Eating Disorders The expanding spectrum between
primary and secondary care
Dr Pallavi Nadkarni MD, MMEdSc, MRCPsych
Attending Psychiatrist & Assistant Professor [email protected]
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