Eating Disorders

1. Eating Disorders Dr. Megan Chapman Senior Clinical Psychologist Royal Children�s Hospital � Mental Health Service

2. Important References Major reference points: NICE guidelines (2004) APA guidelines and their 2005 revision RANZCP Guidelines (2004) Handbook of Eating Disorders (2nd Ed) � Treasure , Schmidt & Van Furth (2003) Handbook of Treatment for Eating Disorders � Garner and Garfinkel (1997) Anorexia Nervosa and Related Eating Disorders in Childhood and Adolescence (3rd Ed) �Lask & Bryant-Waugh (2006/7?)

3. Eating Disorders Diagnosis Assessment Treatment options Case Studies and discussion

4. Diagnostic Classifications

5. Anorexia Nervosa Refusal to maintain body weight at or above a minimally normal weight for age and height (eg weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected) Intense fear of gaining weight or becoming fat, even though underweight. Disturbance in the way in which one�s body weight 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 In post-menarchal females, amenorrhea, i.e. the absence of at least three consecutive menstrual cycles (A woman is considered to have amenorrhea if her periods occur only following hormone, eg oestrogen, administration) Specify type: Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting, or the misuse of laxatives, diuretics, or enemas) Specify type: Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas) Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behaviour (i.e. self-induced vomiting, or the misuse of laxatives, diuretics, or enemas)

6. Bulimia Nervosa Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following: Eating, in a discrete period of time (eg 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 A sense of lack of control over eating during the episode (eg a feeling that one cannot stop eating or control what or how much one is eating) 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 The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months. Self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during episodes of Anorexia Nervosa 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 Non-purging 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 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 Non-purging 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

7. Possible EDNOS Subcategories Food Avoidance Emotional Disorder Selective Eating Restrictive Eating Food refusal Functional dysphagia Pervasive Refusal Syndrome Binge Eating Disorder Food Avoidance Emotional Disorder (Higgs et al, 1989, cited Bryant-Waugh, 2000). � this is primarily an emotional disorder where food avoidance is a prominent feature. � Diagnostic considerations are as follows: A disorder of the emotions in which food avoidance is a prominent symptom in the presenting complaint A history of food avoidance or difficulties (i.e. food fads or restrictions) A failure to meet criteria for anorexia nervosa The absence of organic brain diseases, psychosis, illicit drub abuse, or prescribed drug related side-effects Children with FAED doe not have the same preoccupation with weight and shape, and the also do not have a distorted view of their own weight or shape Children with FAED have mood disturbance, ranging in form from mild depression, anxiety, obsessionality, or phobias especially for specific foods Selective Eating In which children limit their food intake to a very narrow range of preferred foods. Children may be of an appropriate weight and height for their age Boys are more represented in this group than girls Food selectivity has an impact on the appropriate social functioning of the child No pre-occupation with weight and/or shape, or a distorted perception of their own body size No prominent fear of gagging or choking Restrictive Eating: � Children who have never eating large amounts of food Do not have an overt interest in or enjoyment of food No evidence of mood disturbance Range of foods are not restricted, as opposed to portion size Do not have a large appetite May present with weight loss around the time of puberty, but are usually willing to accept energy supplements or dietary advice to facilitate appropriate growth. Food Refusal � �������� Food refusal tends to be episodic, intermittent, or situational �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape � Functional dysphagia � Food avoidance Fear of swallowing, choking, or vomiting �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape � Pervasive Refusal Syndrome � Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help ?trauma based Food Avoidance Emotional Disorder (Higgs et al, 1989, cited Bryant-Waugh, 2000). � this is primarily an emotional disorder where food avoidance is a prominent feature. � Diagnostic considerations are as follows: A disorder of the emotions in which food avoidance is a prominent symptom in the presenting complaint A history of food avoidance or difficulties (i.e. food fads or restrictions) A failure to meet criteria for anorexia nervosa The absence of organic brain diseases, psychosis, illicit drub abuse, or prescribed drug related side-effects Children with FAED doe not have the same preoccupation with weight and shape, and the also do not have a distorted view of their own weight or shape Children with FAED have mood disturbance, ranging in form from mild depression, anxiety, obsessionality, or phobias especially for specific foods Selective Eating In which children limit their food intake to a very narrow range of preferred foods. Children may be of an appropriate weight and height for their age Boys are more represented in this group than girls Food selectivity has an impact on the appropriate social functioning of the child No pre-occupation with weight and/or shape, or a distorted perception of their own body size No prominent fear of gagging or choking Restrictive Eating: � Children who have never eating large amounts of food Do not have an overt interest in or enjoyment of food No evidence of mood disturbance Range of foods are not restricted, as opposed to portion size Do not have a large appetite May present with weight loss around the time of puberty, but are usually willing to accept energy supplements or dietary advice to facilitate appropriate growth. Food Refusal � �������� Food refusal tends to be episodic, intermittent, or situational �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape � Functional dysphagia � Food avoidance Fear of swallowing, choking, or vomiting �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape � Pervasive Refusal Syndrome � Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help ?trauma based

