Transcript Eating Disorders in Children and Adolescents

Eating Disorders in
Children and
Adolescents
MRCPsych Course
Dr Gisa Matthies
History
• Anorexia nervosa recognised condition
in the late 19th century (1873)
Ernest-Charles Lasègue
named the condition
L’Anorexie Histerique
Sir William Gull
coined the term anorexia
nervosa
Early onset ED
• Collins 1894: 7 year old girl
• Marshall 1895: 11 year old girl
•
A girl “seven and a half years old of healthy
ancestry” who persistently refused food for ten
weeks prior to her admission. The physical
stigmata of malnutrition were reported but “more
remarkable were the mental phenomena”. These
included “deceitfulness, intense selfishness, self
absorption and vanity.” ...was “effusively pious in
conversation though she used foul language to
the nurses. She concealed food in her bed and
expressed herself as not wishing to improve”
( Collins, 1894)
Diagnosis and Classification
•
•
Both ICD 10 and DSM IV under review
Planned updates:
•
•
-ICD 11-2015
-DSM V-2013
DSM-IV-TR (2000)
•
•
Eating disorders:
•
•
•
-anorexia nervosa
-bulimia nervosa
-eating disorder not otherwise specified
Feeding and eating disorders of infancy or early
childhood:
•
•
•
-pica
-rumination disorder
-feeding disorder of infancy and early childhood
ICD-10 (1992)
•
Eating disorders (F50):(behavioural syndromes associated with
physiological disturbances and physical factors)
•
•
•
•
•
•
•
•
-anorexia nervosa (F50.0)
-atypical anorexia nervosa (F50.1)
-bulimia nervosa (F50.2)
-atypical bulimia nervosa (F50.3)
-overeating associated with other psychological disturbance (F50.4)
-vomiting associated with other psychological disturbance (F50.5)
-other eating disorder (F50.8)
-eating disorder, unspecified (50.9)
ICD-10 cont.
• Other behavioural and emotional
disorders with onset usually occurring in
childhood and adolescence (F98)
• -feeding disorder of infancy and
childhood (F98.2)
• -pica of infancy and childhood
(F98.3)
ICD-10: diagnostic guidelines AN
• body weight at least 15% below expected weight,
or BMI 17.5 or less
• weight loss is self induced
• body image distortion, ‘dread of fatness’ as an
intrusive overvalued idea and patient imposes low
weight threshold on her-/himself
• widespread endocrine disorder
– amenorrhoea (women)
– loss of sexual interest and potency (men)
• if onset prepubertal the onset of puberty is delayed
or arrested
9
ICD-10: diagnostic guidelines Bulimia nervosa
• persistent preoccupation with eating and
irresistible craving for food, episodes of
overeating
• patient attempts to counteract the fattening
effects of food: vomiting, purgative abuse,
starvation,use of drugs
• psychopathology: morbid dread of fatness and
sharply defined weight threshold, well below
premorbid weight
10
Epidemiology
• Incidence of AN (2000)
• UK: 4.7/100,000 in year 2000 (age and
gender adjusted)
• females: 8.6/100,000
• males: 0.7/100,000
• females 10-19 years: 34.6/100,000
Currin, 2005
Bulimia NervosaIncidence (2000)
• 6.6/100,000 (age and gender adjusted)
• females: 12.4/100,000
• males: 0.7/100,000
• females: 10-19 years: 35.8/100,000
Currin, 2005
Currin et al 2005, BJP
Childhood Eating disorders
British National Survey
< 13 years
• Incidence:
• 3/100,000
• AN: 37%
• BN: 1.4%
• EDNOS: 43%
• 50% admitted to hospital
Nicholls et al 2011
Prevalence of adolescent
ED (no UK data)
• AN overall about: 0.4 -2%
• BN overall: ~1-2%
• EDNOS most common ED
• Strictly defined eating disorders are
uncommon
• ED behaviours and EDNOS commoner
than previously thought
• Disordered eating behaviours are
common in adolescents
• Females are more affected than males
• No clear social patterns
• ED occur across countries
Aetiology of Eating disorders
• multifactorial/ complex
• interaction between
• -genetic
• -biological
• -psychological
• -socio-cultural factors
…creates susceptibility
Genetic Factors
• Twin studies
• heritability estimates ranges
• 31-76% for AN in adults
• 28-83% for BN in adults
• significantly hereditable
• note: genetic factors become more
prominent after puberty
Biological Factors
• Perinatal Factors
• Physiological
• -Oestrogens
• -Reward processing
