anorexia ftx med students 2013

8/12/2019 Anorexia Ftx Med Students 2013

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Anorexia Nervosa

Family Therapy

Campbell Thorpe

Enhanced headspaceSouth Eastern Melbourne


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Starvation


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DSM-5 Diagnostic Criteria

1. Restriction of energy intake relative to requirements

leading to a significantly low body weight in thecontext of age, sex, developmental trajectory, and

physical health.

2. Intense fear of gaining weight or becoming fat, even

though underweight.

3. Disturbance in the way in which one's body weightor shape is experienced, undue influence of body

weight or shape on self-evaluation, or denial of the

seriousness of the current low body weight.


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Fear of gaining weight

Refusal to maintain body weight above 85% ofthe expected weight for a given age and height

Amenorrhea Refusal to admit the seriousness of the weight

loss

Undue influence of shape or weight on one's selfimage

Disturbed experience in one's shape or weight


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Restricting Type

Binge-Eating/Purging Type


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Prevalence

0.53.7% of adolescent and young adult women

meet the criteria for Anorexia Nervosa

1.14.2% meet the criteria for bulimia nervosa

Male: female ratio ranges between 1:6 to 1:10

Sub-clinical eating disorders even more pervasive

64% of normal weight women and 23% of normal

weight men with no history of weight problems

are dieting


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Prevalence

In developed societies, anorexia nervosa is thethird most common chronic illness for youngfemales. (obesity & asthma are 1 & 2)

Ten times more common than insulindependent diabetes.

Average Duration of Disorder 5 years

First degree female relatives are 10 timesmore likely to develop anorexia than otherrelative


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Mortality

Mortality Rate 20% after 20 years

5 times greater than same aged population

Deaths from natural causes 4 times greater (eg.

cardiac arrhythmia, infection) Deaths from unnatural causes 11 greater

Suicide is 32 times that expected for same agedpopulation.

To compare with major depression: Overall mortalityrate is 1.4 times that expected, unnatural deaths 7times and suicide 20 times greater than expected.


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Complications

Brain atrophy - effects on cognition

Cardiac arrhythmias

Growth retardation

Infertility

Osteopaenia leading to osteoposoris

Renal and hepatic function impairment

Neurogenic bowel dysfunction

Dental damage


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Cardiac complications

80% patients with ED affected

Reported complications

Bradycardia


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Biopsychosocial Illness

Biological

SocialPsychological


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Social Influences

Ethnicity

Social class

Career Culture

Family culture

Family changes and adaptations


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Social influences

Ache - body dissatisfaction parallels introduction ofmass visual media

New Zealand a study was done which found that 80%of the females were within normal weight limits, butonly 18% of them thought their weight was normal.

Thirty years ago the average model was 8% thinnerthan the average woman. Now the average model is23% thinner than the average woman.

Dieting is a $33 billion industry in the states

The failure rate for diets is 95-98%.


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Biological

Search for neurotransmitter dysfunction

Abnormal response to anorectic effects of

estrogen

Cognitive dysfunction

Executive

Affective

Self perpetuating nature

Complications


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Psychological

Personality Traits

Perfectionism

Fear of offending others Self Esteem

Control

Fear of psychosexual development Exposure to abuse


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Examination

Postural blood pressure and pulse

Beware bradycardia :ECG

Concern if > 20 mm drop or pulse differential 30

Temperature


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Bloods

EUC/Ca /Mg/PO4/glucose/FBC/LFT

Bloods for differential diagnosis TFT, coeliacscreen, ESR

Micronutritional deficiencies B12, folate VitaminD, Zn, Iron studies

Beware hypokalaemia (


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Treatment


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BED CHART COPY Date: ____________ UR:

LEVEL FIVE

Breakfast:

1 serve cereal with 1 serve milk

2 slices toast with margarine or butter and choice of spread (spread optional)

Tub yoghurt*

2 x juice (apple or orange) or 1 piece fresh fruit (banana or apple or orange or pear) or preserved fruit

Glass of water

Morning Tea: Purple snack (see below for choices) and glass of water

Lunch:

6 point sandwich. Filling to include:

At least one from: tuna or salmon or chicken or ham or cheese* or egg or beef

At least one from: lettuce, tomato, carrot, beetroot, cucumber, onion Margarine

Dessert: yoghurt* or 2 ice creams* or main dessert or jelly and ice cream


Glass of water

Afternoon Tea: Purple snack (see below for choices) and glass of water

Dinner:

