Transcript Eating Disorders - Health in Wales

Eating Disorders
Dr Faye Tarrant ST4
General Adult Psychiatry
 “any
of a range of psychological
disorders characterised by abnormal
or disturbed eating habits”
Aims

Anorexia Nervosa
◦ Definition, diagnosis, causes and treatment
options
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Bulimia
◦ Definition, diagnosis, causes and treatment
options
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Re-feeding syndrome
Anorexia Nervosa Definition
ICD-10 F50.0 Anorexia Nervosa
 “a disorder characterized by deliberate
weight loss, induced and/or sustained by
the patient”
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Anorexia Nervosa ICD-10 Criteria
for Diagnosis
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For a definite diagnosis ALL of the following are
required:
Body weight is maintained at least 15% below that expected
(either lost or never achieved)
 The weight loss is self-induced by avoidance of “fattening
foods” AND one or more of the following:
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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 specific
psychopathology whereby a dread of fatness persists as an
intrusive, overvalued idea and the patient imposes a low
weight threshold on themselves
Anorexia ICD-10 Criteria
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Amenorrhoea in women and a loss of sexual
interest and potency in men.
◦ There may also be elevated levels of growth
hormone, raised levels of cortisol, changes in the
peripheral metabolism of the thyroid hormone, and
abnormalities of insulin secretion.
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If onset is prepubertal, the sequence of pubertal
events is delayed or even arrested (growth ceases;
in girls the breasts do not develop and there is a
primary amenorrhoea; in boys the genitals remain
juvenile).
◦ With recovery, puberty is often completed normally,
but the menarche is late.
Bulimia Definition
F50.2 Bulimia Nervosa
 Bulimia nervosa is a syndrome
characterized by repeated bouts of
overeating and an excessive
preoccupation with the control of body
weight, leading the patient to adopt
extreme measures so as to mitigate the
‘fattening” effects of ingested food.
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Bulimia ICD-10 Criteria
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For a definite diagnosis, ALL of the following are required:
There is a persistent preoccupation with eating, and an irresistible
craving for food; the patient succumbs to episodes of overeating in
which large amounts of food are consumed in short periods of
time.
The patient attempts to counteract the “fattening” effects of food
by one or more of the following:
◦ Self-induced vomiting
◦ Alternating periods of starvation
◦ Use of drugs such as appetite suppressants, thyroid preparations or
diuretics.
◦ When bulimia occurs in diabetic patients they may choose to neglect
their insulin treatment.
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The psychopathology consists of a morbid dread of fatness
◦ There is often, but not always, a history of an earlier episode of
anorexia nervosa, the interval between the two disorders ranging from
a few months to several years.
Who?

