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Eating Disorders Dr Faye Tarrant ST4 General Adult Psychiatry “any of a range of psychological disorders characterised by abnormal or disturbed eating habits” Aims Anorexia Nervosa ◦ Definition, diagnosis, causes and treatment options Bulimia ◦ Definition, diagnosis, causes and treatment options Re-feeding syndrome Anorexia Nervosa Definition ICD-10 F50.0 Anorexia Nervosa “a disorder characterized by deliberate weight loss, induced and/or sustained by the patient” Anorexia Nervosa ICD-10 Criteria for Diagnosis For a definite diagnosis ALL of the following are required: Body weight is maintained at least 15% below that expected (either lost or never achieved) The weight loss is self-induced by avoidance of “fattening foods” AND one or more of the following: ◦ ◦ ◦ ◦ Self-induced vomiting; Self-induced purging; Excessive exercise Use of appetite suppressants and/or diuretics. There is body-image distortion in the form of a specific psychopathology whereby a dread of fatness persists as an intrusive, overvalued idea and the patient imposes a low weight threshold on themselves Anorexia ICD-10 Criteria Amenorrhoea in women and a loss of sexual interest and potency in men. ◦ There may also be elevated levels of growth hormone, raised levels of cortisol, changes in the peripheral metabolism of the thyroid hormone, and abnormalities of insulin secretion. If onset is prepubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). ◦ With recovery, puberty is often completed normally, but the menarche is late. Bulimia Definition F50.2 Bulimia Nervosa Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading the patient to adopt extreme measures so as to mitigate the ‘fattening” effects of ingested food. Bulimia ICD-10 Criteria For a definite diagnosis, ALL of the following are required: There is a persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time. The patient attempts to counteract the “fattening” effects of food by one or more of the following: ◦ Self-induced vomiting ◦ Alternating periods of starvation ◦ Use of drugs such as appetite suppressants, thyroid preparations or diuretics. ◦ When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. The psychopathology consists of a morbid dread of fatness ◦ There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval between the two disorders ranging from a few months to several years. Who? More females diagnosed than males ◦ 1 fifteen-year-old girl in every 150 ◦ 1 fifteen-year-old boy in every 1000 Most common in adolescents and young women BUT can affect anyone! Same in Bulimia BUT usually slightly later onset Why? Social pressure: ◦ Our social surroundings powerfully influence our behaviour. Societies which don’t value thinness have fewer eating disorders. Places where thinness is valued, such as ballet schools, have more eating disorders. Lack of an “off” switch: ◦ Most of us can only diet so much before our body tells us that it is time to start eating again. Some people with anorexia may not have this same body "switch" and can keep their body weight dangerously low for a long time. Control: ◦ It is good to feel that we can control ourselves in a clear, visible way. Puberty: ◦ Anorexia can reverse some of the physical changes of becoming an adult .This may help to put off the demands of getting older, particularly sexual ones. Why? Family: ◦ Saying “no” to food may be the only way to express feelings, or have any say in family affairs. Genetics: ◦ There is a lot of evidence that eating disorders run in families even where the sufferers don't necessarily live together, and that certain genes make people more vulnerable, not only to eating disorders, but to related conditions. Low self-esteem: ◦ People with anorexia often don’t think much of themselves, and compare themselves unfavourably to other people. Losing weight can be a way of trying to get a sense of respect and self-worth. Why? Emotional distress: ◦ ◦ ◦ ◦ ◦ life difficulties sexual abuse physical illness upsetting events - a death or the break-up of a relationship important events - marriage or leaving home. The vicious circle : ◦ An eating disorder can continue even when the original stress or reason for it has passed. Once your stomach has shrunk, it can feel uncomfortable and frightening to eat. Physical causes: ◦ Some doctors think that there may be a physical cause that we don't yet understand. Differentials for Anorexia There may be associated depressive or obsessional symptoms, as well as features of a personality disorder, which may make differentiation difficult and/or require the use of more than one diagnostic code. Somatic causes of weight loss in young patients that must be distinguished include chronic debilitating diseases, brain tumors, and intestinal disorders such as Crohn’s disease or a malabsorption syndrome Differentials for Bulimia upper gastrointestinal disorders leading to repeated vomiting a more general abnormality of personality (the eating disorder may coexist with alcohol dependence and petty offences such as shoplifting) depressive disorder (bulimic patients often experience depressive symptoms). Psychological Effects of Eating Disorders Poor sleep Poor concentration Low mood or depression Become obsessive about food and eating (and sometimes other things such as washing, cleaning or tidiness). Physical Effects of Eating Disorders Feel tired, weak and cold Constipation Hair loss grow downy hair on other parts of the body., typically face Dry skin Pressure sores Not reach full height, or lose height with a 'bowed over' appearance. Osteoporosis Infertility Liver damage In extreme cases death ◦ . Anorexia Nervosa has the highest death rate of any psychological disorder