Eating Disorders Flashcards
How Common are eating disorders?
According to NICE, the lifelong prevalence of anorexia nervosa is 0.1-0.9%, international epidemiological studies estimate 75% of AN cases occur before the age of 22
5-10% of young women attending surgery will have eating disorders - You won’t know about it in 50% of cases
5-10% of adolescent girls will have used pathological weight reducing techniques
Approximately 90% of cases present in females
In developed countries….
Children ____ likely to suffer from an eating disorder than meningococcal disease
Incidence of anorexia nervosa in adolescence ______ than both type 1 Diabetes and Inflammatory Bowel Disease
more
greater
Peak onset mental illness is when?
mid teens to mid twenties
what screening tool is used for eating disorders?
SCOFF Questionnaire
SCREENING TOOLS:
SCOFF Questionnaire
If patients score 2 or more positive answers, then an eating disorder is likely:
what are the questions?
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone (14 pounds or 6.35 kg) in a three month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say that Food dominates your life?
Anorexia nervosa and other ‘eating disorders’ as ‘obsessive weight losing disorders’:
There is obsessive fear of _________…
with avoidance of food & other sources of _______..
..& a range of __________ ‘compensatory’ behaviours when food cannot be avoided
In time, these behaviours are the only way to avoid the experience of ______ AND there are secondary ________ and __________ consequences of starvation
fatness
calories
compulsive
anxiety
physical
psychological
F50.0 Anorexia Nervosa:
what is it?
Restriction of intake to reduce weight
Relies on compulsive compensatory behaviours when food cannot be avoided, Self induced vomiting, laxative abuse, excessive exercise, abuse of appetite suppressants / diuretics
Fear of weight gain
when can someoneb be classed as having Anorexia Nervosa?
Considered anorexic if he/she is 15% below ideal body weight/BMI 17.5 or <
[In postmenarchal females, absence of the menstrual cycle or amenorrhoea (greater than 3 cycles)] - Bottom one no longer part of diagnostic criteria as many healthy reasons causing amenorrhoea. Good for estimating onset of illness
F50.0 Anorexia Nervosa:
what symptom are seen?
Loss of energy stores, fat glycogen from liver. Then start to break down skeletal muscle, cardiac muscle and bone. Heart walls become thinner, pulse slows and blood pressure drops to protect heart and you get physical symptoms due to this like Fainting
Short stature due to never reaching development milestone
Brain can shrink by upto 20%
All these problems can be reversed by nutrition and weight gain sustained over a period of time
F50.2 Bulimia Nervosa:
what is it?
Episodes of binge eating with a sense of loss of control
Binge eating is followed by compensatory behaviour of the purging type (self-induced vomiting, laxative abuse, diuretic abuse) or nonpurging type (excessive exercise, fasting, or strict diets)
Binges and the resulting compensatory behaviour must occur a minimum of two times per week for three months
Dissatisfaction with body shape and weight
If binging and purging but of normal weight = ???
If binging and purging and less than 17.5 = ???
If binging and purging but of normal weight then diagnosis of bulimia nervosa
If binging and purging and less than 17.5 then diagnosis anorexia nervosa, binge purge sub-type
what are the Signs and Symptoms of bulimia nervosa?
Gastric contents coming into mouth causing mouth sores
Upper GI symptoms
Tends to be history of impulsivity in this group
what is a Binge Eating Disorder?
Similar to bulimia nervosa; absence of purging behaviours
Ongoing and/or repetitive cycles often include:
- unusually fast eating, usually alone
- unusually large amounts consumed
- uncomfortably full; often “buzzed” after eating
- (quickly followed by) embarrassment, shame, guilt, depression
how do you treat binge eating disorder?
