Eating Disorders: What You Need to Know

Dr. William Rhys Jones, Consultant PsychiatristDr. Monique Schelhase, Associate Specialist

Yorkshire Centre for Eating DisordersLeeds

r.jones9@nhs.netm.schelhase@nhs.net

0113 855 6400

What you need to know........

• Diagnoses• Screening• How they present• Risk assessment• Referral pathways• Principles of

treatment

Eating Disorders

Anorexia Nervosa

BMI<17.5Core psychopathology

Amenorrhoea

Bulimia Nervosa

BMI>17.5Core psychopathology

Regular binge/purge 2x/week

Eating Disorder Not Otherwise Specified

Subclinical disordersBinge eating disorder

Eating Disorders

Anorexia Nervosa

1 in 250 females1 in 2000 males

Bulimia Nervosa

1 in 50 females1 in 500 males

Eating Disorder Not Otherwise Specified

More common still but rates uncertain

Eating Disorders

Anorexia Nervosa

BMI<18.5Core psychopathology

Bulimia Nervosa

BMI>18.5Core psychopathology

Regular binge/purge 1x/week

Other Specified Feeding and Eating Disorders

Subclinical disorders

Binge Eating Disorder

Clinical Features

• Core psychopathology

• General psychopathology

• Behaviours

• Physical complications

Core Psychopathology

• Fear of fatness

• Pursuit of thinness

• Body dissatisfaction

• Body image distortion

• Self evaluation based on weight and shape

General Psychopathology & Starvation Syndrome

• Minnesota experiment (Keys)

• Depression

• Anxiety, social phobia

• Suicidal ideation

• OCD symptoms

Common Behaviours

• Dieting• Fasting• Calorie counting• Excessive exercise• Water loading• Diet pills, thyroxine,

diuretics, appetite suppressants

• Excessive weighing• Body checking• Culinary behaviours• Avoidance• Isolation

• Bingeing• Purging• Starve-binge-purge cycle• Misuse of insulin• Laxatives• DSH• Substance misuse

System Starvation Bingeing/purgingCVS Bradycardia

HypotensionSudden death

ArrhythmiasCardiac failureSudden death

Renal OedemaElectrolyte abnormalities

Renal calculiRenal failure

Severe oedemaElectrolyte abnormalities

Renal calculiRenal failure

GI Parotid swellingDelayed gastric emptying

Nutritional hepatitisConstipation

Parotid swellingDental erosion

Oesophageal erosion/perforationConstipation

Skeletal OsteoporosisPathological fractures

Short stature

OsteoporosisPathological fractures

Endocrine AmenorrhoeaInfertility

Hypothyroidism

Oligomenorrhoea/amenorrhoea

Haem AnaemiaLeukopenia

Thrombocytopenia

Leukopenia/lymphocytosis

Neuro Generalised seizuresConfusional states

Generalised seizuresConfusional states

Metabolic Impaired temperature regulationHypoglycaemia

Impaired temperature regulationHypoglycaemia

Derm Lanugo, brittle hair and nails Calluses on dorsum of hands (Russell’s sign)

Differential Diagnosis

• Depression• Somatoform disorders• OCD

• Hypopituitarism• Addison’s disease• Thyrotoxicosis• Inflammatory bowel

disease / malabsoprtion (eg Crohn’s, coeliac)

• Diabetes mellitus• Carcinoma• TB

Don’t forget..........

• High rates of comorbidity (substance misuse, PD, depression)

• Cryptic AN• Anorexia tardive• ED in men

SCOFF Questionnaire

S -Do you make yourself SICK because you feel uncomfortably full?

C -Do you worry you have lost CONTROL over how much you eat?

O -Have you recently lost more than ONE stone in a 3-month period?

F -Do you believe yourself to be FAT when others say you are too thin?

F -Would you say that FOOD dominates your life?