8. Food Avoidance Emotional Disorder (Higgs et al, 1989, cited Bryant-Waugh, 2000). � this is primarily an emotional disorder where food avoidance is a prominent feature. �Diagnostic considerations are as follows: A disorder of the emotions in which food avoidance is a prominent symptom in the presenting complaint A history of food avoidance or difficulties (i.e. food fads or restrictions) A failure to meet criteria for anorexia nervosa The absence of organic brain diseases, psychosis, illicit drub abuse, or prescribed drug related side-effects Children with FAED doe not have the same preoccupation with weight and shape, and the also do not have a distorted view of their own weight or shape Children with FAED have mood disturbance, ranging in form from mild depression, anxiety, obsessionality, or phobias especially for specific foods (Higgs et al, 1989, cited Bryant-Waugh, 2000). � this is primarily an emotional disorder where food avoidance is a prominent feature. � Diagnostic considerations are as follows: A disorder of the emotions in which food avoidance is a prominent symptom in the presenting complaint A history of food avoidance or difficulties (i.e. food fads or restrictions) A failure to meet criteria for anorexia nervosa The absence of organic brain diseases, psychosis, illicit drub abuse, or prescribed drug related side-effects Children with FAED doe not have the same preoccupation with weight and shape, and the also do not have a distorted view of their own weight or shape Children with FAED have mood disturbance, ranging in form from mild depression, anxiety, obsessionality, or phobias especially for specific foods (Higgs et al, 1989, cited Bryant-Waugh, 2000). � this is primarily an emotional disorder where food avoidance is a prominent feature. � Diagnostic considerations are as follows: A disorder of the emotions in which food avoidance is a prominent symptom in the presenting complaint A history of food avoidance or difficulties (i.e. food fads or restrictions) A failure to meet criteria for anorexia nervosa The absence of organic brain diseases, psychosis, illicit drub abuse, or prescribed drug related side-effects Children with FAED doe not have the same preoccupation with weight and shape, and the also do not have a distorted view of their own weight or shape Children with FAED have mood disturbance, ranging in form from mild depression, anxiety, obsessionality, or phobias especially for specific foods

9. Selective Eating Children limit their food intake to a very narrow range of preferred foods. Children may be of an appropriate weight and height for their age Boys are more represented in this group than girls Food selectivity has an impact on the appropriate social functioning of the child No pre-occupation with weight and/or shape, or a distorted perception of their own body size No prominent fear of gagging or choking Selective Eating In which children limit their food intake to a very narrow range of preferred foods. Children may be of an appropriate weight and height for their age Boys are more represented in this group than girls Food selectivity has an impact on the appropriate social functioning of the child No pre-occupation with weight and/or shape, or a distorted perception of their own body size No prominent fear of gagging or choking Selective Eating In which children limit their food intake to a very narrow range of preferred foods. Children may be of an appropriate weight and height for their age Boys are more represented in this group than girls Food selectivity has an impact on the appropriate social functioning of the child No pre-occupation with weight and/or shape, or a distorted perception of their own body size No prominent fear of gagging or choking