More females diagnosed than males
◦ 1 fifteen-year-old girl in every 150
◦ 1 fifteen-year-old boy in every 1000
Most common in adolescents and young
women BUT can affect anyone!
 Same in Bulimia BUT usually slightly later
onset
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Why?
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Social pressure:
◦ Our social surroundings powerfully influence our behaviour. Societies
which don’t value thinness have fewer eating disorders. Places where
thinness is valued, such as ballet schools, have more eating disorders.
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Lack of an “off” switch:
◦ Most of us can only diet so much before our
body tells us that it is time to start eating again. Some people with
anorexia may not have this same body "switch" and can keep their body
weight dangerously low for a long time.
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Control:
◦ It is good to feel that we can control ourselves in a clear, visible way.
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Puberty:
◦ Anorexia can reverse some of the physical changes of becoming an
adult .This may help to put off the demands of getting older, particularly
sexual ones.
Why?
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Family:
◦ Saying “no” to food may be the only way to express
feelings, or have any say in family affairs.
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Genetics:
◦ There is a lot of evidence that eating disorders run in
families even where the sufferers don't necessarily live
together, and that certain genes make people more
vulnerable, not only to eating disorders, but to related
conditions.
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Low self-esteem:
◦ People with anorexia often don’t think much of
themselves, and compare themselves unfavourably to
other people. Losing weight can be a way of trying to get a
sense of respect and self-worth.
Why?
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Emotional distress:
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life difficulties
sexual abuse
physical illness
upsetting events - a death or the break-up of a relationship
important events - marriage or leaving home.
The vicious circle :
◦ An eating disorder can continue even when the original stress or
reason for it has passed. Once your stomach has shrunk, it can
feel uncomfortable and frightening to eat.
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Physical causes:
◦ Some doctors think that there may be a physical cause that we
don't yet understand.
Differentials for Anorexia
There may be associated depressive or
obsessional symptoms, as well as features of
a personality disorder, which may make
differentiation difficult and/or require the use
of more than one diagnostic code.
 Somatic causes of weight loss in young
patients that must be distinguished include
chronic debilitating diseases, brain tumors,
and intestinal disorders such as Crohn’s
disease or a malabsorption syndrome
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Differentials for Bulimia
upper gastrointestinal disorders leading to
repeated vomiting
 a more general abnormality of personality
(the eating disorder may coexist with
alcohol dependence and petty offences
such as shoplifting)
 depressive disorder (bulimic patients
often experience depressive symptoms).
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Psychological Effects of Eating
Disorders
Poor sleep
 Poor concentration
 Low mood or depression
 Become obsessive about food and eating
(and sometimes other things such as
washing, cleaning or tidiness).
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Physical Effects of Eating Disorders
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Feel tired, weak and cold
Constipation
Hair loss
grow downy hair on other parts of the body., typically face
Dry skin
Pressure sores
Not reach full height, or lose height with a 'bowed over'
appearance.
Osteoporosis
Infertility
Liver damage
In extreme cases death
◦ . Anorexia Nervosa has the highest death rate of any psychological
disorder
Physical Effects of Eating Disorder if
Vomiting is a Prominent Feature
Puffy face
 Loss of tooth enable
 palpitations (vomiting disturbs the balance of
sodium and potassium in blood)
 Weakness
 Feel tired all the time
 Kidney damage
 Epileptic fits
 Infertility
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Physical Effects of Eating Disorder if
Laxative Use is a Prominent Feature
Persistent stomach pain
 Swollen fingers
 Laxative dependency
 have huge weight swings.
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◦ Fluid loss and gains
Treatment - Anorexia
CBT
 Family Therapy (best evidence)
 Dietician and Eating Disorder Services
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◦ Meal Planning
Physical health and weight monitoring
 Medication
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◦ May be prescribed reduce the anxiety and, in particular, to
reduce the 'ruminations' that sufferers describe.
◦ Most experience has been with the drug Olanzapine, as this is
safest in young people and in people who are at a low weight.
◦ It may be more effective than diazepam and similar drugs and is
less likely to be habit-forming.
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Admission to hospital
Treatment - Anorexia
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Compulsory treatment
◦ This is unusual
◦ It is only done if someone is so unwell they
are severely ill and as a result unable to make
a decision
◦ There must ne a risk of serious harm to them
if they are not treated in the case
Treatment Efficacy in Anorexia
More than half of sufferers make a recovery,
Average length of illness is 6-7 years.
Full recovery can happen even after 20 years of
severe anorexia.
 Past studies of the most severely-ill people
admitted to hospital have suggested that 1 in 5 of
these may die.
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◦ the death rate is much lower, f the person stays in
touch with medical care.
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As long as the heart and other organs have not
been damaged, most of the complications of
starvation seem to improve slowly once a person
is eating enough.
Treatment for Bulimia
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Cognitive Behavioural Therapy
◦ Usually individual
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Interpersonal Therapy (IPT)
◦ This is also usually done with an individual therapist,
but concentrates more on your relationships with
other people.
Eating Disorder Services and Dieticians
Medication
Even if you are not depressed, high doses of
antidepressants SSRIs
 This can reduce your symptoms but the benefit
tend to wear off if no psychological input
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Treatment Efficacy in Bulimia
~50% of sufferers recover, cutting their
bingeing and purging by at least half.
 Co-morbid alcohol or drug misuse or DSH
worsens prognosis
 CBT and IPT work just as effectively
 There is some evidence that a combination
of medication and psychotherapy is more
effective than either treatment on its own.
 Recovery usually takes place slowly over a
few months or many years.
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Re-feeding syndrome
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“a syndrome consisting of metabolic
disturbances that occur as a result of
reinstitution of nutrition to patients who
are starved or severely malnourished”
Re-feeding Syndrome
5 consecutive days of starvation puts
individuals at risk
 Usually occurs within 4 days of starting to
feed.
 Fluid and electrolyte disorders, especially
hypophosphataemia,
 Neurological, pulmonary, cardiac,
neuromuscular, and haematological
complications are also possible
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How Re-feeding Syndrome Occurs
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Patients who are malnourished develop a total body depletion of
phosphorous
◦ serum phosphorous levels are maintained by redistribution from the
intracellular space.
◦ The body uses endogenous fuel stores as it’s main source of energy.
◦ Fat and protein (from muscle) are metabolized.
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The delivery of glucose, as part of a feeding strategy, can cause a
huge increase in the circulating insulin level.
The patient struggles to cope with converting to exogenous fuel
sources.
There is rapid uptake of glucose, potassium, phosphate and
magnesium into cells.
The serum concentration of these agents falls dramatically.
In addition, for an unexplained reason, the body swiftly begins to
retain fluid, and the extracellular space expands.
Re-feeding syndrome
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This change in electrolyte balance leads to
a number of systemic pathologies.:
◦ There is an increase in cardiac workload,
heart rate and oxygen consumption.
◦ This sudden increase in demand for nutrients
and oxygen may outstrip supply.
◦ In patients with cardiovascular disease, the
sudden increase in cardiac work and
circulating fluid can precipitate heart failure
The shifting of electrolytes and fluid
balance increases cardiac workload and
heart rate
 This can lead to acute heart failure
 Oxygen consumption is also increased
which strains the respiratory system (as
well as pulmonary oedema)
 Death rate ~ 5%
 Most common cause of death is cardiac
arrhythmia
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respiratory system strain occurs, possibly causing
dyspnoea and tachypnoea
 The serum phosphorous level falls with refeeding,
due to a shift of phosphate from the extracellular
to the intracellular compartment, due to the huge
demands for this ion for synthesis of
phosphorylated compounds. The result of this
sudden massive reduction in phorphorous levels
is a multitude of life threatening complications
involving multiple organs: respiratory failure,
cardiac failure, cardiac arrhythmias,
rhabdomyolysis, seizures, coma, red cell and
leucocyte dysfunction.
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Re-feeding
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Close monitoring of blood biochemistry is necessary in the early
re-feeding period.
Milk is often the re-feeding food of choice in this early period
(naturally high in phosphate and easily tolerated by those who have
been starved.)
If potassium, phosphate or magnesium are low then this should be
corrected via the oral route
Prescribing thiamine, vitamin B complex and a multivitamin and
mineral is recommended
Calorie intake should remain only 50-70% that of normally required
for the first 3–5 days.
Effects of beginning to eat after a prolonged period include:
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colicky abdominal pain,
reflux symptoms,
nausea and
early satiety
This is to certify that:
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Has reviewed/completed
........Eating Disorders.................
Date
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