Download MRCPsych Course * Across the ages session CAMHS * Prognosis

MRCPsych Course – Across the ages
session
CAMHS – Prognosis of eating disorders
Sarah Stansfeld ST4 CAMHS
Aims of the presentation
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Risk factors for the development of eating disorders
Diagnostic Stability
Comorbidity
Factors which predict a poor prognosis in eating
disorders
• Prognosis
• Junior Marzipan Guidelines.
Risk factors for the development of eating
disorders – Anorexia Nervosa
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Female
History of infant feeding problems
Maternal depressive symptoms
History of under eating
Family History
Adverse life events can often precipitate illness
childhood sexual abuse - evidence suggests this is likely
to predispose to many forms of mental illness and is not
specific to anorexia– if this is present there is a higher
likelihood of psychiatric comorbidity
• Obsessional personality traits and perfectionism
• ASD like personality traits
Risk factors for the development of eating
disorders – Bulimia Nervosa
• Female
• Elevated premorbid poor impulse control
• Family environment with a high degree of
interest in weight, body shape and eating
• Parental and/or childhood obesity
• Family history of psychiatric disorder
• Early menarche
Premenarchal presentation of Anorexia nervosa
• Initially would present with failure to gain the weight
which should accompany growth then later would
present with weight loss
• Delay or arrest of puberty (notable by amenorrhoea and
delay in secondary sexual characteristics such as breast
development)
• Growth arrest (monitor weight and height on growth
charts)
• Adolescence is a crucial period for establishing lifetime
bone density. Prolonged periods of starvation can lead
to a osteopenia and osteoporosis in this age group
Diagnostic Stability
• There is a high level of diagnostic instability in the earlier
stages of an eating disorder.
• 20–40% transition from anorexia into Bulimia
• The cross-over from restrictive type AN to binge/purge
disorders usually occurs after a relatively short period of
time between 12 and 36 months.
• Estimates of transition from Bulimia to Anorexia are
lower at 20–30%
• This is likely to represent the inadequacy of a categorical
diagnostic system in capturing the progression of
symptomatology over time
Comorbidity
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Ulfvebrand 2015 in a large Swedish study of
a database of 11588 of women and men
with eating disorders found that
– 71% had at least one comorbid axis 1 disorder (DSM IV)
– Anxiety disorders were the most common at 53%
– Generalised anxiety disorder was the most common
comorbid diagnosis
Comorbidity in Adolescents
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Rojo-Moreno 2015 in a community study of 933 adolescents
ED prevalence was 3.6%.
62.9% of individuals with an ED had a comorbid disorder
- anxiety disorders (51.4%)
- Attention Deficit Hyperactivity Disorder (31.4%)
- oppositional defiant disorder (11.4%)
- obsessive compulsive disorder (8.6%).
ED incidence rate of 2.76% over the course of 2 years.
22.2% of new cases had received previous psychiatric
diagnoses, of which all were anxiety disorders.
ED exhibited a high comorbidity rate among adolescent
populations and anxiety disorders were the most common
comorbid diagnosis.
Poor Prognostic Factors
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Later age of onset
Longer duration of illness
History of comorbid personality disturbance
Disturbed relationships in the family
Psychiatric comorbidity
Loss of social and educational and
occupational function
Prognosis - AN
• Ratnasuriya et al, a 41 patient, 20 year follow up study of AN found
that 30% of patients had a ‘good’ outcome, 32% had an
‘intermediate’ outcome and 38% had a ‘poor’ outcome.
– 20 year outcome was predicted by outcome at 5 years.
– 15% had died from causes related to anorexia nervosa
– 15% had developed Bulimia nervosa.
• Sullivan carried out a meta-analysis of mortality rates in anorexia
found the aggregate mortality rate to be 5.6% per 10 years (total
patients 3006). This is substantially higher than both female
psychiatric patients and the general population. Cause of death:
was
– complications of Anorexia in 54%,
– suicide 27% and
– other causes 19%.