10. Food Refusal Food refusal tends to be episodic, intermittent, or situational No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape Food Refusal � �������� Food refusal tends to be episodic, intermittent, or situational �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape � Food Refusal � �������� Food refusal tends to be episodic, intermittent, or situational �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape �

11. Functional dysphagia Food avoidance Fear of swallowing, choking, or vomiting No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape Functional dysphagia Food avoidance Fear of swallowing, choking, or vomiting �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape Functional dysphagia Food avoidance Fear of swallowing, choking, or vomiting �������� No abnormal cognitions regarding weight and/or shape No morbid pre-occupations with weight and/or shape

12. Pervasive Refusal Syndrome �Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help ?trauma based Pervasive Refusal Syndrome � Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help ?trauma based Pervasive Refusal Syndrome � Profound refusal to eat, drink, walk, talk, or self-care Determined resistance to efforts to help ?trauma based

13. Binge Eating Disorder A. Recurring episodes of binge eating. The two characteristics of a binge eating episode are: (1) Eating a much larger amount of food than most people would consider normal under similar circumstances and within the same time frame (eating may continue for several hours).(2) While eating, there is a feeling of loss of control over the amount of food or type of food being consumed. B. Binge eating episodes are related to at least three of the following: (1) eating until feeling uncomfortably full.(2) eating large quantities of food when not even hungry.(3) eating noticeably faster than is considered normal.(4) eating alone due to embarrassment of overeating.(5) feelings of disgust, depression, or guilt after a binge. C. There is obvious distress concerning binge eating behaviour. D. On average, binge eating takes place twice weekly, and has done so for 6 months. E. There are no recurring efforts to compensate for binge eating, such as purging or excessive exercise. The disorder occurs at times other than during episodes of anorexia nervosa or bulimia nervosa.

14. Principles of Assessment Once an appropriate paediatric assessment is completed, there are six other areas of assessment that need to be considered (taken from the American Psychiatric Association�s Practice Guidelines for the Treatment of Patients with Eating Disorders, 2000)

15. Assessment of Dangerousness Danger to self Assessment current suicidal ideation History of suicidal ideation Suicide attempts Deliberate self harm Access to means

16. Assessment of Specific ED Symptoms and Behaviours Obtain a detailed report of a single day Observe the patient during a meal (if possible) Assess related psychological symptoms (eg obsessional thoughts related to weight, shape and eating Determine the patient�s insight into the presence of the disorder and the patient�s motivation for change Explore the patient�s understanding of how the illness developed and the effects of interpersonal problems on onset Identify those stressors that exacerbate the symptoms of the eating disorder Consider the use of formal measures

17. Other Psychiatric Symptoms and Behaviours Assess the following: Mood symptoms and disorders Anxiety symptoms and disorders Obsessions/compulsions Substance abuse Impulsive/conduct behaviours Personality disturbance Psychotic disorders

18. Psychiatric History Assess previous episodes and previous treatment response

19. Developmental and Psychosocial History Assess the following: Developmental milestones, including early feeding and attachment histories Psychological, sexual or physical abuse Peer and interpersonal relationships

20. Family Issues Assess the following: Family history of eating disorders, other psychiatric disorders, including obesity Family reactions to the disorder; attitudes towards eating, exercise, and appearance Burden of illness on the family Family dynamics, particularly guilt and blame

21. Patient�s Motivation to Change Motivational Enhancement Interviewing Lecichner, 2005, based on Prochaska and DiClemente Critical in considering treatment, as interventions need to tailor to where a young person currently is, and clinician�s expectations for change also need to match

22. Working within the model Clinician�s expectations of change also need to vary depending on the stage that the client is at Interventions tailored to stages

23. Treatment � Universal Principles Family therapy should be offered within the treatment of child and adolescent eating disorders, with adjunctive individual therapy, regardless of the type of eating disorder Individual therapy should vary depending on the clinical presentation, and the disorder

