management of anorexia nervosa

1: Management of Anorexia Nervosa Immediate physical complications of starvation Long term physical complications of starvation Psychological changes of starvation Maturational issues Family dysfunction Interpersonal dysfunction Comorbid psychiatric conditions Axis 1 and 11 Active non compliance Disability associated with chronic illness Socio cultural issues Early developmental/psychodynamic issues Terminal illness

2: Course and outcome of Anorexia Nervosa (n=94)Sten Theander (Sweden) published 1985

3: LONG TERM OUTCOME OF BULIMIA NERVOSA (1992 Keller & Hertzog) 30 people presented to an eating disorder clinic - 70% recovered at 8 weeks but 63% of the �recoverers� had relapsed in 18 months.

4: �THE SUFFERER WHO FRUSTRATES A KEEN THERAPIST BY FAILING TO IMPROVE IS ALWAYS IN DANGER OF MEETING PRIMITIVE HUMAN BEHAVIOUR DISGUISED AS TREATMENT� T F Main

5: Management of Eating Disorders Recognition assessment and diagnosis Baseline measurement Psycho-education Engagement Engagement Engagement Treatment

6: Recognition - What is Normal Eating 80% of 10yr old girls dieting Ideal Shape more androgenous 60% of female students diet >50% of UK population overweight 40% of Students binge

7: WOMEN AND WEIGHT REMEMBER - FAT IS A FEMINIST ISSUE OBESITY IS A REVOLT AGAINS MALE DOMINATED SOCIETY WOMEN DIET TO PLEASE MEN OBESITY IS MORE ACCEPTABLE IN MEN OBESE WOMEN ARE LESS LIKELY TO MARRY

8: EPIDEMIOLOGY OF BULIMIA NERVOSA * Male-Female ratio is approximately 20-1. * Peak age of onset is late teens or early adulthood. * Prevalence is 2% of women. * Maybe an increased rate in Asian immigrants to Western Countries, emphasising the strong cultural issues involved in Bulimia Nervosa. * Mean age of onset is around 15-16 years of age. * Mean age of presentation is 24 years of age.

9: Normal Population Survey(Cooper et al 1983) * 1.9% of Family Practice Clinic attenders met DSMIIIR criteria for Bulimia Nervosa, * 20% Binged at least once every two months, * 4% induced vomiting to control weight.

10: Recognition - Warning Signs of Anorexia Nervosa Avoiding meals Slow eating/picking at food Eating in secret Cooking for family not for self Denial of being on a diet Daily exercise Raiding the fridge Leaving table immediately Social phobia re eating Excessive school work Low calorie foods

11: DSM IV Anorexia Nervosa 1. Refusal to maintain body weight over a minimal normal weight for age and height. Eg. Weight loss leading to maintenance of body weight 15% below that expected to failure to make expected weight gain during a period of growth heading to body weight 15% below that expected 2. Intense fear of becoming obese even when underweight. 3. Disturbance in the way in which one�s body weight, size or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight. 4. In females, the absence of at least 3 consecutive menstrual cycles when they would otherwise be expected to occur, i.e primary or secondary amenorrhoea. Restricting sub type: Bingeing/Purging subtype:

12: Clinical Features Dysfunctional thoughts about shape and weight which lead to the �relentless pursuit of thinness� characteristic of anorexia nervosa This leads to control of weight and shape by rigorous dieting, laxative abuse, self-induced vomiting, fasting, excessive exercise etc. Marked weight loss Appetite is not lost. Preoccupation with thoughts of food and eating. As weight loss increases so does the body image disturbance which further drives the disorder.

13: Keys et al 1950 The Biology of Human Starvation 34 Conscientious objectors starved for 12 weeks then re-fed for 12 weeks. Starvation Syndrome described Worsened with increasing starvation Ten of the fifteen men who reported for follow up had then placed themselves on reducing diets.

14: Physical Symptoms and signs of Anorexia Nervosa energy lost only in late stages Increased sensitivity to cold / cold blue peripheries Constipation / diarrhoea / malabsorption Hypotension / Bradycardia / dizziness Decrease in sexual appetite / Amenorrhoea / shrinkage of boobs, bum, hips, thighs �Lanugo� hair, loss of hair osteoporosis muscle wasting but power intact hypoalbuminaemia leads to peripheral oedema as late developement

15: Psychological Features of the Starvation Syndrome food preoccupation, cooking, recipes, pictures hoarding and stealing food, eating rituals, binges, social withdrawal, lability and depression of mood, mood swings poor concentration, irritability, loss of energy, bursts of energy and restlesssness sleep disturbance, obsessional symptoms, narrowing of interests.