CBT approach and treated in outpatient setting, in context of group work normally
AVOIDANCE OF CALORIE INTAKE:
how is it done?
diets – becoming vegetarian, vegan
not touching food or grease
developing dislikes, pickiness, even ‘allergies’
Interpreting all symptoms as allergy or indigestion
Eating very slowly, only eating at certain times
Avoiding parties and social occasions (where eating in expected as part of social interaction)
Spoiling or messing of food, bizarre combinations
Refusing to eat more than the person who eats least, rules about always finishing last etc
Medication abuse - Appetite suppressants – including gum, cigarettes - alternative, OTC & www medications
Research in GI medicine has shown an improvement in ______ and ______ function but no significant improvement in ________ function even after a prolonged period of refeeding
gastric
colonic
oesophageal
GETTING RID OF CALORIES:
how is it done?
- Self-induced vomiting
- Chewing & spitting out
- Overexercise – often secret
- Overactivity – obsessive housework, fidgeting, twitching, never sitting down, fetching one item at a time, carrying heavy loads
- Cooling – inadequate dress, open windows etc
- Blood letting (getting rid of body contents, drive number down on scales, never seen personally)
- Medication abuse – including alternative, OTC & www medications, excessive caffeine and stimulant consumption – laxatives, ipecac, pain killers to allow exercise despite damage
what are some OTHER EATING DISORDER BEHAVIOURS?
‘Body-checking’– repeated weighing, mirror gazing, self-measurment, self-photographing, trying on particular tight clothes
Displaying emaciation to elicit reassuringly shocked attention
Cruising ‘pro-ana’ websites/facebooking/emailing fellow sufferers
Competing with self and others to attain lower and lower targets
Compulsive browsing of gossip magazines and websites – celebrities, ‘thinspirations’
Deliberate self harm if ‘rules’ are broken
THESE BEHAVIOURS ARE NOT JUST HANDICAPS TO WEIGHT GAIN - THEY DAMAGE THE QUALITY OF ____ – AND THEY MAINTAIN THE DISORDER
LIFE
WHY DO ‘EATING DISORDERS’ MATTER?
Psychological consequences
Social consequences
Physical consequences
Why do Eating disorders matter? -
What are the Psychological consequences?
The core psychopathology - extreme overvaluation of low weight & thin/lean shape – resembles religious belief, with the ‘adherents’ willing to sacrifice even other highly valued things to the cause
Obsessive weight-losing feels like a solution, not a problem
Cognitive style shows reduced central coherence & narrowed focus of interest – a difficulty in seeing the ‘bigger picture’
And a starved person is unable to interpret emotion – as in Aspergers - but this does improve with better nutrition
Ability to have meaningful relationships can be damaged as a result but can all improve with better nutrition
Malnourished brains experience depression, anxiety, obsessionality and loss of concentration on anything but food
Depression at low weight rarely responds to medication
People who rely on eating-disordered behaviour to ‘solve’ their problems fail to develop other ways to cope with life, tolerate distress or feel rewarded and fulfilled
Anxiety eating in company, followed by guilt after eating
Why do Eating disorders matter? -
What are the Social consequences?
Eating disorders turn other people into mere obstacles to the eating disorder! Normally honest people are forced to lie and cheat, even to steal about eating disorder concerns. Sufferers withdraw from friendships and lose interest in sexual relationships
Research (& experience) shows recovered sufferers put the highest value of all on the recovery of their ___________ ____
interpersonal life
Why do Eating disorders matter? -
What are the Physical consequences?
Starvation causes physical damage, poor repair and resistance, heart damage, reduced immunity to infections, anaemia, bone loss, fertility problems
Purging behaviours cause neuro-chemical disruption with special damage to brain (seizures) and heart (arrhythmias). Potassium is only one crude measure of the problem
Young people need good nutrition to allow growth – height, pubertal development, brain growth and development (especially frontal lobe growth), so re-nutrition is more urgent the younger the patient
Dry Skin, Cold intolerance, Blue hands and feet, constipation, abdominal bloating, delayed puberty, Primary or secondary amenorrhoea, fainting, hypotension, lanugo hair, scalp hair loss, weakness and fatigue, short stature,
CAUSES:
predisposing,
precipitating
and perpetuating factors
what do these terms mean?
What sets someone up to be vulnerable to having an eating disorder
What factors that initiate an eating disorder
Once its there, what keeps the illness going
what is the HYPOTHESESIS on how it occurs?