24. Family Therapy Level B evidence for family therapy as an intervention for anorexia nervosa Unfortunately, there are no studies directly comparing different family therapy methods to enlighten us as to which method is most effective Maudsley Model is being extensively researched in Sydney (Westmead), and is starting to be used in Victoria (Eastern Health CAMHS, Oak House, Grampians Region, Austin)

25. Family Therapy Family therapy has been very involved in the treatment of Anorexia Nervosa for the past forty years. There are three main approaches: Structural Family Therapy (Minuchin et al) Systemic Family Therapy (Palazzoli et al) Narrative Therapy (Michael White, David Epston et al)

26. One approach: Maudsley Initially developed at the Maudsley Hospital, UK (Dare, 1985 et al) aimed for adolescence with Anorexia Nervosa up to 19 years old with less than 3 years duration of the illness. (Russell et al, 1987 & Rhodes et al, 2005) Research trials have been conducted over the past 18 years testing the efficacy of this approach. (Russell et al, 1987;Le Grange et al 1992; Eisler et al 1997; Eisler et al 2000; Mitchell and Carr 200; Lock and Le Grange 2001; Rhodes et al 2004;2005)

27. One Approach: Maudsley What is the Maudsley Model? � It�s an outpatient treatment model which views the family as the most important resource to bring about recovery of their child at home. The model integrates theory and practice from most family therapy approaches. Treatment consists of 3 phases for approximately 12 months. (Rhodes et al, 2005)

28. Outline of the Treatment Model Phase 1: Intensive Re-feeding stage (Initial 15 sessions) Sessions are weekly Parents re-feed the adolescent & manage the anorexic behaviors until adolescent reaches 90-95% of body weight. Anorexia is externalized to manage emotions. Siblings play a support role to the adolescent with AN (Rhodes et al, 2005) Facilitators notes: � The focus of treatment in phase one is to place the family in a therapeutic bind: The family are warned about need for immediate action, via psychoeducation about AN. This strategy is supposed to stir up anxiety for parents, emphasizing that it�s the family�s responsibility to restore their child back to health. The therapist communicates warmth, acceptance and expertise to prevent the parents from being overwhelmed. Facilitators notes: � The focus of treatment in phase one is to place the family in a therapeutic bind: The family are warned about need for immediate action, via psychoeducation about AN. This strategy is supposed to stir up anxiety for parents, emphasizing that it�s the family�s responsibility to restore their child back to health. The therapist communicates warmth, acceptance and expertise to prevent the parents from being overwhelmed.

29. Outline of the Treatment Model Phase 2: Transition to Adolescent Control (Sessions 15-20) Fortnightly sessions Adolescent learns to gradually resume control over eating without parental control. Parental control and sibling support role gradually reduces over time. Completed at menstruation or 100% IBW (Rhodes et al, 2005)

30. Outline of the Treatment Model Phase 3: Adolescent Issues (Sessions 20-24) Monthly sessions Assist family to return to �normal life cycle� after the delay caused by the anorexia. This phase may also involve addressing other issues. e.g. marital/family issues; co-morbidity etc (Rhodes, et al, 2005)

31. Core beliefs of the Maudsley Approach The family is seen as the most important resource for recovery A non-blaming approach is taken as to the cause of the eating disorder Separate the person from the eating disorder Hospitalisation is seen as a temporary solution Target of the intervention is �the Anorexia� Structural changes needed within the family system to defeat Anorexia Therapist resists the �expert� stance Medical safety precedes adolescent issues e.g. focus is solely on restoring the young person�s health. (Rhodes et al, 2005) See Facilitators notes in Facilitators PackSee Facilitators notes in Facilitators Pack

32. Family Therapy for different ED�s Studies using the Maudsley Model have only examined anorexia nervosa. However, a trial examining the technique�s effectiveness for Bulimia Nervosa is underway No studies have examined family therapy for EDNOS subtypes of ED�s

