Download Eating Disorders - Primary Mental Health

PNM Cell Group CME:
Overview of Eating Disorders, in
particular Bulimia Nervosa
Overview of Epidemiology, Aetiology,
Diagnosis
Overview of Evidence-Base re Treatment
Q+A and Cases from Group
Epidemiology of Eating Disorders
 Anorexia Nervosa – relatively rare BUT more
severe, relapsing-remitting and/or chronic
 NZ Community Sample – lifetime risk - 0.3-0.5%
 Female risk 10x male risk
 Age of onset usually adolescence
 Mortality rate highest of any psychiatric condition
 Suicide rate higher than Major Depression
 Co-morbidity very common – Major Depression, OCD,
Personality Disorder
Epidemiology of Eating Disorders
 Bulimia Nervosa – more common BUT less severe
 NZ Community Sample – lifetime risk using formal
diagnostic criteria - 1.5-3.0%
 Secondary school girls – rates of binge eating/vomiting
high – up to 20% - mostly self-limiting/does not progress
to full disorder
 Female risk 10x male risk
 Co-morbidity very common – Major Depression, A+D
conditions, Personality Disorder
Aetiology of Eating Disorders
 Multifactorial
 Stress-vulnerability model useful framework for
conceptualising “why this person, why now?” –
commonly precipitated by stressful event in a
vulnerable individual
 Cultural component – attitudes to women’s ideal body
size/image, media/advertising images and messages,
societal pressure etc.
 Ballerina’s, Gymnasts, Models at higher risk
 Very rare in PI women in Islands, NZ PI women same
rate as pakeha by 3rd generation in NZ
 Onset often after a period of “normal” dieting
Aetiology of Eating Disorders
 Contd…
 Genetic Component – increased risk among 1st-degree
relatives of individuals with an eating disorder, twin
studies show high concordance rates identical twins
 Genetic Component – also increased risk of mood
disorders and A+D conditions among first degree
relatives of individuals with an eating disorder
 ?Family factors – contentious, some evidence
 Early life disruption/trauma – increased risk of Eating
Disorder, most often co-morbid with Personality
Disorder, A+D issues etc.
Diagnosis – Anorexia Nervosa
 Weight loss/refusal to maintain body weight
above 85% of expected weight for age/height
 Intense fear of gaining weight/becoming fat
even though under weight
 Body image disturbance
 Amenorrhoea
 Restricting type vs Binge-Eating/Purging type
Diagnosis – Bulimia Nervosa
 Recurrent episodes of binge eating, associated
lack of control over eating – at least 2x wkly for
at least 3 mths
 Associated compensatory behaviour to avoid
weight gain – dieting, purging, excessive
exercise, misuse of laxatives/diuretics
 Self-evaluation unduly influenced by body
shape/weight, some degree of body image
distortion
 Purging type vs Non-Purging type
Eating Disorders – Medical
Complications
 Purging – dental decay, parotid enlargement,
fluid/electrolyte disturbance esp. hypokalemia
(subsequent risk of arrythmias)
 Starvation – anaemia, hypotension,
hypothermia, elevated LFT, impaired renal
function, sinus bradycardia and arrythmias, EEG
abnormalities, enlarged brain ventricles/cerebral
atrophy, osteoporosis
Eating Disorders – EvidenceBased Treatments
Best treatment approach
multidisciplinary/multidimensional –
Medical – assess for and treat medical
complications
Dietician – dietary advice/prescription
Psychology – CBT/Family Therapy
Psychiatry – symptomatic treatment,
treatment of co-morbid conditions
Eating Disorders – EvidenceBased Treatments
Behavioural Interventions –
Eating diary
Psychoeducation, advice re healthy eating
and body weight
Motivational interviewing
Eating Disorders – EvidenceBased Treatments
Medications –
Some evidence for benefit of high-dose SSRI
in Bulimia
Otherwise no effective drug treatment
Benefits from treating co-morbid conditions
e.g., depression
Medication can be helpful targeting specific
symptoms – e.g., sleep disturbance, anxiety
Eating Disorders – EvidenceBased Treatments
Psychotherpeutic interventions Family Systems Therapy and CBT both
effective
Some evidence for Family Therapy better in
teens/unemancipated individuals, CBT better
in adult/emancipated
Group CBT programme very cost-effective in
treating Bulimia Nervosa
Cognitive Behaviour Therapy
(CBT)
 Structured, time-limited, ‘here and now’
 Specific skills for now and future
 Five components to problem (“Five-Part
Model”)
 Cognitive model
 Evidence
 Balanced thinking
CBT - 5-Part Model
Environment (Past & Present), Situation
Thoughts or
Cognitions
Behaviours,
Actions
Physiology,
Sensations
Feelings,
Emotions
CBT - 5-Part Model (contd)
COGNITIVE COMPONENT
EMOTIONAL
SITUATION
AUTOMATIC
THTS AND
IMAGES
LENS OR FILTER THROUGH
WHICH WE PRECEIVE OR
INTERPRET SITUATIONS
REACTION
BEHAVIOUR
PHYSIOLOGY
?Questions
?Cases to Discuss