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Eating Disorders:
What You Need to Know
Dr. William Rhys Jones, Consultant Psychiatrist
Dr. Monique Schelhase, Associate Specialist
Yorkshire Centre for Eating Disorders
Leeds
[email protected]
[email protected]
0113 855 6400
What you need to know........
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Diagnoses
Screening
How they present
Risk assessment
Referral pathways
Principles of
treatment
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
BMI<17.5
Core psychopathology
Amenorrhoea
BMI>17.5
Core psychopathology
Regular binge/purge 2x/week
Eating Disorder Not
Otherwise Specified
Subclinical disorders
Binge eating disorder
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
1 in 250 females
1 in 2000 males
1 in 50 females
1 in 500 males
Eating Disorder Not
Otherwise Specified
More common still but rates
uncertain
Eating Disorders
Anorexia Nervosa
BMI<18.5
Core psychopathology
Other Specified Feeding and
Eating Disorders
Subclinical disorders
Bulimia Nervosa
BMI>18.5
Core psychopathology
Regular binge/purge 1x/week
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
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Dieting
Fasting
Calorie counting
Excessive exercise
Water loading
Diet pills, thyroxine,
diuretics, appetite
suppressants
Excessive weighing
Body checking
Culinary behaviours
Avoidance
Isolation
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Bingeing
Purging
Starve-binge-purge cycle
Misuse of insulin
Laxatives
DSH
Substance misuse
System
Starvation
Bingeing/purging
CVS
Bradycardia
Hypotension
Sudden death
Oedema
Electrolyte abnormalities
Renal calculi
Renal failure
Parotid swelling
Delayed gastric emptying
Nutritional hepatitis
Constipation
Osteoporosis
Pathological fractures
Short stature
Amenorrhoea
Infertility
Hypothyroidism
Anaemia
Leukopenia
Thrombocytopenia
Generalised seizures
Confusional states
Impaired temperature regulation
Hypoglycaemia
Arrhythmias
Cardiac failure
Sudden death
Severe oedema
Electrolyte abnormalities
Renal calculi
Renal failure
Parotid swelling
Dental erosion
Oesophageal erosion/perforation
Constipation
Osteoporosis
Pathological fractures
Lanugo, brittle hair and nails
Calluses on dorsum of hands (Russell’s sign)
Renal
GI
Skeletal
Endocrine
Haem
Neuro
Metabolic
Derm
Oligomenorrhoea/amenorrhoea
Leukopenia/lymphocytosis
Generalised seizures
Confusional states
Impaired temperature regulation
Hypoglycaemia
Differential Diagnosis
• Depression
• Somatoform disorders
• OCD
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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
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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
Starvation
Hypoglycaemia
Vomiting
Hypokalaemia
Water-loading
Hyponatraemia
Laxative misuse
Hyperkalaemia
Hyponatraemia
Diuretics misuse
Hypokalaemia, hyponatraemia
Thyroxine misuse
↑T3/T4, ↓TSH
Bone marrow
hypoplasia
Normocytic anaemia
Leucopenia
Re-feeding syndrome
Hypophosphataemia
Hypomagnesaemia
Hypocalcaemia
Hypokalaemia
Proximal myopathy
↑ CK, ↑ LFTs
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FBC
U&Es
LFTS
Glucose
CK
Phos, Mg, Ca
TFTs
Physical Risk in Eating Disorders Index
(PREDIX)
SYSTEM
Nutrition
Cardiovascular
Musculo-skeletal
Temperature
Blood profile
Biochemistry
Electrocardiogram
TEST OR
INVESTIGATION
BMI
Rate of weight loss
Blood pressure
Postural drop
Pulse rate
Peripheral cyanosis
Stand up or sit up test
(proximal myopathy)
White cell count
Neutrophils
Haemoglobin
Platelets
Potassium
Sodium
Phosphate
Pulse rate
Corrected QT interval
MODERATE
RISK
<15
>0.5kg/week
<90/60 mmHg
>10 mmHg
<50 bpm
Grade 2
<35°C
Concern if
outside normal
limits
Concern if
outside normal
limits
<50 bpm
HIGH RISK
<13 kg/m2
>1kg/week
<80/50 mmHg
>20 mmHg
<40bpm
Yes
Grade 0-1
<34.5°C
<2.0 x 109/l
<1.0 x 109/l
<9.0 g/dl
<110 x 109/l
<2.5 mmol/l
<130 mmol/l
<0.5 mmol/l
<40 bpm
>450 msec
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
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
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
na
Psychological
Pharmacological
A = ≥ 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?
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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 Literature
Anorexia 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:
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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.
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Have severe Bulimia Nervosa i.e. daily bingeing AND daily purging; biochemical abnormalities;
complicating factors such as diabetes or pregnancy.
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Require consideration for in-patient care for re-feeding or symptom interruption.
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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.
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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?
YCED Outreach Service
• 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
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
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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 staff
FUNDING........................
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
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consultancy and liaison
recovery
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 posttreatment values indicated an improvement in self-esteem which was also
demonstrated to be statistically significant.
Treatment of eating disorders
• Foundation of treatment
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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
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MI/MET
CBT
CAT
IPT
Motivational Interviewing
‘The sun and the wind were having a dispute as to who
was the most
powerful. They saw a man walking along and they
challenged each other about which
of them would be most successful at getting the man to
remove his coat. The wind
started first and blew up a huge gale; the coat flapped but
the man only closed all his
buttons and tightened up his belt. The sun tried next and
shone brightly making the
man 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
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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