33. Individual Treatment options Anorexia Nervosa Bulimia Nervosa

34. Anorexia Nervosa Level C recommendations can be made for the treatment of adolescents with CBT This recommendation may be upgraded depending on the results of the TOUCAN trial currently underway in the UK CBT is not recommended for pre-pubertal eating disorders APA�s (2005) guideline revisions notes difficulties in sustaining CBT for anorexia nervosa, but that it does reduce the risk of relapse post weight gain A review of research into the efficacy of CBT in the treatment of adults with anorexia nervosa found that the treatment may be moderately effective, but not necessarily more so than other psychological therapies (eg, interpersonal or psychodynamic; NICE, 2004). There is evidence to suggest that CBT is particularly effective in targeting core symptoms of the disorder, such as reducing body-image disturbance (Norris, 1984). TOUCAN - Although no evidence is available at present, the researchers have highlighted that the aim of their manualised CBT program is to identify the ways in which thoughts about eating, weight, and physical appearance have a negative impact upon one�s understanding of self worth, education/career and family or social relationships (Gowers, 2005). A review of research into the efficacy of CBT in the treatment of adults with anorexia nervosa found that the treatment may be moderately effective, but not necessarily more so than other psychological therapies (eg, interpersonal or psychodynamic; NICE, 2004). There is evidence to suggest that CBT is particularly effective in targeting core symptoms of the disorder, such as reducing body-image disturbance (Norris, 1984). TOUCAN - Although no evidence is available at present, the researchers have highlighted that the aim of their manualised CBT program is to identify the ways in which thoughts about eating, weight, and physical appearance have a negative impact upon one�s understanding of self worth, education/career and family or social relationships (Gowers, 2005).

35. Anorexia Nervosa Level C recommendations can also be made for the treatment with the following techniques: Cognitive analytic therapy (CAT) Interpersonal psychotherapy (IPT) Focal psychodynamic therapy It is recommended that the type of intervention be determined by characteristics of the client.

36. Bulimia Nervosa A specific program of CBT for bulimia nervosa (CBT-BN) be considered as the �gold standard� treatment for adults with this disorders (NICE, 2004). However, no studies have examined adolescents, therefore the recommendation can only be at Level C In particular, CBT-BN aims to treat unhealthy eating behaviours and teach people to challenge irrational thoughts about one�s weight, shape and body-image, which can perpetuate the illness (Wilson & Fairburn, 2002). The guidelines published by the compiled by NICE (2004) recommend that maximum therapeutic benefits are attained from scheduling weekly therapy sessions over a period of four to five months (i.e., 16 to 20 sessions). In particular, CBT-BN aims to treat unhealthy eating behaviours and teach people to challenge irrational thoughts about one�s weight, shape and body-image, which can perpetuate the illness (Wilson & Fairburn, 2002). The guidelines published by the compiled by NICE (2004) recommend that maximum therapeutic benefits are attained from scheduling weekly therapy sessions over a period of four to five months (i.e., 16 to 20 sessions).

37. Bulimia Nervosa Agras, Stewart, Walsh, Fairburn, Wilson & Kraemer (2000) studied 220 (adult) patients with Bulimia Nervosa. The patients were randomly allocated to 19 sessions of either CBT or IPT conducted over 20 weeks and evaluated one year post-treatment. CBT was found to be more effective initially, but at follow-up IPT was found to have been equally effective.