16: Diagnostic Criteria for Bulimia Nervosa A.Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: (1) eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

17: Diagnostic Criteria for Bulimia Nervosa A.Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: (1) eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances (2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Purging Type:./ Nonpurging Type:.

18: Diagnostic Criteria for Bulimia Nervosa (contd) Specify type: Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

19: COMORBIDITY OF BULIMIA NERVOSA 50% of previously met DSMIIIR criteria for anorexia nervosa however briefly, 80% have met DSMIIIR criteria for major depression, 15% self harm, 5% shoplift, 5% abuse street drugs, 3% have alcohol problems

20: PERSONALITY DISORDER IN BULIMIA NERVOSA 80% of people with Bulimia Nervosa meet criteria for more than three personality disorders each, After treatment the rate of personality disorder is much less, suggesting that personality disorder diagnosis is an artefact of the illness in a chronic fluctuating disorder.

21: FACTORS WHICH DETERMINE DEVELOPMENT OF BULIMIA IN SOMEONE WITH ANOREXIA NERVOSA 1. Prolonged dietary restraint is possible for only a small proportion of people 2. Personality factors - people with Bulimia may be more extrovert, more socially skilled and have less impulse control. 3. Age - Bulimia tends to start at a slightly later age and present to doctors in the mid-20�s.

22: FACTORS WHICH DETERMINE DEVELOPMENT OF BULIMIA IN SOMEONE WITH ANOREXIA NERVOSA 4. Physiological pressures - prolonged high protein, low carbohydrate diet depletes brain of L-tryptophan a precursor of serotonin. High Carbohydrate binges increases rapidly the amount of L-tryptophan within the brain. 5. Bulimia may be maintained by a variety of feedback loops as described.

23: CLINICAL FEATURES OF BULIMIA NERVOSA Most patients conceal the problem, it may be identified because of hypokalemia, metabolic acidosis, dental erosion, peptic ulceration, dehydration, enlarged parotid glands, cardiac arrhythmias, Russell�s sign. If you don�t ask, you wont get told. All young women with mood disorders, low self-esteem, should have their dietary and body shape and weight issues explored.

24: CLINICAL FEATURES OF BULIMIA NERVOSA BULIMIA IS A DIETING DISORDER. CHRONIC PREOCCUPATION WITH FOOD. WORRIES ABOUT SHAPE AND WEIGHT. REPEATED WEIGHING. BODY IMAGE DISPARAGEMENT. BINGEING WITH LOSS OF CONTROL.

25: Clinical Features of Bulimia Nervosa Binge/Purge/Diet Cycle Continuous pre-occupation with shape and weight and food Mood swings, Low self esteem, Secretive,

26: THE STARVE/BINGE/PURGE CYCLE Bulimia is a Dieting Disorder STARVE PURGE BINGE WORRY ABOUT SHAPE AND WEIGHT

27: A Binge 1 gin and bitter lemon Prawn cocktail Roll & butter 2 glasses wine 1 slice roast beef 1 slice roast pork 1 slice ham Portion potato salad Portion red cabbage Portion sweetcorn Portion coleslaw Lettuce, cucumber and tomato Portion curried rice Large baked potato and dressing 1/2 large bakewell tart 4 oz Black Magic 1 lb tablet

28: A Binge (cont) 2 profiteroles, cream and chocolate sauce 1 can diet coke 1 can 7-Up Large gin and bitter lemon 5 sandwiches and meat filling 6 pancakes and butter 7 scones with butter + jam Bowl ice cream 2 slices date and walnut cake 1 litre fresh orange juice 3 glasses lemonade Packet crisps Cup of tea 2 slices fruit cake 4 biscuits

29: Eating Disorders for Clinical Examinations Common in exam settings Think all young women Depression Borderline Personality Disorder Low self esteem AN ( usually ) obvious BN if you don�t ask you won�t get

30: Eating Disorders for Clinical Examinations HoPC Wgt Hx, BMI, LMP, Bingeing, Vom, Lax, Exercise, other, Body Image Distortion and Disparagement, Preoccupations with Food, Preoccupations with fear of fatness. Chronology, agg reliev factors Co Morbid - Depression, OCD, PD, (psychosis), substance abuse, self harm. Effect on life, family, secrecy, Things patient finds problematic