Risk Assessment in Eating Disorders

• AN has highest mortality rate of any psychiatric disorder (Arcelus et al, 2011)

• Most deaths due to physical complications of dieting, bingeing and purging

• 20-40% of deaths in AN due to suicide

• Severe and enduring eating disorders (SEED)

Physical Risk Assessment

1. Clinical history and physical examination

2. Body mass index (BMI)

3. Electrocardiogram (ECG)

4. Blood investigations

1. Clinical History and Physical Examination

• Rapid weight loss (>1kg/week)• Physical comorbidity (e.g.

diabetes)• CVS (chest pain, postural

dizziness, palpitations, blackouts)

• Excessive exercise• Water-loading• Alcohol• Infection• Haematemesis• Pregnancy

• BMI• Irregular pulse• Bradycardia• Hypotension• Postural hypotension• Hypothermia• Proximal myopathy

2. Body Mass Index (BMI)

• BMI = wt(kg)/ht(m)2

• <17.5 – AN

• <15 – moderate risk

• <13 – high risk

• Proxy measure of physical risk

3. Electrocardiogram (ECG)

• Most deaths due to cardiac arrest• Cardiac abnormalities in up to 86% of patients

with AN (Lesinskiene et al 2007)• T wave changes (hypokalaemia)• Arrhythmias• Bradycardia (<40bpm!!)• QTc prolongation (>450ms!!)

4. Blood Investigations

• FBC• U&Es• LFTS• Glucose• CK• Phos, Mg, Ca• TFTs

Starvation Hypoglycaemia

Vomiting Hypokalaemia

Water-loading Hyponatraemia

Laxative misuse HyperkalaemiaHyponatraemia

Diuretics misuse Hypokalaemia, hyponatraemia

Thyroxine misuse ↑T3/T4, ↓TSH

Bone marrow hypoplasia

Normocytic anaemiaLeucopenia

Re-feeding syndrome HypophosphataemiaHypomagnesaemia

HypocalcaemiaHypokalaemia

Proximal myopathy ↑ CK, ↑ LFTs

Physical Risk in Eating Disorders Index (PREDIX)SYSTEM TEST OR

INVESTIGATIONMODERATE

RISKHIGH RISK

Nutrition BMIRate of weight loss

<15>0.5kg/week

<13 kg/m2

>1kg/week

Cardiovascular Blood pressurePostural drop

Pulse ratePeripheral cyanosis

<90/60 mmHg>10 mmHg<50 bpm

<80/50 mmHg>20 mmHg

<40bpmYes

Musculo-skeletal Stand up or sit up test (proximal myopathy)

Grade 2 Grade 0-1

Temperature <35°C <34.5°CBlood profile White cell count

NeutrophilsHaemoglobin

Platelets

Concern if outside normal

limits

<2.0 x 109/l<1.0 x 109/l<9.0 g/dl

<110 x 109/l

Biochemistry PotassiumSodium

Phosphate

Concern if outside normal

limits

<2.5 mmol/l<130 mmol/l<0.5 mmol/l

Electrocardiogram Pulse rateCorrected QT interval

(QTc)Arrhythmias

<50 bpm <40 bpm>450 msec

Yes

Planning and Coordinated Care

• Coordinated care by MARSIPAN group:– Physician with special interest in

ED– ED/Liaison Psychiatrist +/- CMHT– Dietician and nutrition support

team – Nursing team

• Regular MARSIPAN meetings• Clarify local care pathways• Role of commissioners

Principles of Treatment

• Usually done as an outpatient

• Most AN require specialist Rx

• BN & EDNOS will mainly be treated either in primary care or secondary services

• NG feeding last resort• Treatment on a medical

unit relatively rare

• Nutritional rehabilitation and psychological intervention

• Guided self-help, CBT, IPT, CAT, psychodynamic psychotherapy, family interventions, DBT

• Fluoxetine 60mg daily in BN• Best services offer eclectic

mix of therapies – not ‘one size fits all’

• CBT is not the panacea

Grading of Support

AN BN BED & EDNOS

Psychological

CBT A A A

DBT na A A

Family therapy A C na

Guided self help na A A

IPT B A A

CAT A na na

Pharmacological

Antidepressants C A A

Antipsychotics C na na

Antiobesity agents na na A

Naltrexone na C na

Ondansetron na C na

Topiramate na A A

Benzodiazepines na na naA = ≥ 1 RCT is supportive, B = RCT(s) not/less supportive, C = mixed/inconsistent results, na = no RCT, or not applicable

What can the GP do?