38. EDNOS � Binge Eating Disorder CBT is currently proposed to be the most effective treatment for adults with binge-eating disorder (NICE, 2004). no specific research has been conducted into the use of CBT in the treatment of binge eating disorder in young people It is appropriate to use a modified CBT program for adolescents with binge eating disorder, with careful consideration of the young person�s developmental and cognitive levels in modifying aspects of family involvement, psycho-education, and activity planning within the individual treatment plan. These recommendations are given a Grade C rating because they are largely based on expert opinion. CBT is currently proposed to be the most effective treatment for adults with binge-eating disorder (NICE, 2004). Again, no specific research has been conducted into the use of CBT in the treatment of binge eating disorder in young people; however it has demonstrated efficacy in the treatment of adults. Individual CBT in adults has been shown to be effective in reducing the frequency and severity of binge eating behaviours as well as associated problems, such as low self-esteem, lowered sense of control, lowered mood, and obesity (Grilo, Masheb & Wilson, 2005; Hilbert & Tuschen-Caffier, 2004; Ricca et al., 2001). Group programs and guided self-help programs have also demonstrated similar results (Carter & Fairburn, 1998; Wilfley et al., 2002). � As with the treatment of adolescents with bulimia nervosa, it is considered appropriate to employ a modified CBT program for the treatment of adolescents with binge eating disorder. Again, this requires careful consideration of the young person�s developmental and cognitive levels in modifying aspects of family involvement, psycho-education, and activity planning within the individual treatment plan. These recommendations are given a Grade C rating because they are largely based on expert opinion. CBT is currently proposed to be the most effective treatment for adults with binge-eating disorder (NICE, 2004). Again, no specific research has been conducted into the use of CBT in the treatment of binge eating disorder in young people; however it has demonstrated efficacy in the treatment of adults. Individual CBT in adults has been shown to be effective in reducing the frequency and severity of binge eating behaviours as well as associated problems, such as low self-esteem, lowered sense of control, lowered mood, and obesity (Grilo, Masheb & Wilson, 2005; Hilbert & Tuschen-Caffier, 2004; Ricca et al., 2001). Group programs and guided self-help programs have also demonstrated similar results (Carter & Fairburn, 1998; Wilfley et al., 2002). � As with the treatment of adolescents with bulimia nervosa, it is considered appropriate to employ a modified CBT program for the treatment of adolescents with binge eating disorder. Again, this requires careful consideration of the young person�s developmental and cognitive levels in modifying aspects of family involvement, psycho-education, and activity planning within the individual treatment plan. These recommendations are given a Grade C rating because they are largely based on expert opinion.

39. EDNOS - others The general recommendation for EDNOS is to follow the recommendation for the Eating Disorder which the presentation most closely resembles

40. Alternative Approaches Creative Art Therapies have long been used as an adjunct to the treatment of eating disorders No RCT�s exist for such therapies, however, there is bodies of descriptive literature outlining their usefulness Can be delivered either individually or in a group setting Modalities can include music therapy, art therapy, dance movement therapy, drama therapy, or a combined approach

41. Inpatient Settings Guidelines for inpatient admission (RANZCP, 2004) � o������ HR< 40bpm, BP< 90mm Hg, electrolyte disturbances, orthostatic changes in BP +- HR o������ Active suicide plan o������ BMI <14 +- rapid weight loss o������ Obsessive thoughts not amenable to treatment unless in highly structured environment o������ Needing every meal supervised or needing Nasogastric feeds o������ Severe family problems o� Out of control vomiting/purging

