Transcript Eating Disorders - Peninsula MRCPsych

For the treatment of eating disorders
Eating Disorders
Dr Bert Laszlo
Consultant Psychiatrist
HALDON Eating Disorders Service
Devon Partnership NHS Trust
November 2009
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For the treatment of eating disorders
What are we doing today?
• Discussion of major eating disorders – Dr.
Laszlo
– Break
• Etiology and psychological aspects – Elisa
Rivera
– Break
• Vignette discussions x 3 – Everyone
• Dietetic aspects of ED – Tanya Sturley
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For the treatment of eating disorders
History of Anorexia Nervosa
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For the treatment of eating disorders
• The term was first used 130 yrs ago, only
more recently that the diagnostic criteria
have become medical knowledge.
• Due to an increase in incidence and
diagnosis the impression may well be that
the disorder is a fairly “new” one however
a 1000 year old legend exists which
suggests that the illness was known to the
ecclesiastical authorities of the time.
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For the treatment of eating disorders
According to the legend, St Wilgefortis was the 7th
daughter of the King of Portugal. The King was known to
be tyrannical and cruel and their relationship was poor and
possibly incestuous. The relationship further deteriorated
upon her discovery of her father’s plans to marry her to the
King of Sicily. She had already made a vow of virginity and
planned to give her life to God and not man. She therefore
prayed to God to help her avoid the proposed marriage.
The intensity of her prayers impressed others and she
overcame her appetite as an expression of her selfless love
of God and to enhance her spiritual development. “She
begged the Lord to deprive her of all her beauty and God
granted her prayer” by causing her to develop a hairy body
and grow a beard. The King of Sicily withdrew his offer, and
her enraged father had her crucified. She claimed that she
had been liberated from “worldly care”.
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For the treatment of eating disorders
• The legend is one of a saintly, virgin
martyr who avoided her sexuality by
growing hair. She was seen to have
divested herself of female “care” or
problems. It spread throughout Europe
and a cult developed.
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Why is the legend suggestive of
a case of anorexia nervosa?
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For the treatment of eating disorders
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Driven, striving females
High ethical and moral standards
Higher social classes
Arises during early adolescence
Inability to cope with demands
Fears of adult sexuality
History of Abuse
Personality structure
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For the treatment of eating disorders
• Traditionally in medicine, both food
avoidance and overeating have been
looked upon as symptoms of
gastrointestinal disorders. Preoccupations
with body weight and shape have only
acquired medical attention in the last part
of the 20th century and only in
westernised countries. Therefore they
appear to be relatively “modern” clinical
entities.
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For the treatment of eating disorders
• For centuries extreme fasting was part of
the penitential or ascetic practice of pious
Christians. Later forms of long-lasting food
refusal not accompanied by symptoms of
well known diseases e.g. tuberculosis
were likely to stir up speculation about
supernatural powers or demonic
influences.
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For the treatment of eating disorders
• Morbid self-starvation only became recognised
as a distinct clinical entity in the second half of
the 19th century. In 1873 Lasegue (French) and
Gull (English) both provided independently the
first explicit description of anorexia nervosa.
• It was in the context of anorexia nervosa that the
modern notion of bulimia nervosa emerged. In
1979 Gerald Russell coined the term “bulimia
nervosa”
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For the treatment of eating disorders
ICD 10 – Anorexia Nervosa
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Weight < 85% expected (BMI <17.5)
Intense fear of gaining weight
Body image disturbance
Amenorrhoea (hypogonadotrophic hypogonadism)
• Restrictive vs binge-eating / purging
subtype in the DSM IV criteria(very
helpful)
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For the treatment of eating disorders
ICD 10- Bulimia Nervosa
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Recurrent episodes of binge eating –both of:
Large amount, discreet time period,craving
Sense of lack of control
Recurrent compensatory behaviour – to avoid wt gain
Eg;purging activities,periods of starvation,medication
At least twice a week X 3months
Self evaluation unduly influenced by body shape and
weight
Usually in normal weight range
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For the treatment of eating disorders
Differences between Anorexia nervosa
and Bulimia nervosa
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1. Incidence and prevalence rates:
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Incidence = number of new cases
presenting in a given time
Prevalence = total number of cases in
the population at one time
AN : incidence = 4-10/100 000/yr
prevalence = 10-30/100 000
BN: incidence = 5-15+/100 000/yr
prevalence = 50 -150/100 000
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2. Course and prognosis:
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AN: long time for recovery to occur
Recovery rates increase with time as chronicity rates decrease
10 yr follow up: 47% recover
33% improved
20 -25 % chronic course
High rates of relapse in the first year following treatment.
