eating disorders - shared careeating disorders the expanding spectrum between primary and secondary...

Eating Disorders The expanding spectrum between

primary and secondary care

Dr Pallavi Nadkarni MD, MMEdSc, MRCPsych

Attending Psychiatrist & Assistant Professor nadkarnp@kgh.kari.net

14th CCMHCC

Disclosure Grants/supports: Nil

Conflict of interest: Nil

Eating Disorders Diagnostic enigma

Learning objectives Impact of ED on mental health Impact of ED on physical health Importance of collaborative care

Topics covered Classification of ED Statistics Clinical features Aetiology Comorbid mental health issues Medical complications Management

Classification

AN BN

(Fairburn & Wilson 1993)

EDNOS

DSM- IV Vs 5

DSM IV DSM 5

BED EDNOS Separate

ARFID - +

AN/BN + +

Magnitude of the problem

EDNOS 5%

BN 3%

AN 1%

AN 45%

BN 12%

Core clinical features

Triad of •Fear of fatness •Dissatisfaction •Intense loathing

Historical aspects Religion- St Catherine (1380) Morton (1689) Lasegue & Gull (1870’s) Pierre Janet Hilda Bruch Russell (1990’s) Minnesota experiments (Keys et al 1940’s)

Aetiology Genetic: MZ (65%), DZ (32%)

Familial: obesity, drug use, affective disorders

Personality Psychodynamic theory Social

Aetiology Organic basis- fMRI findings, 5HT, BDNF, NE, HPA

Behavioural basis

Ethnic variations African-American

Latin- American

Japanese

Broad comparison ED AN BN

Described William Gull (1868) Gerald Russell (1979) Eating Starvation Bingeing BMI < 17.5 > 17.5 Age 16 yrs avg Early 20s M:F 1:6- community

1:10- clinical Types • Restricting

• Binge-eating/purging • Purging • Non-purging

PMP Cluster C Cluster B Crossover As much as 50% Fewer (? 1%) Menses Amenorrhoea x3 cycles -

Males Vs females Rapid osteoporosis GID Premorbid obesity M:F= 1:4 in adolescents, 1:10 adult Binge/exercise > purge

(Carlat et al 1997, Andersen et al 2000)

Psychiatric comorbidity

•Affective disorders •Anxiety spectrum disorders (Hudson et al, 2007)

•Dissociative disorders •Body dysmorphic disorder •Substance use •Personality disorder •Multi-impulsive variant: BN (Lacey 1993)

Depression & ED

Depression Eating disorder

•Fatigue

•Lethargy

•Self harming

•High cortisol

•Low T3

Medical complications

REPRODUCTIVE SYSTEM

•Amenorrhoea: 20% •Infertility •Pregnancy: Caesarean section, PPD, SGA babies •Polycystic ovaries: BN

Medical complications

PERINATAL COMPLICATIONS

•Nuchal cord •Placental infarctions •Hypotonia •Cardiomyopathy •Hypothermia (Favaro et al, 2006)

Medical complications OTHER ORGANS

•Pancreas •Liver- NASH •Endocrine- thyroid, cortisol •Kidneys •Bone •Heart- QTc •Blood •Glands •Skin •Eyes •Teeth

Associated disorders

•Orthorexia •Muscle dysmorphia •Anabolic steroid use

Interesting facts Anorexia: misnomer Bulimia: ox-hunger Reverse AN/ bigorexia nervosa

True or False Childhood sexual abuse is an absolute risk factor for ED.

(Pope et al 1994)

Management APA (2006) NICE (2004)

Principles of treatment Therapeutic alliance Collaboration Physical complications Psychiatric issues

“Therapeutic alliance and not treatment

dictates improvement.”

(Krupnick et al, 1996)

Screening questions

SCOFF: =/>2

S- sick C- control loss O- one stone in 3 months F- fat F- food dominates

(Morgan et al, 1999)

Rating scales Yale- Brown- Cornell Eating disorder scale Eating Disorders Inventory Eating Attitudes Test

Physical examination Vitals BMI General Systemic SUSS test

Laboratory tests Haematology: low Hb, low WBCs Thyroid: low T3 Electrolytes: low Na, Ka, Mg, P, Ca, Cl alkalosis Sugars: < 60mg/dl Hepatic: high enzymes, bilirubin GI: raised amylase Gynaecology: low FSH, LH ECG: prolonged QTc, RAD, ST-T abn

Treatment setting- inpatient HR< 40/min BP< 90/60 mm Hg K< 3meq/l Glucose < 60 mg/dL BMI <13, <16

Dehydration Organ failure

Ethical issues Compulsory treatment

Other aspects Refeeding syndrome Drug prescribing: antidepressants, antipsychotics Psychological treatments

Treatment implications Purging behaviours- ?? Retained ADD CPS guidance on anti-depressant

Novel treatments CREST = cognitive remediation & emotional skills training EABT= emotion acceptance behaviour therapy DBT MANTRA (UK) Salut-BN

Studies INTERBED (Germany) SWAN (Australia)

Prognosis Chronicity Cross-over Mortality: 6% per decade (Sullivan 2002)

Case vignette- 1 Alice was a perfect child. Her room was always clean & her school

work was always completed on time. At age 6 she was fascinated

with her Barbie doll. She would say, “ I wish I could look like her.”

At age 18, she left for college. When she returned for the summer

vacation, she had lost 20 pounds. When her family pointed it out,

she exclaimed, “ I need to lose weight, I am too fat.” While her

family dined, Alice ate a dry toast & drank a diet Pepsi. She

exercised excessively .She began buying cookbooks & preparing

family meals.

Diagnosis AN: restricting type

Case vignette- 2 Russ is a 27-year old model who is concerned about his weight &

figure. He constantly fasts & exercises to maintain his weight. For

the last year he has started engaging in binge eating. At least

thrice a week, he visits a restaurant that serves buffet meals. He

piles food on his plate. He generally eats huge portions over 2

hours. Then he goes to the bathroom and makes himself sick with his

fingers. He continues his binge after which he is subsumed with

guilt. He then compensates by running to burn extra calories.

Diagnosis BN: purging type

Case vignette- 3 Judy is a 23 yr old medical student who has always been

concerned about her weight. She often feels an uncontrollable urge

to eat junk food such as cookies & pastries. She is concerned about

her weight gain. Hence she routinely chews & spits out the food

rather than swallowing it.

Diagnosis EDNOS

Take home message Eating disorders: dilemma Collaborative care

BMI, physical examination, lab reports Avoid bupropion

Thank You