31: Eating Disorders for Clinical Examinations Past Psych Hx Past treatment cycles, partic IP stays followed by wgt loss, lack of engagement. Self Harm, Suicide,other impulse control problems Fam Hx Idealised Dep, OCD, Subst, Eating attitudes, enmeshment, rigidity, lack of conflict resolution, Critical mum, absent but �warm� father, perfectionism, pressure to achieve, Personal Hx, Idealised, Good child / student, chubby child, peer attitudes, low self esteem, sexual abuse,

32: Eating Disorders for Clinical Examinations Premorbid Personality, low self esteem, perfectionism, caring, good fa�ade, obsessional traits, MSE unremarkable Phys exam, AN starvation signs BN Parotid gland enlargement, teeth decay, russel�s sign, cutting

33: Management of Eating Disorders If criteria present make diagnosis, Comorbid - depression OCD Panic Disorder Comorbid Personality Disorder Time course and relative severity will help distinguish primary and secondary problems.

34: Establish severity History (also developmental and social context) Physical Examination Use as an opportunity to identify aspects of their current state that they find distressing. Feedback of all relevant signs and symptoms and findings related to weight loss and weight control. Combine information gathering, education and engagement. BMI BDI BITE BSQ SAS Investigations FBE & ESR U&E, LFT,TFT,Ca&P, Gluc. ECG, BMD, Creatinine Clearance Ovarian and Uterine US., repeating according to need.

35: BODY MASS INDEXBMI(QUETELET INDEX)

36: Anorexia Nervosa Treatment Setting Inpatient setting reserved for severely underweight with health problems, suicide risk, or failure of outpatient treatment. Day hospital treatment may provide alternative Outpatient treatment adequate for most Anorexia Nervosas If inpatient treatment provided, emphasis should be placed on maintenance of healthy change on return to outpatient environment.

37: Development of AN Abnormal eating, body image and self attitude Diagnosable Disorder Self maintaining disorder independent of precipitants and vulnerability factors AN as the identity of the person.

38: FOR AN

39: Management of Eating Disorders Health Education for patient and family Psychological and physical consequences of starvation Complications of vomiting, and laxatives Mortality rates and prognosis Eating disorders as illnesses that effect people - get some distance from the disorder in order to change it. Binge Vomit Diet cycle, BN as dieting disorder, efficacy of laxatives, vomiting

40: Management of Eating Disorders Health Education for patient and Family Focus on recovery of health rather than recovery of weight. Focus on reversal on unwanted aspects of the condition, ask person to set goals of therapy. Focus on regaining control from the disorder. Focus on reality checking rather than fears, fantasies and opinions �I feel fat therefore I am fat� Refer family and sufferer to local support groups. eg ANBNF 9885 0318

41: Management of Anorexia Nervosa Immediate physical complications of starvation Long term physical complications of starvation Psychological changes of starvation Maturational issues Family dysfunction Interpersonal dysfunction Comorbid psychiatric conditions Axis I and II Active non compliance Disability associated with chronic illness Socio cultural issues Early developmental/psychodynamic issues Terminal illness

42: FOR AN

43: Psycho social treatment Education and CBT can begin before refeeding but education will need to be repeated. Involve family from the start: education support family treatment - short duration, young??

44: Management of Eating Disorders Initial management of nutritional deficits and problems associated with weight control behaviours Begin to record a daily food diary Obtain agreement to maintain weight at prsent level Introduce simple behaviour changes from �Principles of Normal Eating� In AN obtain agreement to gradually introduce a weight restoration programme in consultation with a dietitian In BN introduce a none dieting approach to none binge food intake. Plan this the day before. ? Use of supplements

45: Anorexia Nervosa Treatment Nutritional rehabilitation Reversal of biological and physical concomitants of starvation is early and central goal. Emphasis taken away from weight and placed on health and well being. Education re causes, course and consequence of Anorexia Nervosa and with particular emphasis on reversible complications. Emphasis on problems identified by patient produced by starvation or reversal on these. Thorough physical examination and investigations to allow frequent and accurate feedback to patient of current health status NB: creatinine clearance

46: Anorexia Nervosa Treatment Nutritional rehabilitation (contd) Dietitian input important Emphasis on self control and self monitoring Avoid target weights, restoration of health is the goal eg. In long term return to menstruation Use BMI rather than absolute weight Requires highly experienced staff

