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GP Trainee Teaching Day 8th December 2010

GP Trainee Teaching Day 8th December 2010. Eating Disorders and Psychiatric Emergencies in Primary Care. Aims To prepare trainees for managing cases of high risk eating disorders and anxiety provoking psychiatric presentations.

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GP Trainee Teaching Day 8th December 2010

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  1. GP Trainee Teaching Day 8th December 2010 Eating Disorders and Psychiatric Emergencies in Primary Care

  2. Aims To prepare trainees for managing cases of high risk eating disorders and anxiety provoking psychiatric presentations. • ObjectivesFor trainees to have a framework for understanding the broad concepts of eating disorders, and know where to seek readily accessible advice about the specifics of medical risk management.For trainees to have a structure in place for conducting a risk assessment and a better understanding of referral processes for mental health services and the conduct of Mental Health Act Assessments.

  3. 09.00-10.30Theoretical Models and general approach to Eating Disorders

  4. What is an eating disorder? • How do you think about it? • Is it a mental illness?

  5. F50.0 Anorexia Nervosa AN is a disorder characterised by deliberate weight loss, induced and/or sustained by the patient… Diagnostic Guidelines For a definite diagnosis, all the following are required: • Body weight is maintained at least 15% below that expected or BMI is 17.5 kg/m2 or less. • The weight loss is self induced by avoidance of “fattening foods”. One or more of the following may also be present: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics. • There is body image distortion in the form of a dread of fatness persisting as an intrusive, overvalued idea and the patient imposing a low weight threshold on themselves. • A widespread endocrine disorder… amenorrhoea. • (Delayed puberty)

  6. ICD F50-F59 • Behavioural Syndromes associated with physiological disturbances and physical factors

  7. Transdiagnostic Model

  8. Black Box – “Emotional Problems” • Smoking • Alcohol • Heroin • Cutting • Overdosing • Gambling • Abusive relationships • Dietary Restriction • Purging • Appetite suppressants • Laxatives • Diuretics • Excessive exercise Self Defeating Behaviours

  9. Trainspotting – Renton’s commentary on heroin “People think it’s all about misery and desperation and death and all that shite, Which is not to be ignored, But what they forget is the pleasure of it. Otherwise we wouldn’t do it. After all, we’re not fucking stupid. Or at least we’re not that fucking stupid.”

  10. Change? Therapist factors- Warmth Honesty listening skills Trust therapeutic optimism

  11. How many psychiatrists does it take to change a lightbulb?

  12. Hunt for Red October Jack Ryan reasoning with himself whilst shaving, “Wait a minute. We don't have to figure out how to get the crew off the sub, he's already done that. He would have had to. All we have to do is figure out what he is going to do. So how is he going to get the crew off the sub? They'd have to want to get off. So how do you get a crew to want to get off a submarine? How do you get a crew to want to get off a nuclear submar...”

  13. Transtheoretical Model of Change • (Prochaska and DiClemente 1986-92)

  14. Recovery Maintenance Change Determination Relapse Contemplation Precontemplation

  15. Motivational Interviewing • Matching patient’s readiness • Non-critical alliance • Non-authoritarian • Boundaries, responsibility, ownership of problem • “Rolling with resistance” • Balance of pros and cons of change • (Biological, psychological, social) • Decision to change or not

  16. Role play in pairs (discuss) • 19 yo female dance student admits that her nausea and loss of appetite are as a result of abusing ephedrine that she has bought over the internet as an appetite suppressant. She also takes frusemide that was prescribed for her friends dog, as well as vomiting after every meal. She has a complex history of childhood abuse and insists that she has to keep her weight below BMI 19 to be successful as a dancer.

  17. Treatment? • Inside the black box?

  18. Treatment • Very little evidence. “Best practice” Summary of NICE Guidance for Anorexia Nervosa • “Psychological interventions are treatments of choice and should be accompanied by monitoring of the patient’s physical state” ie Balance between “Therapy” and Medical Risk Management

  19. Eisler ’97. RCT n=80 5yr f/u. Family Therapy vs Individual Supportive Therapy. “Outcomes favourable for FT if onset <19yrs and duration <3yrs. Outcomes favourable for IST for late onset/chronic.”

  20. Chris Fairburn’s Transdiagnostic Model – CBT-E • Clinical perfectionism • Low self-esteem • Mood intolerance • Problems with relationships • Overvaluation of size and weight

  21. “Coercive procedures should be reserved for the very small group of non-compliant patients whose situation is truly life-threatening; if possible they should be avoided altogether.” Companion to Psychiatric Studies 6th Edition 1998

  22. Minnesota Starvation Experiment Ancel Keys et al 1950 • demonstrated profound physical and psychological changes in 36 healthy volunteers placed on a very low calorie diet.