42. If Admit, Where? Psychiatric Unit Medical/Paed Unit Specialist Unit If Admit: Where? The American Psychiatric Association (2000) believes weight and medical status are the most important parameters in determining choice of setting, whether medical or psychiatric ward, but the availability of suitable intensive outpatient, partial and day hospitalisation also plays a role. Their recommendation is to hospitalize before a patient becomes medically unstable. � Honig & Sharman (2000) continue to debate medical/psychiatric inpatient treatment and have advantages and disadvantages for both. Advantage of psychiatric unit is stated as skilled staff, milieu therapy, group/family/individual therapy, and the chance for clients to mix with others not obsessed with body weight. Peer pressure at mealtimes can also be helpful. Yet they state this can be seen as a disadvantage by parents as they are concerned their child might adopt the disturbed behaviour of others. Competition between individuals can also arise for staff attention. They believe it is essential for parents and clinicians to work together in their approach and to be consistant. Advantages of the medical/paediatric ward are seen as readily available expert medical care. Nursing staff skilled at artificial feeding and distress to young person and their family may be less than a psychiatric hospital. Parents may deny psychiatric difficulties and may feel more comfortable with medical services. Disadvantages of this are no room for family/group/individual therapy and a lack of skills/understanding in nursing staff as pointed out below by Ramjan (2004). For both medical/psychological inpatient treatment to be productive nurses and patients must be able to develop a therapeutic relationship. In a study by Ramjan (2004) on nurses and the �therapeutic relationship�: caring for adolescents with anorexia nervosa, based on an acute medical ward where no nurses were mental health trained. Found that nurses on the ward had little understanding of anorexia nervosa many nurses believing they �caused their own harm� and �needed to fix it themselves� Nurses becoming angry as their were �really sick kids on the ward�. Staff felt betrayed or cheated when the patients went to extremes to regain control. This highlights the importance of education for nursing staff on the medical wards if this is how we are going to manage anorexia nervosa. � Winston & Webster (2003) state �Clinical experience strongly suggests that patients with anorexia nervosa should be treated in specialist units whenever possible and that those treated on general psychiatric or medical wards tend to have a poorer outcome (chap 22, p350-1)�. � Note: If on initial referral to inpatient service the patient is medically compromised they will first have to be admitted into a medical facility. Once medically stable if appropriate inpatient admission could be arranged If Admit: Where? The American Psychiatric Association (2000) believes weight and medical status are the most important parameters in determining choice of setting, whether medical or psychiatric ward, but the availability of suitable intensive outpatient, partial and day hospitalisation also plays a role. Their recommendation is to hospitalize before a patient becomes medically unstable. � Honig & Sharman (2000) continue to debate medical/psychiatric inpatient treatment and have advantages and disadvantages for both. Advantage of psychiatric unit is stated as skilled staff, milieu therapy, group/family/individual therapy, and the chance for clients to mix with others not obsessed with body weight. Peer pressure at mealtimes can also be helpful. Yet they state this can be seen as a disadvantage by parents as they are concerned their child might adopt the disturbed behaviour of others. Competition between individuals can also arise for staff attention. They believe it is essential for parents and clinicians to work together in their approach and to be consistant. Advantages of the medical/paediatric ward are seen as readily available expert medical care. Nursing staff skilled at artificial feeding and distress to young person and their family may be less than a psychiatric hospital. Parents may deny psychiatric difficulties and may feel more comfortable with medical services. Disadvantages of this are no room for family/group/individual therapy and a lack of skills/understanding in nursing staff as pointed out below by Ramjan (2004). For both medical/psychological inpatient treatment to be productive nurses and patients must be able to develop a therapeutic relationship. In a study by Ramjan (2004) on nurses and the �therapeutic relationship�: caring for adolescents with anorexia nervosa, based on an acute medical ward where no nurses were mental health trained. Found that nurses on the ward had little understanding of anorexia nervosa many nurses believing they �caused their own harm� and �needed to fix it themselves� Nurses becoming angry as their were �really sick kids on the ward�. Staff felt betrayed or cheated when the patients went to extremes to regain control. This highlights the importance of education for nursing staff on the medical wards if this is how we are going to manage anorexia nervosa. � Winston & Webster (2003) state �Clinical experience strongly suggests that patients with anorexia nervosa should be treated in specialist units whenever possible and that those treated on general psychiatric or medical wards tend to have a poorer outcome (chap 22, p350-1)�. � Note: If on initial referral to inpatient service the patient is medically compromised they will first have to be admitted into a medical facility. Once medically stable if appropriate inpatient admission could be arranged

43. Inpatient models BC Children�s Hospital Focuses on motivation to change model Offers inpatient and intensive day patient admissions for clients not responding to outpatient therapies Inpatient treatment involves: Meal Support Therapy Activity Responsibility Levels Nutrition Responsibility Levels Meal Support Therapy - �On their first day, a nurse is assigned to spend time with patient supporting them and distracting them throughout meals. From second day they are expected to join others. For MST to be effective staff members must eat appropriate meals with patients, providing an appropriate role model. Coach with empathy and positive feedback, address disordered eating at the time in a non-emotional tone, distract them and be consistent. 100% of meals are expected. Responsibility Levels - � Increased physical activity with reduced supervision. The levels provide a range of physical activities ranging from A, (stretch/relaxation) to D (various activities). Nutrition Responsibility Levels- Prepare patients for monitoring own nutrition with less supervision. From Level 1, eating with close supervision, to level 5, eating in caf� with peersMeal Support Therapy - �On their first day, a nurse is assigned to spend time with patient supporting them and distracting them throughout meals. From second day they are expected to join others. For MST to be effective staff members must eat appropriate meals with patients, providing an appropriate role model. Coach with empathy and positive feedback, address disordered eating at the time in a non-emotional tone, distract them and be consistent. 100% of meals are expected. Responsibility Levels - � Increased physical activity with reduced supervision. The levels provide a range of physical activities ranging from A, (stretch/relaxation) to D (various activities). Nutrition Responsibility Levels- Prepare patients for monitoring own nutrition with less supervision. From Level 1, eating with close supervision, to level 5, eating in caf� with peers

