Transcript 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.
• 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.
09.00-10.30
Theoretical Models and general
approach to Eating Disorders
• What is an eating disorder?
• How do you think about it?
• Is it a mental illness?
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)
ICD F50-F59
• Behavioural Syndromes associated with
physiological disturbances and physical
factors
• Transdiagnostic Model
Black Box – “Emotional Problems”
Smoking
Alcohol
Heroin
Cutting
Overdosing
Gambling
Abusive relationships
Dietary Restriction
Purging
Appetite suppressants
Laxatives
Diuretics
Excessive exercise
Self Defeating Behaviours
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.”
Change?
Therapist factorsWarmth
Honesty
listening skills
Trust
therapeutic optimism
How many psychiatrists
does it take
to change a lightbulb?
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...”
Transtheoretical Model of Change
• (Prochaska and DiClemente 1986-92)
Recovery
Maintenance
Change
Determination
Relapse
Contemplation
Precontemplation
Motivational Interviewing
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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
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.
Treatment?
• Inside the black box?
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
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.”
Chris Fairburn’s Transdiagnostic
Model – CBT-E
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Clinical perfectionism
Low self-esteem
Mood intolerance
Problems with relationships
Overvaluation of size and weight
“Coercive procedures should
be reserved for the very small
group of non-compliant patients
whose situation is truly lifethreatening; if possible they
should be avoided altogether.”
Companion to Psychiatric Studies 6th Edition 1998
10.30-10.45
Coffee
10.4512.30
Physical Risks and Medical Management
in Eating Disorders
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.
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
Cardiovascular
• Poor peripheral circulation (Cold fingers and
toes)
• Hypotension (Fainting, collapse)
• Oedema
• Bradycardia
• Arrhythmia
• Sudden death
• Cardiomyopathy
• Cardiac valve disease
Endocrine
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Amenorrhoea
Infertility (acute and chronic)
Low libido
Low LH, LHRH, FSH
Low Thyroid Hormone (T3)
High Cortisol
High Fasting Growth Hormone
Erratic Vasopressin release
Renal
• Electrolyte abnormalities (low Sodium,
Phosphate, Magnesium, Calcium,
Potassium)
• Renal calculi
• Hypokalaemic nephropathy
• Proteinuria
• Reduced Glomerula Filtration Rate
Haematological and Dermatological
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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
Gastrointestinal
• Slowed gut transit time
• (Abdominal pain, bloating, delayed gastric
emptying
• Constipation)
• Parotid swelling
• Nutritional hepatitis
• Refeeding pancreatitis
Metabolic
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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
Musculoskeletal
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Weakness
Aches, pains, minor soft tissue injuries
Loss of muscle mass
Proximal myopathy (squat test)
Osteoporosis
Osteopenia
Pathological fractures
Neurological and Psychiatric
• Generalised Seizures
• EEG abnormalities
• Peripheral neuropathies (electrolyte abnormality,
mechanical)
• Ventricular enlargement (brain shrinkage)
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Depression (all biological symptoms)
Cognitive impairment
Worsening anxiety
(Fear of fatness, bodyimage disturbance, OCD, rituals,
control of food)
• Acute confusion, halucinations, coma
Maudsley Guide to
Medical Risk
Assessment
for Eating Disorders
Janet Treasure (2009) - online
Signs and symptoms of medical instability
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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
“The Handbook of Treatment for Eating Disorders” 2nd Edition 1997 (Garner and Garfinkel)
“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.”
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.
12.30-13.30
Lunch
13.30-14.30
Psychiatric Emergencies in Primary Care and Mental Health Act Assessments
Primary Care
Psychiatric Emergencies?
Stress for GP due to risk?
- Risk Assessment
Risk factors (for suicide)
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Mental illness (if not..?)
Alcohol/drugs
Age
Gender
Occupations
Help seeking
- Limitations
History
Previous behaviour predicts future behaviour
- Limitations
Current Mental State
• Thoughts
• Planning
• Intent
Protective Factors
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Family
Dog
Religious beliefs
Hope for future/possible treatment
Engagement with services
Engagement with safety plan
Interface with Mental Health Services
Community Mental Health Teams
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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
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
Admission to Ward?
• Mental illness
• Risk
• Necessity
Date of referral
Time of referral
Team Member
Service User Information:
Referrer Details:
Name
Referrer
P / NHS No.
Base
D.O.B
Contact Details
Care Coordinator
GP Details:
Address
GP
Practice
Tel. No.
Tel. No.
1.What is the referrer requesting (inpatient care, home treatment, early d/c, MHA assessment)?
2.Has the referrer (or other MH professional) assessed the service user in person within the past 24 hours?
3.Does the patient need to be seen in the next four hours? (If patient does not need assessment within four hours, then other
contingency plans should be put in place by the referrer until a re-referral is made in keeping with the four hour target).
4.Can the referrer attend a joint visit?
5.Has the crisis and contingency plan been implemented?
Questions on IHTT Triage Form
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What is the referrer requesting (inpatient care, home treatment, early d/c, MHA
assessment)?
Has the referrer (or other MH professional) assessed the service user in person
within the past 24 hours?
Does the patient need to be seen in the next four hours? (If patient does not need
assessment within four hours, then other contingency plans should be put in place
by the referrer until a re-referral is made in keeping with the four hour target).
Can the referrer attend a joint visit?
Has the crisis and contingency plan been implemented?
When was the last medical review?
Is there a significant risk history?
Has the SAMP been updated recently?
Can the referrer supply a copy of the SAMP and management plan?
What medications, if any, are they currently prescribed?
Are they concordant with medication?
If the person is in A&E/hospital, are they medically fit?
Are there any children at home?
Is there a carer/family member at home?
Mental Health Act Assessments
14.30-15.00
Tea
15.00-16.15
Case discussion exercises
Part 2. Medical Scrutiny
Date Section papers sent for scrutiny:………………………………………………………………………
Print name of scrutinising doctor:………………………………….…………………………………………
Yes
No
a) Are the reasons for detention sufficient for the patient to be detained
under the recommended section?
b) Have the recommending doctors written an adequate clinical
description of symptoms?
Medical Recommendation 1…………………………………………..…(name)
Medical Recommendation 2………………………………………….….(name)
c) Is the appropriate medical treatment described and the availability
confirmed? (treatment sections only)
d) Have the doctors stated why informal admission is not appropriate?
Medical Recommendation 1…………………………………………..…(name)
Medical Recommendation 2………………………………………….….(name)
e) Are you satisfied with the medical examinations?
If “Yes”, please sign and date below. If “No”, please state your reasons clearly below.
(NB If you have indicated a medical recommendation requires amending, this form will be returned with the
medical recommendation and you may be contacted about any queries.)
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Signed:………………………………………………Print Name:…………………………………………..
Date:…………………………………………………