Adolescents with AN
• Follow up studies of younger patients with AN
show consistently better outcomes than adults
• Wenz et al – community sample of adolescent
onset AN followed up for 10 years (51 patients)
– 1 in 4 had a persisting ED at 10 years
– Outcome was ranked as poor in 27%, intermediate in 29% and
good in 43%
– Half the AN group had poor psychosocial functioning at 10
years
– Poor ongoing psychosocial functioning was accounted for by
ongoing ED or chronic obsessive compulsive behaviour or
problems with social interaction
Prognosis of Binge eating disorder and
Bulimia Nervosa (purging type)
• Fichter et al 2008 – 12 year follow up study of patients who
had been admitted to hospital for treatment of an eating
disorder
– 36% of BED and 28.2% of BN still had a diagnosis of an
eating disorder at 12 years
– Psychiatric comorbidity was the predominant predictor of
poor outcome in both diagnoses.
– Predictors for poor BED outcome were body
dissatisfaction, history of sexual abuse, and impulsivity.
Mortality following hospital discharge- UK
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(SMR = standardised mortality ratio –> an SMR of 1.0 would mean the same likelihood of dying as the
general age matched population. An SMR of 10.0 would mean a 10x greater chance of dying than the
general age matched population)
• Hoang et al 2014 found that the standardized mortality ratio (SMR)
for adolescents and young adults (aged 15-24) with a diagnosis of
ED was 7.8 (95% confidence interval: 4.4–11.2) within the first year
post discharge from any NHS hospital
- for anorexia nervosa (AN) was 11.5 (6.0–17.0
- for bulimia nervosa (BN) was 4.1 (0–8.7)
- for ED NOS was 1.4 (0–4.0)
• SMR for people of the same age with schizophrenia was 10.2 (8.3–
12.2), with bipolar disorder was 3.6 (1.1–6.1) and with depression
of 4.5 (3.6–5.3)
Mortality following hospital
discharge- UK
• For older adults aged 25–44 years, the SMR
for ED was 10.7 (7.7–13.6)
• AN was 14.0 (9.2–18.8)
• BN was 7.7 (3.5– 11.9)
• ED NOS was 4.7 (1.4–8.0)
Junior Marzipan Guidelines
• Produced by RCPsych - For the management
of really sick patients under 18 with Anorexia
Nervosa
• Available free online at;
• http://www.rcpsych.ac.uk/usefulresources/pu
blications/collegereports/cr/cr168.aspx
• (or type Junior Marzipan guidelines into a
search engine)
The Junior MARSIPAN report provides
guidance on:
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risk assessment, physical examination and associated action
location of care and transition between services
compulsory treatment
paediatric admission and local protocols
management of re-feeding
management of compensatory behaviours associated with an
eating
disorder in a paediatric setting
management in primary care and paediatric out-patient
settings
discharge from paediatric settings
management in specialist CAMHS in-patient settings.
Risk Stratification - Weight
Red (high risk)
Amber (alert to
high concern)
Green (moderate
risk)
Blue (low risk)
Percentage median
BMI <70%
(approx below 0.4th
BMI centile)
Recent loss of weight
of 1 kg or more/week
for 2 consecutive
weeks
Percentage median
BMI 70–80%
(approx between 2nd
and 0.4th BMI centile)
Recent loss of weight
of 500– 999g/week
for 2 consecutive
weeks
Percentage median
BMI 80–85%
(approx 9th–2nd
BMI centile)
Recent loss of weight
of up to 500g/week for
2 consecutive weeks
Percentage
median BMI>85%
(approx. above
9th BMI centile)
No weight loss
over past 2 weeks
Risk Stratification - Cardiovascular
Red (high risk)
Amber (alert to
high concern)
Green (moderate
risk)
Blue (low risk)
Heart rate (awake)
<40 bpm
Heart rate (awake)
40–50 bpm
Heart rate (awake)
50–60 bpm
Heart rate (awake)
>60 bpm
History of
recurrent syncope;
