestrogen • ? Antipsychotics e.g. Olanzapine

38. Drug treatmentBulimia Nervosa • SSRI’s • direct but modest anti-bulimic effect • Fluoxetine best tested • Paroxetine and Fluvoxamine don’t work • Need high doses 60mg Fluoxetine • Other drugs as per A.N. • Potassium supplements if low potassium

39. Hospital Admission • What are the aims? • to save life • to treat the disorder • to relieve anxiety (doctors / patient / relatives • Medical of Psychiatric • Voluntary or compulsory

40. Mother of 2 20lbs heavier than 1966