  23. Consequences of Starvation Exercise • Body is machine made of fat/protein • Emaciation – global/sytemic dysfunction Fill in the blank spaces for systemic symptoms, signs or abnormalities

  24. Cardiovascular • Poor peripheral circulation (Cold fingers and toes) • Hypotension (Fainting, collapse) • Oedema • Bradycardia • Arrhythmia • Sudden death • Cardiomyopathy • Cardiac valve disease

  25. Endocrine • Amenorrhoea • Infertility (acute and chronic) • Low libido • Low LH, LHRH, FSH • Low Thyroid Hormone (T3) • High Cortisol • High Fasting Growth Hormone • Erratic Vasopressin release

  26. Renal • Electrolyte abnormalities (low Sodium, Phosphate, Magnesium, Calcium, Potassium) • Renal calculi • Hypokalaemic nephropathy • Proteinuria • Reduced Glomerula Filtration Rate

  27. Haematological and Dermatological • Anaemia • Leukopenia (recurrent/dangerous infections) • Thrombocytopenia (bruising) • Bone marrow hypoplasia • Reduced Serum Complement levels • Low ESR • Dry, thin, brittle hair and nails • Lanugo • Loss of collagen, easy bruising, poor healing

  28. Gastrointestinal • Slowed gut transit time • (Abdominal pain, bloating, delayed gastric emptying • Constipation) • Parotid swelling • Nutritional hepatitis • Refeeding pancreatitis

  29. Metabolic • Loss of energy • Cold intolerance • Impaired temperature regulation • Hypoglucosaemia • Hypercholesterolaemia • Hypercarotenaemia • Hypoproteinaemia • Impaired Glucose Tolerance • High Beta-hydroxybutyrate • High Free Fatty Acids • Impaired Calcium metabolism • Vitamin deficiencies

  30. Musculoskeletal • Weakness • Aches, pains, minor soft tissue injuries • Loss of muscle mass • Proximal myopathy (squat test) • Osteoporosis • Osteopenia • Pathological fractures

  31. Neurological and Psychiatric • Generalised Seizures • EEG abnormalities • Peripheral neuropathies (electrolyte abnormality, mechanical) • Ventricular enlargement (brain shrinkage) • Depression (all biological symptoms) • Cognitive impairment • Worsening anxiety • (Fear of fatness, bodyimage disturbance, OCD, rituals, control of food) • Acute confusion, halucinations, coma

  32. Maudsley Guide to Medical Risk Assessment for Eating Disorders Janet Treasure (2009) - online

  33. Signs and symptoms of medical instability • Rapid weight loss >7kg in 4/52 • Seizures • Fainting • Confusion • Bradycardia <40 • Frequent exercise induced chest pain • Renal impairment/ urine <400ml/day • Dehydration • Tetany • Rapidly diminishing exercise tolerance “TheHandbook of Treatment for Eating Disorders” 2nd Edition 1997 (Garner and Garfinkel)

  34. “Although a medical professional can fairly easily identify an emergency situation in progress, ther are few definitive indicators of impending crisis. Death from anorexia nervosa is often the result of a sudden, unheralded cardiac event.”

  35. Role play in pairs (discuss) • 23 yo man presents with depression. All biological symptoms of depression including loss of apetite and weight which he says is due to stress and depression – not deliberate. He does admit that he has been exercising as a way of managing his mood, and he is a vegan. Weight loss has been gradual over 8 months. His BMI is now 14.3. He wants an antidepressant.

  36. Primary Care Psychiatric Emergencies?

  37. Stress for GP due to risk? - Risk Assessment

  38. Risk factors (for suicide) • Mental illness (if not..?) • Alcohol/drugs • Age • Gender • Occupations • Help seeking - Limitations

  39. History Previous behaviour - predicts future behaviour - Limitations

  40. Current Mental State • Thoughts • Planning • Intent

  41. Protective Factors • Family • Dog • Religious beliefs • Hope for future/possible treatment • Engagement with services • Engagement with safety plan

  42. Interface with Mental Health Services

  43. Community Mental Health Teams • 2/52’s target • Severe and Enduring • Risk • “short term work” • Up to x2 weekly contact • MDT – CPN, MHSW, OT, CSW, Clin Psy, and Psychiatry

  44. Intensive Home Treatment Team (Crisis) • 4hr target • Assessment in conjunction with Duty Psychiatrist (Junior) • Up to x2 daily contact • Telephone through night • Alternative to ward admission • Must be safe enough for home alone at night • Must be insightful and cooperative enough for visits • Gatekeepers for admission to ward

  45. Admission to Ward? • Mental illness • Risk • Necessity

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