Medium serve of a hot meal from menu. Meal to include:

Hot main (from the 3 listed in the left column of menu)

Choice of 2 from the following: Rice (if available) or potato (chips or mashed) or slice of bread with

margarine (may have 2 serves of the same item)

At least one hot vegetable or side salad

Dessert: yoghurt* or 2 ice creams* or main dessert or jelly and ice cream


Glass of water

Supper: Purple snack (see below for choices) and glass of water

Purple snack list

Muesli bar

Fruit & nut bag

Breaka and (chocolate or strawberry) dry biscuits and cheese*

Breaka and (chocolate or strawberry) Fruche*

Custard and sultanas

Custard and muesli bar

Yoghurt and muesli (available at morning tea only)*

2 packets of dry biscuits, 2 portions cheese and 1 serve milk*

2 packets of sweet biscuits, glass of milk and muesli bar

* Denotes 1 serve of calcium. You need to include 4-6 serves of calcium on each menu

Please note that flavour preferences may only be nominated for items with flavour options listed

Dislikes: Boluses:

Ensure Plus

Breakfast 2 cans

1.___________________________ Morning Tea 1 can

Lunch 2 cans

2. ___________________________ Afternoon Tea 1 can

Dinner 1 cans

3. ___________________________ Supper1 can

Developed by Dietetics Department, Monash Medical Centre Updated June 2010

G:\diet\Dietetics\Eating Disorders\Meal Plan Levels\Bed Chart Meal Plans.doc


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Treatment

Resuscitation

Nutritional support

Family Therapy Maudsley FBT

eCBT

Longer term supportive therapy


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Medication

No evidence


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Reversibility with weight restoration

Spanish study 40 adolescent girls with AN

f/u 9 -18 months

Echo changes Myocardial mass returned to normal

ECG changes

QT prolongation improved Bradycardia resolved


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Family Therapy

What is it?


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Family Therapy

Using relationship(s) with a family or subsystem

To change

Relationships

Understandings

Beliefs

Expectations

Behaviour

Communication


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Why Use Family Therapy?

Family role:

Aetiology of a disorder

Maintenance of a disorder

Management of a disorder

Recovery from a disorder

Achieving a developmental process


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Ideal Family Characteristics

Boundary - defined, semi-permeable

Clear internal boundariesage appropriate

Clear hierarchy of authority

Clear communication between members

Effective conflict resolution and problem

solving


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Ideal Family Characteristics

Flexibility and definition of members roles

Tolerance of difference and encouragement of

individual identity

Positive emotional climaterespectful,

committed, trusting, caring, forgiving, playful,

humorous

Consideration of individual and group needs


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Spectrum of Family Input

Collateral history

Psychoeducation

Illness effect upon family

Co-opted therapists/treating team

Maintaining factors

Causative factors


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High Care

Low Control

High Control

Low Care


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High Care

Low Control

High Control

Low Care

ChaoticConduct disordered

DepressedRebellious

AnxiousAnorexic

Psychosomatic

Enmeshed


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Family as a System

Components interact

Established patterns of interaction

Homeostatic mechanisms

Keep things the same

Information and behaviour change the system

System in regular developmental flux


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Symptoms

Symptoms may have a role within the family

What role could the symptom serve within

this family?

What role does the family have in maintaining

the symptom?


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Cyclical Interactions

Child anxiousabout

relationship

Child seeks outparent and

becomes clingy

Parent feelsintruded upon

and sick ofclinginess

Parentreluctantly

comforts childand disengages

as fast aspossible

Parent does notgive spontaneouscomfort to child


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Simple Family Therapy Techniques

Changing perspectives

New information

Getting in the others shoes

Noticing exceptions

A different understanding

Doing something different

Changing roles

Prescribed behaviour


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Simple Family Therapy Techniques

Different forms of communication

Reinforcing hierarchy and subsystems

Defining the real problem

Who?

Externalising

Avoiding the detail

Redefining development

Umpiring/Brokering


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Family Therapy and Anorexia

Family to help feeding

Family roles and conflict resolution

Adequate attention and valuation

Encouraging independence

Solving other problems within the family


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anorexia ftx med students 2013

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