47: Management of Eating Disorders Assessment and management of psychological issues Simple anxiety management, geared to mastery and controlling fear of fatness Relaxation tape Breathing Control Avoiding avoidance Simple self talk Distraction

48: Management of Eating Disorders Use of information to substitute opinion with fact �I feel fat, therefore I am fat� �If I eat I�ll lose control and blow up like a balloon�

49: EXAMPLE OF ANOREXIC/BULIMIA THOUGHTS (cont�d) As classified by Cognitive Therapy MAGNIFICATION, or overestimation of the likelihood of a disaster occurring because of some trivial incident. Examples �I will be laughed at openly if I venture outside because I have put on so much weight�. �If I eat normally, I will get fatter and fatter until I look like a pig�. �If I don�t stop this very soon, I will kill myself�. DICHOTOMOUS REASONING, or all or nothing thinking, or thinking in extremes. Examples �If I am not in complete control, I lose control of every aspect of my life�. �I am only acceptable as a human-being when I am thin�. �My life is meaningless unless I can look perfect� �That�s it I�ve blown it I�ve eaten 1 chocolate, I may as well make the most of it�.

50: COGNITIVE RESTRUCTURING - EATING DISORDERS (1) Eliciting thoughts (not usually difficult) - homework tasks - record thoughts - provoke in treatment (2) Dieting/eating behaviour - bingeing - vomiting - starving (3) Weight and size - magical 99lbs, 7st 13 lbs - size 8 or 10 (4) Body image - avoidance - colour blind (5) Self esteem (6) Explore meaning of terms eg fat (markedly over-defined

51: ADAPTING CBT FOR ANOREXIA NERVOSA 1. The idiosyncratic beliefs regarding shape and weight. 2. The interaction between physical and psychological components of the disorder. 3. The patients desire to retain certain focal symptoms. 4. The development of motivation for treatment. 5. The evolution of a trusting therapeutic relationship. 6. Prominence of fundamental deficits in self concept and self esteem. 7. Longer duration of treatment.

52: Components of Therapy proven to be of some value include: Self monitoring change in eating pattern education self control (cue restriction) cognitive restructuring focus on relationships (IPT) exposure with response prevention (ERP) self help behaviour therapy and anxiety management distraction alternate behaviours

53: How to Break the Vicious CycleStressful Situationeg Starving, Dieting, Worrying about Weight & FatnessThreats to Self-Esteem Challenge Thoughts Alternative Helpful Behaviour Relaxation Distraction Elastic Band Flash cards Problem Solving PONE

54: Where does CBT fit into a Comprehensive Treatment Regime for Bulimia Nervosa? (A tiered approach to Treatment)

55: FOR AN

56: Management of Eating Disorders Assessment and management of psychological issues (Cont) Use of Antidepressants AN after weight restoration BN if severe co-morbid depression Role of Prozac Support, ventilation, problem solving, here and now approach Tool Box Patient as co-therapist

57: Pharmacotherapy for AN Treat comorbid illnesses appropriately OCD, Depression, Psychosis ADPs will not work until BMI > 16-17 SSRI�s - Fluoxetine has a role in maintenance of weight gain post re-feeding-why? BZDs useful as anxiolytics pre meal in some patients Antipsychotics Is AN a psychosis?? The Graham Burrows experience! Increase appetite but this may make things worse HRT to re-establish ovulation and bisphosponates for osteoporosis

58: Management of Treatment Resistance Develop collaborative alliance Provide psycho education Set Realistic goals Promote autonomy Ensure balance between containment and flexibility Involve the family Consider pros and cons of imposing treatment Ensure non punitive treatment Obtain support Treatment resistance is an evolutionary process

59: Management of Eating Disorders Mobilisation of community supports Influence mental health referral and explain course of treatment Help to decide if and when more intensive therapy is necessary Shared care with Specialist referee

60: The Chronically Underweight 15% of all Anorexics develop a Chronic Illness Can be considered treatment resistant Aim to maintain in community Minimise physical complications Maintenance of maximum tolerable weight Encourage development of alternative coping strategies Consider support in a group setting

61: POOR PROGNOSIS

62: Outcome of Anorexia NervosaHerzog et al (1988) Mortality 0%-22% of patients Underweightness 15%-43% Amenorrhoea 4%-42% Food restriction continued in 23%-67% of patients followed up.

63: SUMMARY Establish Diagnosis Assess stage and severity Primary care Vs Specialist referral