Physical Effects of Eating Disorder if Vomiting is a Prominent Feature Puffy face Loss of tooth enable palpitations (vomiting disturbs the balance of sodium and potassium in blood) Weakness Feel tired all the time Kidney damage Epileptic fits Infertility Physical Effects of Eating Disorder if Laxative Use is a Prominent Feature Persistent stomach pain Swollen fingers Laxative dependency have huge weight swings. ◦ Fluid loss and gains Treatment - Anorexia CBT Family Therapy (best evidence) Dietician and Eating Disorder Services ◦ Meal Planning Physical health and weight monitoring Medication ◦ May be prescribed reduce the anxiety and, in particular, to reduce the 'ruminations' that sufferers describe. ◦ Most experience has been with the drug Olanzapine, as this is safest in young people and in people who are at a low weight. ◦ It may be more effective than diazepam and similar drugs and is less likely to be habit-forming. Admission to hospital Treatment - Anorexia Compulsory treatment ◦ This is unusual ◦ It is only done if someone is so unwell they are severely ill and as a result unable to make a decision ◦ There must ne a risk of serious harm to them if they are not treated in the case Treatment Efficacy in Anorexia More than half of sufferers make a recovery, Average length of illness is 6-7 years. Full recovery can happen even after 20 years of severe anorexia. Past studies of the most severely-ill people admitted to hospital have suggested that 1 in 5 of these may die. ◦ the death rate is much lower, f the person stays in touch with medical care. As long as the heart and other organs have not been damaged, most of the complications of starvation seem to improve slowly once a person is eating enough. Treatment for Bulimia Cognitive Behavioural Therapy ◦ Usually individual Interpersonal Therapy (IPT) ◦ This is also usually done with an individual therapist, but concentrates more on your relationships with other people. Eating Disorder Services and Dieticians Medication Even if you are not depressed, high doses of antidepressants SSRIs This can reduce your symptoms but the benefit tend to wear off if no psychological input Treatment Efficacy in Bulimia ~50% of sufferers recover, cutting their bingeing and purging by at least half. Co-morbid alcohol or drug misuse or DSH worsens prognosis CBT and IPT work just as effectively There is some evidence that a combination of medication and psychotherapy is more effective than either treatment on its own. Recovery usually takes place slowly over a few months or many years. Re-feeding syndrome “a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished” Re-feeding Syndrome 5 consecutive days of starvation puts individuals at risk Usually occurs within 4 days of starting to feed. Fluid and electrolyte disorders, especially hypophosphataemia, Neurological, pulmonary, cardiac, neuromuscular, and haematological complications are also possible How Re-feeding Syndrome Occurs Patients who are malnourished develop a total body depletion of phosphorous ◦ serum phosphorous levels are maintained by redistribution from the intracellular space. ◦ The body uses endogenous fuel stores as it’s main source of energy. ◦ Fat and protein (from muscle) are metabolized. The delivery of glucose, as part of a feeding strategy, can cause a huge increase in the circulating insulin level. The patient struggles to cope with converting to exogenous fuel sources. There is rapid uptake of glucose, potassium, phosphate and magnesium into cells. The serum concentration of these agents falls dramatically. In addition, for an unexplained reason, the body swiftly begins to retain fluid, and the extracellular space expands. Re-feeding syndrome This change in electrolyte balance leads to a number of systemic pathologies.: ◦ There is an increase in cardiac workload, heart rate and oxygen consumption. ◦ This sudden increase in demand for nutrients and oxygen may outstrip supply. ◦ In patients with cardiovascular disease, the sudden increase in cardiac work and circulating fluid can precipitate heart failure The shifting of electrolytes and fluid balance increases cardiac workload and heart rate This can lead to acute heart failure Oxygen consumption is also increased which strains the respiratory system (as well as pulmonary oedema) Death rate ~ 5% Most common cause of death is cardiac arrhythmia respiratory system strain occurs, possibly causing dyspnoea and tachypnoea The serum phosphorous level falls with refeeding, due to a shift of phosphate from the extracellular to the intracellular compartment, due to the huge demands for this ion for synthesis of phosphorylated compounds. The result of this sudden massive reduction in phorphorous levels is a multitude of life threatening complications involving multiple organs: respiratory failure, cardiac failure, cardiac arrhythmias, rhabdomyolysis, seizures, coma, red cell and leucocyte dysfunction. Re-feeding Close monitoring of blood biochemistry is necessary in the early re-feeding period. Milk is often the re-feeding food of choice in this early period (naturally high in phosphate and easily tolerated by those who have been starved.) If potassium, phosphate or magnesium are low then this should be corrected via the oral route Prescribing thiamine, vitamin B complex and a multivitamin and mineral is recommended Calorie intake should remain only 50-70% that of normally required for the first 3–5 days. Effects of beginning to eat after a prolonged period include: ◦ ◦ ◦ ◦ colicky abdominal pain, reflux symptoms, nausea and early satiety This is to certify that: ......................................... Has reviewed/completed ........Eating Disorders................. Date ........................................