BN: course and outcome is more favourable.
50% - 74% recover completely therefore a significant number
still have clinically significant symptoms.
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3. Mortality rates:
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AN: MR = 6% overall, 0.5% per year.
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Higher MR than for BN – highest MR for any
functional psychiatric illness
Reasons: the illness,comorbidity,suicide
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BN: lower MR than for AN – 0.3% -1%
overall
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For the treatment of eating disorders
4. Treatment options:
Anorexia
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Limited evidence base from which to recommend the
most effective treatment
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NICE Guidelines – January 2004:
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Outpatient , psychological treatment for at least 6
months
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Family therapy > Ind.Th. (child and adolescents)
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Dietary counselling should not be provided as sole
treatment
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Limited evidence base for the use of medication in AN
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For the treatment of eating disorders
BN: NICE Guidelines – January 2004:
• First step = evidence based self-help
programme
• CBT-BN + IPT > BT (CBT-BN to be 16-20
sessions over 4-5 months)
• IPT is alternative to CBT-BN (8-12 months to
achieve results – improvement occurs 4 months
after treatment ends.
• May be offered trial of antidepressant – 1st
choice :SSRI’s esp. Fluoxetine
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For the treatment of eating disorders
Aetiology of eating disorders
•Predisposing
•Precipitating
•Perpetuating
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For the treatment of eating disorders
Predisposing factors - AN
• Personality traits: low self-esteem, perfectionism
seek ‘compliance’
• Depression & anxiety disorders (OCD)
• Pre-morbid obesity: 7 - 20% anorectics
• Female
• Feeding/GI problems –early child
• ? Over concerned parenting
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For the treatment of eating disorders
Predisposing factors -BN
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Female
Childhood obesity
Sexual abuse/adversity
Parental depression, alcohol or drug
abuse
• Parental obesity, weight/shape criticism
• Adverse family experiences
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For the treatment of eating disorders
The discovery of past abusive experiences
should be the beginning of further thought
for the clinician.
It should not be the occasion for premature
closure around the notion that all is now
explained
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For the treatment of eating disorders
Family Psychiatric History
• Lifetime risk of AN and depression in 1st
degree relative 3 times greater than
controls
• Genetic vulnerability:
– ? to anorexia nervosa
– ? to pre-morbid obesity
– ? to predisposing personality traits
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For the treatment of eating disorders
Family dynamics
Speculative research driven by dogma, but :
– ?More rigid family systems
– “Consensus sensitive”
– Family intervention particularly useful for
younger anorectics
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Sociocultural factors
• Sociocultural factors may better explain
body image dysphoria among Western
women in general than AN in particular
• Contiguity between thin female beauty
ideal and increased prevalence of eating
disorders
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For the treatment of eating disorders
Precipitating factors
• Dieting :
- intentional
– positive reinforcement (social, psychological,
physiological)
• Major life events
– (puberty, loss events, trauma)
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For the treatment of eating disorders
Perpetuating factors
• Cognitive distortions
• Interpersonal factors
• Physiology
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For the treatment of eating disorders
Risk assessment in Eating
Disorders
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For the treatment of eating disorders
Is it Anorexia Nervosa?
• Usually the history from self or informants
is clear
• 20%-30% atypical cases do occur
• Differential diagnosis: examine over time
(can they gain weight? – “watchful waiting”
over a few weeks) ESR, platelets, TFT,
albumin are useful screening tests.
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For the treatment of eating disorders
Risk factors in History:
• Excessive exercise with low weight
• Blood in vomit
• Inadequate fluid intake in combination with poor
eating – young patients tend to do this
• Rapid weight loss = 1kg/wk over a few months.
• Factors which may have interfered with ritualized
eating patterns e.g. holiday,
• exams,times of being evaluated etc.
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For the treatment of eating disorders
Monitoring:
• Weigh at each weekly therapy/review appointment
• Make sure that environment is conducive
• More detailed risk assessment if there are concerns regarding
nutritional and metabolic safety.
• If medical risk becomes high then:
(a)other professional and carers need to be involved
(b)intensity of care increased with family work, day or inpatient care.
– Estimate of calories needed for weight gain
– Estimate time needed for sufficient weight gain to occur to reduce
risk
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For the treatment of eating disorders
Medical risk assessment:
• on assessment, with weight loss and if previous risk
•Weight, height and BMI
•Tanner stage and height centile if premenarchal
•Stand up from squat test (SUSS) or sit up test
•BP, HR/sitting and standing
•Look for signs of peripheral shutdown, skin breakdown
•Core temp –tympanic membrane(electronic)
•Blood tests – FBC, U&E, LFT, glucose, phosphate,
magnesium, zinc
•ECG
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For the treatment of eating disorders
• Muscle power: patient is asked to squat
down on haunches and is asked to stand
up without using arms as levers if at all
possible.