44. Karolinksa Institute The Karolinksa model does not recognise ED�s as a psychiatric condition Treatment is directed at the disordered eating behaviour, altered perception of satiety, hypothermia, physical hyperactivity and disordered social life (Bergh, Brodin, Lindberg & Sodersten, 2002). Treatment includes: Use of a mandometer, a computer scales used when eating Warming jackets and heat rooms Reduction of physical activity �Re-teaching� (reprogramming) clients in how to eat Treatment involves the use of a Mandometer, a computer scale that stores the weight loss of the plate placed on it. Patients are expected to eat one warm meal a day on the Mandometer. The patient is asked to record their satiety by use of a questionnaire at one-minute intervals, the computer then interprets this and a linear curve is displayed which the patient is asked to follow. The aim is to train the anorexic/bulimic to ingest 350g per 10-15min. The training curve always looks the same but the values are modified twice during a median of 35 days. Thus the anorexics eat progressively more food and the bulimics less. External heat is also used and after each meal the patient is expected to rest in a room with temp upto 40oC Physical Activity is reduced and anorexic patients placed in a wheel chair or allowed to walk slowly within the clinic. Bulimics allowed 30min walks a day with a member of staff. Meal Plan specified with clients being asked to indicate the weight gain they could tolerate, with no less than a 2kg gain accepted as their goal. Once goal achieved a new weight would be negotiated. To be considered in remission, a patient could no-longer meet the criteria for an eating disorder and bulimic patients should have stopped binge eating for a period of 3months. Body weight, psychiatric profile and lab tests had to be normal. The patients had to be able to state they no longer had problems with food and dieting. A study of 168 patients who entered treatment during 1993 and 2000 showed 93% remained free of symptoms for a period of 12months post treatment. As risk of remission is highest in the first year we suggest most patients treated with this model recover (Bergh, Lindberg, Brodin & Sodersten (2002)). Treatment involves the use of a Mandometer, a computer scale that stores the weight loss of the plate placed on it. Patients are expected to eat one warm meal a day on the Mandometer. The patient is asked to record their satiety by use of a questionnaire at one-minute intervals, the computer then interprets this and a linear curve is displayed which the patient is asked to follow. The aim is to train the anorexic/bulimic to ingest 350g per 10-15min. The training curve always looks the same but the values are modified twice during a median of 35 days. Thus the anorexics eat progressively more food and the bulimics less. External heat is also used and after each meal the patient is expected to rest in a room with temp upto 40oC Physical Activity is reduced and anorexic patients placed in a wheel chair or allowed to walk slowly within the clinic. Bulimics allowed 30min walks a day with a member of staff. Meal Plan specified with clients being asked to indicate the weight gain they could tolerate, with no less than a 2kg gain accepted as their goal. Once goal achieved a new weight would be negotiated. To be considered in remission, a patient could no-longer meet the criteria for an eating disorder and bulimic patients should have stopped binge eating for a period of 3months. Body weight, psychiatric profile and lab tests had to be normal. The patients had to be able to state they no longer had problems with food and dieting. A study of 168 patients who entered treatment during 1993 and 2000 showed 93% remained free of symptoms for a period of 12months post treatment. As risk of remission is highest in the first year we suggest most patients treated with this model recover (Bergh, Lindberg, Brodin & Sodersten (2002)).