• -Appetite regulation
Psychological Factors
• Anxiety disorders (OCD)
• Personality traits: harm avoidance, rule
abiding, rigid, perfectionism
• Low self esteem
• Sexual Abuse non specific for AN, but
significant minority
• Sexualised trauma and BN (specific
association)
Psychodynamic theories
• Hilde Bruch 1904-1984 German
born American psychoanalyst
• eating problems as a ‘solution or
camouflage for problems of living’
• ‘having failed to develop a sense of self
as independent and entitled to take
initiative’
Sociocultural Factors
• increase in developing countries ( mass
media)
• Bullying teasing by peers, social
pressure to be thin
• Exposure to social network media
Course and Outcome AN
• mean crude mortality rate: 5.0%
• of surviving patients:
• -full recovery in less than 1/2
• -improvement 1/3
• -20% chronic course of disorder
• 40% probability of a comorbid mental disorder
at follow up
•
better outcome and lower mortality in
adolescent onset AN
Steinhausen, 2002
Course and Outcome BN
• Mean crude mortality rate: 0.3%
• Full recovery: 45%
• Considerable improvement: 27%
• Chronic protracted course: 23%
• Comorbidity at follow up: affective
disorder most frequent
Assessment
•
•
•
•
•
•
•
•
Child/YP:
•
•
-psychological
-physical (including diet history)
The family: strength and difficulties
Wider context: social and educational factors
Risks: short and long term
Maintaining factors
Motivational issues
Engagement (child and family)
Consent to treatment, Confidentiality issues
Family assessment
• Account of difficulties and context in
which they arose
• Current eating patterns (typical day)
• Who has control and responsibility for
eating
• Explore mealtime dynamics
Family assessment
•
•
•
•
•
•
•
Family hx of mental disorder, current parental mental
health
Family relationships, extended family (tension,
support)
Parents capacity to work together in the interest of
their children
Communication style
Family attitudes, beliefs about food, weight shape
Social context
Developmental hx (feeding, attachment, premorbid
personality)
Medical/nutritional assessment
•
•
•
•
Intake < 1000 kcal/day for some time likely significant
risk of cardiovascular decompensation
Self induced vomiting and purging exacerbate risks,
due to electrolyte disturbance and possibility of
cardiac arrhythmia
Vegetarian diet: likely to be deficient in a number of
essential nutrients
Children will generalise restriction to fluid as well as
food intake
Nicholls, 2012
•
Nutritional Risk
History
•
•
•
•
rapid weight loss (> 1kg/week) more destabilising
menarcheal status
Current Status
•
•
•
•
•
duration of low weight
BMI centile (Percentage weight for height)
haemodynamic stability
Pulse < 50, ask for ECG
Muscle weakness, peripheral neuropathy signs of serious
nutritional deficit (SUSS test: sit up, squat, stand up without using
hands)
Future
•
•
predicted intake
fluid intake restricted or excessive
Individual assessment
Eating disorder psychopathology
•
•
•
•
•
•
•
Eating behaviours, patterns, current intake, dietary
restrictions & rules,compensatory behaviours, binge
eating
Beliefs about weight and shape
Preoccupation with weight and shape
Concerns about eating
Fear of weight gain
Self evaluation with respect to weight shape or eating
Motivation to change
Comorbitdities are common
consequence of starvation or separate
• AN:
• -Depression
• -OCD
• -Anxiety
• -Social
phobia
• -ASD
BN:
-Depression
-Self harm
-Substance misuse
-Impulse disorders
-ADHD
Risk
multidimensional, short term and long term
• Physical
• Psychological
• Social
• Educational
Physical Risks
•
•
•
•
•
•
Electrolyte imbalance, low blood glucose,cardiac
abnormalities
Purging subtype of AN most dangerous, low potassium
levels can lead to cardiac arrhythmia
GI bleeding, mesenteric artery syndrome
Chronic malnutrition in growing children can lead to
stunting, delay in sexual development
Chronic malnutrition causes osteoporosis and/or infertility
Chronic malnutrition and effect on the developing brain
not known, studies suggest damage to cognitive
development, MRI suggest show cerebral atrophy
Psychological Risks
• ~25% of deaths in AN are due to suicide
