Download Information for relatives and friends

Eating Disorders
Information for relatives and friends
Dr Harry Millar
• What are eating disorders?
• What are the effects on families and friends?
• What help is available?
What are Eating Disorders?
Anorexia Nervosa
• Body weight < 15% below expected or
BMI 17.5 or less
• Self induced weight loss
• Eating restraint
• Self induced vomiting,laxative abuse, excessive
exercise, abuse of appetite suppressants /
diuretics
• Body image distortion
• Amenorrhoea (Loss of sexual libido in
men)
Body Mass Index (BMI)
Weight in Kilograms/Height in metres squared
e.g. 70Kg weight 1.8Metre height
70/1.8x1.8
=70/3.24
=21.6
e.g 37 Kg weight 1.7 Metre height
37/1.7x1.7
=37/2.89
=12.8
Healthy range 20-25 approx
Anorexia Nervosa
• Body weight < 15% below expected or
BMI 17.5 or less
• Self induced weight loss
• Eating restraint
• Self induced vomiting,laxative abuse, excessive
exercise, abuse of appetite supressants / diuretics
• Body image distortion
• Amenorrhoea (Loss of sexual libido in
men)
F50.2 Bulimia Nervosa
Greek:
Bous=Ox
Limos=Hunger
Bulimia Nervosa (F50.2)
• Persistent food craving pre-occupation,
and binge eating
• At least one of
• Self induced vomiting, laxative abuse, starvation,
abuse of appetite suppressants, thyroid drugs,
diuretics
• Morbid dread of fatness
Other Eating Disorders
“Atypical” or Eating Disorder Not Otherwise
Specified (EDNOS)
– One or more of key features absent
– Otherwise can be typical picture
– Includes Binge Eating Disorder
• Overweight binge eaters
• No compensatory behaviours
Patients often move from one group to another
Fairburn CG and Harrison PJ. Lancet 2003
Symptoms
• Fear of uncontrolled eating and weight gain
• Binge eating and compensatory behaviours
• Distorted body image perception, mirror
gazing
Distorted Body Image
Symptoms
• Fear of uncontrolled eating and weight gain
• Binge eating and compensatory behaviours
• Distorted body image perception, mirror
gazing
• Pursuit of thinness
• Food preoccupation, avoidance, restricted
choice
• Anxiety eating in company
• Guilt after eating
• (True loss of appetite)
Non specific symptoms
•
•
•
•
•
•
Depression, low self esteem and self blame
Lack of assertiveness
Obsessional, rigid and inflexible thinking
Thinking slowed
Social withdrawal and irritability
Self harm
Physical features
Anorexia nervosa
• Emaciation, Cold
extremities, Lanugo
• Slow Pulse, low BP
• Anaemia/leucopaenia
• Hypothermia
• Osteoporosis
• Oedema
• Constipation
• Infertility
Bulimia nervosa
• Electrolyte abnormalities
• Dehydration
• Parotid enlargement
• Hoarse voice
• Damaged tooth enamel
• Loss of bowel tone
• Vomiting blood
• Finger Scars - Russell’s
sign
Effects on Families and
Friends
Effects on families
• Extreme level of burden – greater than
schizophrenia
• Perplexed about cause
– Often self blame by parents
– Frustration at other’s lack of understanding
• Including professionals
• Fear of long term effects
– Physical, mental, and social
• Helplessness and hopelessness
–
–
–
–
–
Uncertainty about how much daughter can help herself
Tried everything – nothing makes any difference
Feeling controlled by the illness
Interference with family life
Difficult to make plans
Responses in the family
•
•
•
•
•
•
•
Sadness up to severe depression
Extreme anxiety – fear she will die
Spending hours over meals, shopping etc.
Anger and hostility
Fear of stigma
Wishful thinking
Externalising the illness
– The anorexia as an enemy or alien possession
Help for Eating Disorders
• Community, voluntary and self help
• Primary care
• Specialist care
Community/self help
• Books
• Web sites
• Support services
– beat
– NEEDS
– NHS services
– SEDIG
Books – See beat web site
click on books from Amazon
• Eating Disorders: helping your child recover
– S Bloomfield, 2006, Eating Disorders Association
• Understanding eating disorders
– R Palmer, 2005, Family doctor publications
• Anorexia nervosa. A survival guide for families friends
and sufferers
– J Treasure, 1997, Psychology Press
• Skill based learning for caring with a loved one with an
eating disorder : the new Maudsley method
– J Treasure, G Smith and A Crane, 2007, Routledge
• Anorexia and Bulimia in the family
– G Smith, 2004, Wiley
NICE and QIS Guidance
• NICE
Eating disorders: anorexia
nervosa, bulimia nervosa and
related eating disorders
Understanding NICE guidance: a guide for
people with eating disorders, their advocates
and carers, and the public
• QIS
Eating Disorders in Scotland
A Patient’s Guide
Some useful web sites
• http://www.something-fishy.org – Full of excellent
information including a chat room.
• http://www.grrr.demon.co.uk/eat.html – Lucy Serpell’s
eating disorder resource page has many links.