Precise cause of eating disorders remains uncertain
Believed that social pressures to be slim are most important cause but other factors must be involved
Eating disorders run in family but exact genetics have not been found
Need a life event to trigger eating disorders
Can get better or worse as seen in right side of chart
what are the Causes of anorexia?
Genetic predisposition – OCD, anxiety disorders, perfectionism
Perinatal factors
Life events – and traumas
Perpetuating consequences of starvation and of avoidance
See in members in family
Also association with Asperger’s and eating disorders
Perinatal – birth trauma, prematurity, take perinatal history e.g. did mum have post natal depression and did this effect development of the young toddler and this can effect someone’s emotional development
what are some precipitating factors of anorexia?
Puberty – physical effects of hormonal changes on the brain , also psychological response to body changes
Dieting or even non-deliberate weight loss
Increased exercise (Overexercise causes endorphin release and may result in a picture which resembles both addictive and obsessive-compulsive psychopathology)
Stressful life events
neglect, abuse, difficult transitions eg to High School or from school to uni, deaths and losses, separations and family breakup, bullying (but sometimes ‘perceived bullying’ occurs as a consequence of a disorder), stresses – especially exams
what are Perpetuating factors of anorexia?
Consequences of ‘starvation syndrome’
- Delayed gastric emptying - sensations of fullness interpreted as fatness,
narrowing focus with avoidance of interpersonal interest, change of values so that food becomes the most salient stimulus.
Obsessionality. Phobia of ‘fat’ increases as avoidance increases. ‘Body checking’ amplifies body image concern
Families, School, Clinic staff - High EE (expressed emotion) in family(and other carers) may delay recovery (Butzlaff & Hooley, 1998)
does anorexia cause death?
Anorexia nervosa has the highest mortality rate of any psychiatric disorder
20% of them died prematurely as a result of Anorexia
About half from direct consequences of starvation and the other half from self harm which may or may not have been truly ‘suicidal’
Modern specialist Units are associated with lower mortality rates
AN still multiplies risk of premature death at least 10fold
Death is not the only outcome:
what is the other outcome?
There is no ‘one size fits all’ treatment for complex AN
Average time for recovery from anorexia nervosa – where this occurs – has been estimated at 6 – 7 years
Specialist centres report some recoveries after decades
How can we help?
NICE guidelines (2017) & QIS recommendations (2006)
Re-feeding (paramount to renurish body and brain)
CBT –ED, (40 sessions) Mantra (20 sessions) SSCM (specialised supportive clinical management) (20 sessions) CBT (including self-help) for normal weight Bulimia Nervosa
Alternatively IPT, or fluoxetine 60mg daily (in fact any antidepressant in high dose) - fluoxetine for patients who have binging as part of their presenting illness, often use SSRI in high dose
Olanzapine (anti-psychotic) - shuts out intrusive obsessional thoughts around the fear of weight gain, food etc and allows opportunity to have peace, rest and better sleep and allows them to engage in psychological work
Specialised family work for anorexia nervosa, particularly for younger patients:
- Parents empowered to refeed their child, allows passes to be built up to support family members to allow them to know they do know how to feed their children
- Parents effectively become nursing staff, dietician, medical staff etc
What is our approach ?
Diagnosis – not accusation! An eating disorder is an illness not a crime. Climate of sympathetic awareness
Remember patients are obliged by their illness to defend their weight-losing behaviour
What the patient says is not the same as what the patient is able to do (driven by obsesionality and fear) (Patients will hide things like food, drink water to falsify weight, exercise)
Patience AND urgency – psychological recovery will take years but physical recovery cannot wait in the period of maximum growth
Empowerment of parents and all adults working against the illness together
Human rights
The Human Rights Act (1998) gives us many rights - freedom, confidentiality, home life etc
Some Absolute Rights take precedence over the others, even the right to liberty
One such is the RIGHT TO LIFE
The ScottishMental Health Act gives us responsibility to treat people even in the absence of consent to save life or prevent serious deterioration
(Often do have to use mental health act to make sure patients are getting life saving treatment)