• Sit up test: patient lies flat on a firm
surface such as the floor and has to sit up
without, if possible using her hands.
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For the treatment of eating disorders
NICE Guidelines (2004)
Medical risk assessment:
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For the treatment of eating disorders
• In the management of these patients good
practice involves discussions of issues of
confidentiality and necessary involvement
of other parties.
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For the treatment of eating disorders
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Examination:
BMI
Height centile (for stunting)
BP lie and stand
HR
Temperature
Sit up and squat test
Look for signs of peripheral shutdown
Skin breakdown
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For the treatment of eating disorders
• Investigations:
• HB, WCC, FBC –platelets
• U&E, renal function, LFT (if abnormal
check clotting profile)
• Glucose
• Mg, Ca, Phosph
• ECG
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For the treatment of eating disorders
• Moderate risk:
• See table (for guidance)
• Priority should be given to physical
examination
• Weekly monitoring
• Good practice – actively encourage
involvement of carers
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For the treatment of eating disorders
• High risk:
• See table (for guidance)
• Priority should be given to physical
examination
• CONSIDER URGENT MEDICAL
ADMISSION
• Consult specialist
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For the treatment of eating disorders
Indication for Admission
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Very low weight or rapid weight loss
Serious physical complications
Severe psychiatric co-morbidity
Failure of outpatient treatment
Need for separation from family
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For the treatment of eating disorders
IF VOLUNTARY ADMISSION REFUSED:
ASSESS CAPACITY
•Understand the nature of the health risk
•To assess the risks and benefits of
treatment /no treatment
•Able to weigh up the information rationally
•Make a fully informed choice with full
capacity
•Consider use of the Mental Health Act
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Treatment
The Mental Health Act
For the treatment of eating disorders
• Anorexia may be treated under Mental
Health Act
• Anorexia Nervosa may affect capacity to
make decisions about treatment due to
starvation effects and psychopathology
• Should be last resort
• In life-threatening circumstances,
compulsory feeding (e.g. naso-gastric)
under Section 3 of MHA is lawful
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For the treatment of eating disorders
Medical complications
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For the treatment of eating disorders
• Mouth, face and skin provide diagnostic clues…
• “Russell’s sign” – biting down on the hand to induce
repeated vomiting
• Dental erosion due to repeated exposure of teeth to
gastric acid
• Parotid or submandibular salivary gland enlargement
due to repeated vomiting
• Lanugo hair
• Dry skin
• Carotenoderma – high levels of betacarotene
• Cold blue hands, nose and feet.
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For the treatment of eating disorders
• Gastrointestinal complications…
• Constipation, esp with laxative abuse, atonic
bowel with sustained laxative abuse.
• Delayed gastric emptying
• Abnormal liver function tests
• Upper gastrointestinal bleeding - Mallory –
Weiss tear (oesophageal mucosa)
• oesophagitis (acid reflux)
• Very rare – acute pancreatitis, acute gastric
dilatation, volvulus, rectal prolapse, oesophageal
or gastric perforation.
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For the treatment of eating disorders
• Cardiovascular complications…
• Account for ~ 50% of deaths in AN
• Occur frequently in eating disorder patients, esp low weight
AN and BN patients with electrolyte abnormalities.
• Bradycardia
• Hypotension
• Poor peripheral circulation
• ECG abnormalities – sinus bradycardia
- ST and T wave changes
- reduced size of QRS complex
- prolonged QT/QTc interval (normal
QTc<450 msec)
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For the treatment of eating disorders
• Arrhythmias –serious in patients with disturbed electrolyte balance
• ECG changes are compounded by electrolyte disturbances, partic
K+
• Reduced oral intake (dehydration) = low BP + sinus bradycardia.
• Sinus bradycardia and sinus arrhythmia are both common in low
weight patients with AN but do not pose an increased risk of death.
• Ventricular arrhythmias cause sudden death.
• Reduced cardiac mass
• Mitral valve prolapse
• Cardiac failure – most likely on refeeding, parenteral feeding esp
dangerous, hypophosphataemia may be a factor.
• Refeeding oedema not due to cardiac failure but? due to low serum
proteins (albumin) but can occur with normal albumin. Also occurs
with previous heavy laxative abuse.
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For the treatment of eating disorders
• Neurological complications …
• myopathies – generalised weakness and muscle wasting
commonest, usually improves on weight restoration.
