Treating Eating Disorders in Primary Care

1. Treating Eating Disorders in Primary Care Helen Root Practice Nurse University Health Service Sheffield Belfast June 2006

2. ASSESSMENT Should include: Physical, Psychological & Social Components • Physical Health : (BMI, Menstrual status, Blood Chemistry: FBC, U&E’S, TFT’s & LFT’s). History of weight loss. Possibly bone scan and ECG. (refer to website address in list of resources at the end of the presentation) • Any obvious psychological triggers : Bereavement, attitude to body shape & weight, impact on self esteem, motivation to change. • Impact on social functioning, studies, occupation, relationships, leisure activities etc.

3. ASSESSMENT FORMAT • Personal & family history/social situation • History of eating disorder - how did it begin - develop current situation • Current eating patterns – typical day, food restriction, frequency of bulimic episodes & compensatory behaviours • Physical risk factors height, weight, BMI & any appropriate investigations • Questionnaires: CoreBiteEat 26 (Psychological risk factors are measured within the Core) • Attitude to body image and self esteem • Mood and motivation to change

4. CLASSIFICATION

5. EXCLUSION CRITERIA • Psychiatric co-morbidity (referral to CMHT) • Severity (refer to Specialist Service) • Motivation (poor social support and lack of motivation will render intervention unsuccessful, attempts to continue will further undermine confidence and cause loss of faith in process)

6. INCLUSION CRITERIA • Readiness to change • Good social support • Mild to moderate difficulties

7. GUIDED SELF-HELP • Uses cognitive behavioural therapy techniques • Encourages a collaborative approach, using self-help books • Offers psycho-education on effects of starvation/purging and nutritional needs • Exploratory exercises developed to build motivation for change and to identify triggers • Monitoring sheets for eating and mood • Self-esteem and relaxation exercises

8. MOTIVATIONAL WORK MONITORING ESTABLISHING A MEAL PLAN IDENTIFYING PATTERNS AND INTERVENING MANAGING ANXIETY AND PROBLEM SOLVING ELIMINATING DIETING CHANGING THE WAY YOU THINK IMPROVING SELF-ESTEEM PROMOTING POSITIVE BODY IMAGE RELAPSE PREVENTION THE JOURNEY TOWARDS CHANGE!

9. Why are you here? If you want to change, why? How will you benefit by changing? How will you benefit by staying the same? Helpful tools for eliciting this information include: Pro’s and Con’s exercise. Benefit and Cost Chart. The Five Years on Letter. MOTIVATIONAL WORK

10. MONITORING • Encourage the patient to be their own analyst • Collect full and frank data on their moods and eating behaviour • At the next session assist them in analysing data, making particular note of connections between mood, physical state, thoughts and behaviour

11. MEAL PLANNING • Establishing patterns of regular eating • Use balance for healthy eating, emphasise evidence base • Encourage continued analysis, use graded experiments if necessary, e.g. traffic light system • Continue keeping detailed diary

12. IDENTIFYING TRIGGERS • Use the information collated to identify triggers • Are they associated with mood, thoughts, eating behaviour • Collate more information about the triggers by exploring the connections between the triggers and the consequent thoughts, feelings and behaviour

13. INTERVENTION STRATEGIES • Find suitable ways to manage the difficult times • Continued reassurance and education is usually necessary • Identify activities that will provide distraction • Point out successes and occasions when distractions have worked. Why?

14. MANAGING ANXIETY • Anxiety may occur as a result of applying intervention strategies • Or may be a maintaining factor • Describe the anxiety cycle, establish connections • Work on anxiety management

15. PROBLEM SOLVING • Frequently the disordered eating is perceived as the problem • The collected information should by now indicate that it is in fact a response to a problem/s • Work on tackling problems using problem solving methods. A useful life tool!

16. ELIMINATING DIETING • When regular eating is established it is often apparent that the diet is limited • Certain foods remain a threat and maintain a powerful hold • Work on slowly introducing unsafe foods into the diet

17. CHANGING THE WAY YOU THINK • Identify persistent thoughts and thinking styles • Challenge the difficult thoughts • Find evidence for and against • Weigh up the evidence • Come up with an alternative belief

18. IMPROVING BODY IMAGE AND SELF-ESTEEM • Often a significant maintaining factor • Identify areas of low self-esteem • Find exercises that will help develop skills that raise self-confidence • Establish link between self-image and body image

19. BODY IMAGE • Encourage recognition between the influences that shape attitudes to body acceptance and explore the connections. e.g. regular weighing and body checking • Graded experiments to reduce these behaviours

20. RELAPSE PREVENTION • Review material • Come up with an individual plan, with strategies already in place • Lapses do not mean failure, continue to be the analyst and learn and move on

21. CASE STUDY 1 Maria, 20yr old medical student, binges and vomits approximately 2-3 times a week. Identified problems of low self worth and frequently compares herself unfavourably with others. Is shy and feels she goes un-noticed. Examination of food diary and circumstances surrounding the binges, elicited information that showed it usually occurs when she needs to “block” or “repress” thoughts or feelings, e.g. Phone call with new boyfriend or academic studies.

22. CASE STUDY 2 Jane 19 yr old geography student with a BMI of 28. Frequently binges, feels guilty and then embarks on periods of restriction. These usually occur as result of stress. Identified stressors were studies, insists on setting high standards and worries about her body shape.

23. RESOURCE LIST • Adams, Jo. Go Girls! Supporting Girls’ Emotional Development and Building Self-Esteem. Centre for HIV & Sexual Health, Sheffield, 2002 • Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. Penguin Books, London, 1989 • Bennett-Levy, James, et al, ed. Oxford Guide to Behavourial Experiments in Cognitive Therapy. Oxford University Press, 2004 • Cash, Thomas F. The Body Image Workbook. An 8-step program for learning to like your looks. New Harbinger Publications, Oakland, CA, 1997 • Cooper, Peter J. Bulimia Nervosa and Binge-eating. A self-help guide using Cognitive Behavioural Techniques. Constable & Robinson Ltd, London, 1995 • Crisp, A H, et al. Anorexia Nervosa: The Wish To Change. Self-help and Discovery The Thirty Steps.Brunner-Routledge, Hove, 2001 • Fairburn, Christopher G. Overcoming Binge Eating. The Guildford Press, New York, 1995

24. 8Fennell, Melanie. Overcoming Low Self-Esteem. A clinically-proven step-by-step program to recovering on your own. New York University Press, 1999 9 Greenberger, Dennis and Padesky, Christine A. Mind Over Mood. Change How You Feel by Changing the Way You Think.The Guildford Press, New York,1995 10 Jeffers, Susan. Feel The Fear And Do It Anyway. Arrow Books, London, 1991 11 Powell, Trevor. The Mental Health Handbook. Revised edition. Speechmark Publishing Ltd, Bicester, 2003 (2000) 12 Treasure, Janet. Anorexia Nervosa. A Survival Guide for Families, Friends, and Sufferers. Brunner-Routledge, Hove, 2001 13 The Personal Notebook: A Self-Help Guide. Sheffield Eating Disorders Service, St George’s Community Health Centre, Winter Street, Sheffield S3 7ND. Cost of the booklet is £5.00 (plus postage & packing) 14 Treasure, Janet. A Guide to the Medical Risk Assessment for Eating Disorders www.IOP.KCL.UK/IOP/Departments/psychmed/edu/professionals.shtml