• Diagnosis & screening• Risk assessment / management• Medical monitoring (BMI, bloods, ECG)• Medication review• Food/thought diaries

(www.recoveryrecord.com)• Guided self help and support groups • Knowledge of local care pathways and

MARSIPAN

Self-help LiteratureAnorexia nervosa• Overcoming Anorexia Nervosa (Freeman 2009)• The Anorexia Workbook (Heffner 2004)

Bulimia nervosa and binge eating disorder• Overcoming Bulimia Self-help Course: A Self-help Practical Manual Using Cognitive

Behavioral Techniques (3-Book Set) (Cooper 2007)• Overcoming Bulimia Nervosa and Binge Eating: A Guide to Recovery (Cooper 1993)• Overcoming Binge Eating (Fairburn 1995)

Family and carers• Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New

Maudsley Method (Treasure 2007).

Eating disorders in men• The Invisible Man: A Self-help Guide for Men with Eating Disorders, Compulsive

Exercise and Bigorexia (Morgan 2008)

YCED REFERRAL CRITERIA & CARE PATHWAYS

Referral Criteria

We accept referrals for individuals who: • Have moderate to severe Anorexia Nervosa i.e. BMI<17kg/m², where weight loss is induced by dietary

restriction; self-induced vomiting/purging; excessive exercise; use of appetite suppressants or diuretics.

• Have severe Bulimia Nervosa i.e. daily bingeing AND daily purging; biochemical abnormalities; complicating factors such as diabetes or pregnancy.

• Require consideration for in-patient care for re-feeding or symptom interruption.

• Are 18 years of age or above, however, we can also accept referrals for individuals who are 17 if they are not in full time education.

• YCED will also offer consultation in complex cases, where an eating disorder is part of a comorbid condition.

We do not, however, accept referrals for individuals who have a current history of substance misuse or dependence and we would ask that such individuals remain abstinent for a period of 6 months before we offer any clinical input.

Care Pathways

For individuals registered with a GP within the Leeds catchment area:

• We accept direct GP referrals for individuals with a BMI<15kg/m²

• All other individuals should be referred to secondary mental health services through the Single Point of Access for a screening assessment (including a holistic and FACE risk assessment) in the first instance. Following this assessment secondary mental health services can then refer to YCED if specialist input is still felt to be needed.

For individuals registered with a GP outside of the Leeds catchment area: • All individuals require a named care

coordinator. This person should be based within the local CMHT but a GP can also take on this role if required.

• Referral via SPA.

• What about those who do not meet YCED referral criteria?

• Weekly YCED support group – 5:30pm, Weekly, Wednesday –OPEN group.

• b-eat (National Charity) website- www.b-eat.co.uk , chat forum.

• Self help literature• PCMHW/IAPT• YCED website - http://www.leedspft.nhs.uk/our_services/yced

What’s new in Leeds?

• 2010 - Alternative to repeated hospital admissions for SEED patients

• Maintain health and social functioning in the community

• Support patients to achieve independent living, promote confidence, self-efficacy and autonomy

• Tailored to patient’s needs

YCED Outreach Service

Referral Criteria

• Meets DSM-V criteria for AN for minimum of 4 years

• BMI 12.5-15• Several admissions to SEDU• Lack of response to long-term individual or

group therapies• >18 years• Must be at a minimum or above crisis weight for

hospital admission

2012 Evaluation Report

• Reduced number of hospital admission by 38%• Slight improvement in outcome measures• Face to face contact = 19 hr/week• Length of contact = 2-7.5 hr• Weekly to daily (5x/week) visits• Contact with other health professional =

2.5hr/week• Positive feedback from patients, carers, staff, LTHT

and most GPs

2012 Evaluation report recommendations:

• Offer Outreach service to more service users

• Offer Outreach service to less severe cases

• Increase staffing

• Rotation of staffFUNDING........................

Community Treatment Service

CTS aims and objectives • Promoting weight gain and healthy eating, reducing other eating

disorder related symptoms and promoting psychological recovery.