fall in systolic blood
pressure on standing of
20 mmHg or more,
or increase
in heart rate of
>30 bpm)
Irregular heart
rhythm (does
not include sinus
arrhythmia)
Sitting blood
pressure: systolic
<0.4th centile
84–98 mmHg
diastolic
<0.4th centile
35–40 mmHg
Occasional
syncope;
fall in
systolic blood
pressure of
15 mmHg or
more, or diastolic
blood pressure
fall of 10 mmHg
or more
Sitting blood
pressure: systolic
<2nd centile
(98–105 mmHg
diastolic
<2nd centile
40–45 mmHg
Pre-syncopal
symptoms but
normal orthostatic
cardiovascular
changes
Normal sitting
blood pressure for
age and gender
prolonged peripheral
capillary
refill time (normal
central capillary
refill time)
Normal orthostatic
cardiovascular
changes
Normal heart
rhythm
Calculating Percentage BMI
Percentage BMI =
Actual BMI × 100___________
Median BMI (50th percentile) for age and gender
Median BMI is obtained from the relevant growth charts
Assessment of the unwell patient
with anorexia would also include…
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ECG (arrhythmias, heart rate, QTc)
Hydration status
Temperature (hypothermia indicates physiological instability)
Bloods including FBC, U&Es, LFTs, Bone Profile, Mg2+, glucose
Assessment of muscular weakness (sit up and stand or hand grip
strength)
History of food and fluid intake
Assessment of level of Engagement with management plan
Level of current exercise
Self harm and suicidality
Mental state/psychiatric assessment
Full physical examination
Collateral History!
References
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Anorexia nervosa: outcome and prognostic factors after 20 years.
R H Ratnasuriya, I Eisler, G I Szmukler, G F Russell
The British Journal of Psychiatry Apr 1991, 158 (4) 495-502; DOI: 10.1192/bjp.158.4.495
Mortality in anorexia nervosa.Authors:Sullivan PF; University Department of Psychological Medicine, Christchurch
School of Medicine, New Zealand.Source:The American Journal Of Psychiatry [Am J Psychiatry] 1995 Jul; Vol.
152 (7), pp. 1073-4
HOANG, U; GOLDACRE, M; JAMES, A. Mortality following hospital discharge with a diagnosis of eating disorder:
national record linkage study, England, 2001-2009. The International Journal Of Eating Disorders. United States,
47, 5, 507-515, July 2014. ISSN: 1098-108X.
Wentz, E., Gillberg, C., Gillberg, I. C. and Råstam, M. (2001), Ten-year Follow-up of Adolescent-onset Anorexia
Nervosa: Psychiatric Disorders and Overall Functioning Scales. Journal of Child Psychology and Psychiatry,
42: 613–622. doi: 10.1111/1469-7610.00757
Gelder, Michael G. New Oxford Textbook Of Psychiatry. Oxford: Oxford University Press, 2012. Print.
FICHTER, MM; QUADFLIEG, N; HEDLUND, S. Long-term course of binge eating disorder and bulimia nervosa:
relevance for nosology and diagnostic criteria. The International Journal Of Eating Disorders. United States, 41, 7,
577-586, Nov. 2008. ISSN: 1098-108X.
CR168. JUNIOR MARSIPAN: MANAGEMENT OF REALLY SICK PATIENTS UNDER 18 WITH ANOREXIA
NERVOSA, Royal College of Psychiatrists available at
http://www.rcpsych.ac.uk/usefulresources/publications/collegereports/cr/cr168.aspx
ULFVEBRAND, S; et al. Psychiatric comorbidity in women and men with eating disorders results from a large
clinical database. Psychiatry Research. Sept. 6, 2015. ISSN: 0165-1781.
TREASURE, J; STEIN, D; MAGUIRE, S. Has the time come for a staging model to map the course of eating
disorders from high risk to severe enduring illness? An examination of the evidence. Early Intervention in
Psychiatry. 9, 3, 173-184, June 2015. ISSN: 17517885.
ROJO-MORENO, L; et al. Prevalence and comorbidity of eating disorders among a community sample of
adolescents: 2-year follow-up. Psychiatry Research. 227, 52-57, May 30, 2015. ISSN: 0165-1781.