• Risk of self harm is increased
• Comorbities are common
Social Risks
• Impact of severe eating disorders on
families
• Risk of family conflict and family
breakdown
• Financial burden of care and attending
appointments
Educational Risks
• Loss of education
• Failure to achieve educational potential
Assessment of BN
•
•
•
•
•
Explore nature of emotions around binge
episodes and the frequency of bulimic symptoms
Explore motivation
Often kept secret from family and friends, engage
individual first, then explore family support can be
achieved
Common: self harm, substance misuse, low
mood
Link between BN and negative sexual
experiences
Treatment
• NICE guidelines (2004) were due for
revision 2011
• there was not enough new evidence to
revise
• mostly consensus rather than strong
evidence
NICE for all ED
Additional considerations for children and adolescents
•
• Family members, including siblings, should normally be included in the
treatment of children and adolescents with eating disorders.
Interventions may include sharing of information, advice on behavioural
management and facilitating communication.
•
•
•
•
• In children and adolescents with eating disorders, growth and
development should be closely monitored. Where development is
delayed or growth is stunted despite adequate nutrition, paediatric
advice should be sought.
• Healthcare professionals assessing children and adolescents with
eating disorders should be alert to indicators of abuse (emotional,
physical and sexual) and should remain so throughout treatment.
• The right to confidentiality of children and adolescents with eating
disorders should be respected.
• Healthcare professionals working with children and adolescents with
eating disorders should familiarise themselves with national guidelines
and their employers’ policies in the area of confidentiality.
NICE - AN
•
•
•
•
• Family interventions that directly address the eating disorder
should be offered to children and adolescents with anorexia
nervosa. B
• Children and adolescents with anorexia nervosa should be
offered individual appointments with a healthcare professional
separate from those with their family members or carers.
• The therapeutic involvement of siblings and other family
members should be considered in all cases because of the effects
of anorexia nervosa on other family members.
• In children and adolescents with anorexia nervosa, the need for
inpatient treatment and the need for urgent weight restoration
should be balanced alongside the educational and social needs of
the young person.
NICE - BN
• Adolescents with bulimia nervosa may
be treated with CBT-BN adapted as
needed to suit their age, circumstances
and level of development, and including
the family as appropriate.
Extreme Physical Risk
• Feeding against the will of the patient is
a highly specialised procedure requiring
expertise in the care and management
of those with severe eating disorders
and the physical complications
associated with it. This should only be
done in the context of the Mental Health
Act 1983 or Children Act 1989.
Refeeding Syndrome
• fluid and electrolyte dysregulation
• severe hypophosphatemia, hypokalemia,
hypomagnesemia, abnormal glucose
metabolism, deficiencies in vitamins and trace
elements
• serious cardiac, neurological and
haematological dysfunction
• 27.5% of inpatient adolescents undergoing
refeeding developed hypophosphatemia
(lowest day 4)
Ornstein et al, 2003
Treatment
• Collaboration, communication,
consistency
• Family based treatment
• Individual therapy
• Medical and nutritional interventions
Minnesota semi-starvation study
Ancel Keys
TOuCAN
• A randomised controlled multicentre trial
of treatments for adolescent anorexia
nervosa including assessment of costeffectiveness and patient acceptability –
the TOuCAN trial
• SG Gowers,1* AF Clark,2 C Roberts,3 S
Byford,4 B Barrett,4 A Griffiths,1 V
Edwards,5 C Bryan,1 N Smethurst,1 L
Rowlands1 and P Roots6
• BJPsych 2007
Junior MARSIPAN
• Management of Really Sick Patients
under 18 with Anorexia Nervosa
• College Report CR 168
• January 2012
The Golden Cage
• The enigma of anorexia nervosa
Hilde Bruch, 1978