Raised CK (Creatine Kinase), very high if exercising
• peripheral neuropathies – may be due to mechanical
pressure on nerve from loss of fat and subcutaneous
tissue, may be due to nutritional deficit or metabolic
disturbance, peroneal nerve palsy (foot drop)
commonest.
• Brain changes – loss of volume and some functional
changes. Generally reversible on weight restoration.
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For the treatment of eating disorders
• Electrolyte disturbances …
• Hypokalaemia (Potassium deficiency)
• The most common electrolyte abnormality in eating
disorders
• Do U&Es and ECG in all low weight or vomiting patients
• Common (~30%) in those who vomit/abuse laxatives
• Rare in pure restrictors – suggests daily purging
• May need supplementation – oral (Sando-K) best not IV
• Total body potassium may be low despite normal serum
potassium
• Haemolysis
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For the treatment of eating disorders
• Acute changes most dangerous
• Effects:
• ECG changes (including prolonged QT
interval)
• Cardiac arrhythmias, palpitations
• Muscle weakness, absent reflexes,
constipation
• Impaired renal concentrating ability polyuria/nocturia
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For the treatment of eating disorders
• Hyponatraemia (Sodium deficiency)
• May result from excessive water drinking,
purging, diuretics
• Effects:
• Confusion
• Seizures
• Coma and death
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For the treatment of eating disorders
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Hypocalcaemia (Calcium deficiency)
Ionised (albumin corrected) Ca < 2.20mmol/l
Effects:
Paraesthesiae
Muscle cramps
Fits
Long QT interval, heart block, arrhythmias
Contributes to osteoporosis
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For the treatment of eating disorders
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Hypomagnesaemia (Magnesium deficiency)
Effects:
Muscular weakness
Vertigo, fits
Depression, psychosis
ECG abnormalities (including prolongation of
QT) and ventricular arrhythmias
• Refractory hypokalaemia and hypocalcaemia
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For the treatment of eating disorders
• Hypophosphataemia (Phosphate deficiency)
• May be precipitated by large carbohydrate load
– Refeeding, bingeing
• Or rapid correction of hypokalaemia
• Effects:
• Hypocalcaemia
• Muscle weakness
• Cardiac failure (especially during refeeding) and
arrhythmias
• Irritability, delirium and coma
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For the treatment of eating disorders
• Other biochemical points to consider …
• In eating disorders, biochemical
abnormalities tend to develop slowly…..so
correct slowly, oral not IV, seek advice.
• Imbalance of one electrolyte may lead to
the imbalance of other(s)
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For the treatment of eating disorders
• Nutritional deficiencies …
– Vitamin and nutritional deficiencies
surprisingly rare
• Thiamine (B1) can occur, contributes to
muscle weakness
• Wernicke’s Encephalopathy
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• Osteoporosis …
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= bone mineral density at least 2.5 standard deviations below young adult mean
value.
Identifiable within 2 years of onset of AN
May result in pathological fractures
Measured by DEXA scan
Aetiology uncertain – oestrogen deficiency major risk factor, failure to reach peak
bone density in teens
Also occurs in men
Role of medication in treatment not clear
Mixed evidence for effectiveness of oestrogen replacement
Role of calcium supplements is not clear
Best treatment is: (a) balanced refeeding diet
(b) weight restoration
(c) resumption of normal menstruation
(d) not Bisphosphonates
(e)Adcal D3 or Calcichews
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For the treatment of eating disorders
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Haematological complications …
Mild leucopenia is common
Don’t generally suffer recurrent infections
Mild anaemia quite common, usually normocytic
Iron, folate, vitamin B12 usually normal
Thrombocytopenia can occur
All probably a result of non-specific reduction in
bone marrow activity
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For the treatment of eating disorders
• Endocrine complications …
• Endocrine aspects incompletely understood – based on more than
loss of weight.
• 15% - 20% of patients have oligo/amenorrhoea before excessive
weight loss
• Amenorrhoea is due to – primary hypothalamic disturbance - low
GNRH
– reduced secretion of FSH and LH from the pituitary
– reduced secretion of oestrogens from the ovary
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women have low levels of Oestradiol, FSH and LH
men have low levels of Testosterone
male equivalent of amenorrhoea is loss of libido/impotence
raised Cortisol, low ACTH, low T3, normal TSH, raised GH
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For the treatment of eating disorders
Predictors of sudden death
in AN
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For the treatment of eating disorders
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Suicidal behaviour and co morbid depression
Rapid rate of weight loss – 1kg /wk over a few months.
Low BMI =13.5/14 , weight <30 kg
BMI is a measure of medical risk, forms part of the medical risk
assessment.