• http://www.anred.com/toc.html - Information about
anorexia nervosa, bulimia nervosa, binge eating disorder,
and other less-well-known food and weight disorders.
• www.anitt.org.uk/ - Click on downloads for care pathways
for anorexia nervosa
• http://www.iop.kcl.ac.uk/iopweb/departments/home/defaul
t.aspx?locator=308 - Institute of Psychiatry
• www.patient.co.uk – Links to information and other sites
•
http://www.rcpsych.ac.uk/ Royal College of Psychiatrists
Sources of information, advice, support
• Beat
– Helplines, 01603 621 414 - under 18, 01603 765 050
– www.edauk.com
• Local NEEDS Group – Meetings first Monday of month
– 01224 557652 - Answering service
– www.needs-scotland.org
• North of Scotland Managed Clinical Network (MCN)
– 01224 557858
– www.eatingdisorder.nhsgrampian.org
• Grampian Eating Disorders Service
– 01224 557392
• Scottish Eating Disorders Interest Group (SEDIG)
– www.sedig.members.beeb.net
Primary care
• Usual first point of contact for professional
help
– variable response
• Have continuing responsibility even if
patient is seeing a specialist
– During normal hours your practice
– Out of hours
• NHS 24 – 08454 242424
– G-Meds
• A and E
• Can access psychiatric services via them
Specialist Care
• Can be
– General Medical if uncertain diagnosis or physically
unwell
– General Psychiatric if urgent or emergency worry
about mental state e.g. depression and suicidality
– Specialist Eating Disorders (Psychiatric)
• For Advice
• For Assessment and advice
• For Treatment
– Usually multiprofessional mental health team
– Most patients will just see one or two team members
but other team members may advise
Grampian Eating Disorder
Service
Staffing
• Consultant Psychiatrist 0.5
• Psychologist 0.8
• CBT therapists 3.0
– Nurses 1.6
– OT 0.4
– Psychologist 0.8
• Dietitian 1.0
• Secretaries 1.0
?social work, general medical, junior psychiatrist
Referral to Triage Assessment
• Referral received (usually from GP)
↓
• Referral documented
↓
• Clinical Meeting
↓
• Referral accepted / not accepted
↓
• Opt in procedure with standard letter and questionnaires
↓
• Scoring of questionnaires
↓
• Triage assessment clinic
↓
• Suitable / unsuitable for EDS
↓
• Waiting Lists for Treatment
Assessment
• Opt in questionnaires
• Risk assessment/prioritisation
– But don’t do emergency/urgent
– GP and General Medical/General Psychiatric
Services
• Triage Assessment
– Extended assessment
– In patient assessment
• Therapy Assessment
• Physical Assessment
– In abeyance
Telelinks
• Peripheral clinics
–
–
–
–
–
–
–
–
Orkney
Shetland, Lerwick and Unst
Peterhead
Fraserburgh
Aboyne
Stonehaven
Elgin
Turriff
• Priory Hospital
• Management meetings
Treatment/Management
• Individual therapy
– Maybe alongside group treatments
e.g.Self esteem, body image
• Group treatments
– Bulimia group
– Overeaters group
• Video therapy
• Dietetic input (alongside other therapy)
– Nutritional education - 6 group sessions
– Individual sessions
• Medical
– Medication
– Monitoring
• Family support
Specialist Treatment Strategies
• Engage the patient
Motivational Interviewing
• Psychological treatments
• Drug treatments
• Hospital admission
Psychological Treatments
Anorexia Nervosa
• Individual Psychotherapy OP.
– continuity of care with single therapist who
can co-ordinate other aspects of treatment.
– long term follow up.
• Family therapy / counselling
• Group therapy - usually an adjunct
– psychoeducational /nutritional/cooking
– psychodynamic / CBT
Psychological Treatments
Bulimia Nervosa
• More effective than drug treatment
• Cognitive Behavioural Therapy (CBT)
– 10 to 18 sessions of one hour (Video?)
– response rates of 60-80%
• Other techniques eg Interpersonal therapy
(IPT) but less available
• Individual/Group treatments
• Self help/Guided self help/Internet/CD/
Drug treatment
Anorexia Nervosa
• No drugs affect the course of illness.
• Some drugs may help particular
symptoms:
– Depression - antidepressants
– obsessionality – anti–obsessional drugs i.e.
clomipramine in low dose / Selective
Serotonoin Reuptake Inhibitors (SSRIs)
– dietary supplements eg. calcium / oestrogen
– ? Antipsychotics e.g. Olanzapine
Drug treatment
Bulimia Nervosa
• SSRI’s
– direct but modest anti-bulimic effect
– Fluoxetine best tested
– Paroxetine and Fluvoxamine don’t work
– Need high doses 60mg Fluoxetine
• Other drugs as per A.N.
• Potassium supplements if low potassium
Hospital Admission
• What are the aims?
– to save life
– to treat the disorder
– to relieve anxiety (doctors / patient / relatives
• Medical of Psychiatric
• Voluntary or compulsory
Mother of 2
20lbs heavier
than 1966