• Management of the complex needs of patients with eating disorders.

• To both minimise the instances of hospital admission, reduce inpatient stay and facilitate early discharge for those that can be appropriately treated in the community.

• treatment interventions recovery

• consultancy and liaison

CTS Operational information

• The CTS operates between the hours of 08:00 to 18:00 Monday to Friday and is based in the Newsam Centre.

• Interventions are largely be delivered within the community setting.

• HSW – will work 7 days a week (when needed) - weekend safety/advice

First 12 months.....EDE –Q• Reduction in the mean EDEQ scores = improvement in mental health. • Clinical improvement in eating disorder psychopathology - statistically

significant. CORE and Hospital Anxiety and Depression (HAD) scale• A decrease over time in the CORE and HAD scale scores typically indicates an

improvement in mental health. Both pre- and post- treatment means for all three outcome measures altered in accordance with a clinical improvement.

Rosenberg Self Esteem Questionnaire • An increase over time in the mean Rosenberg score indicates improvement in

self-esteem. An increase in the mean pre- and post- treatment values indicated an improvement in self-esteem which was also demonstrated to be statistically significant.

Treatment of eating disorders

• Foundation of treatment – Adequate nutrition– Stopping purging behaviours– Reducing excessive exercise– Individual /group therapy – Family interventions– Medication – Education

Treatment of AN

• CBT or other comparable modality eg IPT, CAT, DBT. – No difference between modality

• Medication – No evidence for SSRI for AN symptoms. – SSRI beneficial for treatment of comorbid

anxiety and depression

Treatment of BN

• Self help/guided self help programme (30%)

• E.g. Overcoming Bulimia Nervosa and Binge-Eating, Peter Cooper

• CBT-BN (1:1) is the most rapidly effective. • Equivalent evidence for other modalities

eg IPT, DBT

Medication

• Antidepressant drugs. • The antidepressants (SSRIs) - in particular

Fluoxetine - are the ones most often chosen for treating BN. Antidepressants can help the number of times an individual binges and purges. Their long term effects on eating problems are not known.

Psychological therapies

• MI/MET• CBT• CAT• IPT

Motivational Interviewing

‘The sun and the wind were having a dispute as to who was the mostpowerful. They saw a man walking along and they challenged each other about whichof them would be most successful at getting the man to remove his coat. The windstarted first and blew up a huge gale; the coat flapped but the man only closed all hisbuttons and tightened up his belt. The sun tried next and shone brightly making theman sweat. He proceeded to take off his coat.’ (Aesop’s fables)

• MI - useful intervention to engage individuals with severe eating disorders prior to participation in intensive treatment.

• MI as a brief prelude to hospital-based treatment for an eating disorder may help to improve completion rates in such programs.

Facilitated self help• SH and FSH approaches do not deal with the underlying factors that

precipitated the individual’s eating disorder. • The FSH sessions are delivered between 20 to 30 minutes• The model is explained to the client• The approach is delivered within a framework of collaborative working • The client’s readiness for change is assessed• The approach is focused – working on one goal at a time • Offer educational material on effects of starvation, purging and nutritional

needs • Offer exploratory exercises to build motivation for change• Use monitoring exercises to identify trigger factors • Self management skills

Cognitive Behavioural Therapy

• Suits most.• a combination of behavioural and cognitive

procedures to change individuals‟ behaviours, their attitudes and where relevant other cognitive distortions.

• The intervention normally last for 16 to 20 sessions over 4 to 5 months.

Cognitive Analytical Therapy

• Integrated –CBT and psychoanalytic approaches• Looks at how a patient thinks, feels and acts. • Think about problems/difficulties, naming

how previously learned patterns of thinking or behaving have contributed to difficulties and finding new ways of addressing them.

• Encourages reflection regarding the importance of relationships in ones psychological life.

Interpersonal Psychotherapy

• Enhanced interpersonal (IP) functioning will result in an improvement in psychiatric state.

IP event

mood/eating disorder

Focus: NOT on eating problem, instead on the IP context.

• In this approach, there is no emphasis on directly modifying eating habits; rather it is expected that they will change as interpersonal functioning improves.

Questions