At any BMI – height, sex, developmental age, rate of weight loss and
physiological variables adjust the risk.
BMI 12 -13.5 = critical AN, organ failure occurs
BMI < 12 = life threatening AN
Prolonged electrolyte disturbance – esp Hypokalaemia as leads to cardiac
arrhythmias which are a major cause of death.
Conduction defects, esp QT interval prolongation
Risk factor for ventricular arrhythmias and sudden death
May be due to low K+, Ca, Mg
Can occur with normal electrolytes
Avoid drugs which prolong QT interval – tricyclic antidepressants, old
antipsychotics, erythromycin, terfenadine/ astemizole.
ventricular arrhythmias
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For the treatment of eating disorders
Outcomes in Eating
Disorders
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For the treatment of eating disorders
• Little information available on the outcome
of BED or EDNOS. EDNOS is under
researched despite it making up > 50% of
cases of eating disordered patients.
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For the treatment of eating disorders
Anorexia Nervosa:
• Remember: Anorexia Nervosa has the
highest mortality rate of any functional
psychiatric illness.
• Follow up needs to be long term as some
studies indicate that improvement does not
occur until 6 years after first treatment in 50% of
cases.
• Published data comes from studies of treated
patients and there is little information on what
happens without treatment.
• Most data comes from tertiary centres.
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For the treatment of eating disorders
How many get better?
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30% -75% recover completely
Up to 25% remain anorectic
40% -80% partially recover
Binge eating and relapse are common during course of
the illness
• “Recovery” from AN is a risk factor for the development
of BN – typically occurs within 2 yrs of onset of AN,
unusual more than 5 yrs after onset. (20%)
• Mortality rate: around 6% overall, and 0.5% per year.
• High prevalence of co-morbid depression, alcohol
dependence, anxiety disorders and OCD
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For the treatment of eating disorders
What predicts a good outcome?
• Short duration of illness
• Onset during adolescence
• Non constricted personality make-up
• Good family function
• Ongoing good motivation
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For the treatment of eating disorders
What predicts a poor outcome?
• Initial severity and long duration of illness
• High levels of general psychopathology
• Personality problems and mood disorders
• Poor motivation and social withdrawal
• Poor family relations and maternal criticism
• Long period of in-patient treatment
• Vomiting
• Purgative abuse
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For the treatment of eating disorders
What is the course of recovery?
• 10 -15 yr follow up :
• 75% fully recovered
• 30% relapsed before recovery
• Relapse rare after recovery
• Time to recovery ranges from 57 -79
months (4.75 – 6.5 yrs)
• 30% developed binge eating
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For the treatment of eating disorders
Eating Disorders and
Other Mental Disorders
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For the treatment of eating disorders
General Points
• Nutritional factors influence mental state and
vice versa
• Under and over nutrition are both significant
problems
• Mental disorder may impact on nutrition in a
number of ways
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Poor living environment
Lack of money
Substance misuse
Poor access to healthy eating and lifestyle advice
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For the treatment of eating disorders
Mental Disorder and Nutrition
Depression
• Loss of appetite
• Self-neglect
• Delusions e.g. guilt, punishment,
persecution
• Inadequate fluid intake in context of
severe depression is an indication for
emergency ECT
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For the treatment of eating disorders
Mental Disorder and Nutrition Mania
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Elated or irritable mood
Over-activity (increased energy output)
Loss of appetite
Delusions e.g. don’t need to eat, or too
busy acting on delusions to stop for food
or rest
• “Manic exhaustion” now rare
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For the treatment of eating disorders
Mental Disorder and Nutrition
Schizophrenia
“Positive” symptoms
• Delusions e.g. food poisoned, bizarre
ideas about properties of certain foods
• Hallucinations e.g. commands not to eat
“Negative” symptoms
• Self neglect, apathy, social withdrawal –
impact on self-care including nutrition
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Mental Disorder and Nutrition
Children
For the treatment of eating disorders
Effects of parental mental illness on children
• Child abuse
• Children as subjects of delusions
• May lead to neglect of feeding
• Social exclusion
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Summary
For the treatment of eating disorders
• Disordered eating consists of dietary restraint, binge
eating and abnormal means of weight control
• The principal eating disorders are Anorexia Nervosa,
Bulimia Nervosa and Binge Eating Disorder
• Sufferers get trapped in bio-psycho-social vicious cycles
• Successful management of eating disorders requires
attention to psychological, physical and social aspects
• Refeeding is potentially hazardous and should be done
cautiously
• Other psychiatric disorders can also impact on nutritional
health and present as ED symptomatology
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