Eating Disorders

Question 1

How Common are eating disorders?

Answer 1

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

Question 2

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

Answer 2

more

greater

Question 3

Peak onset mental illness is when?

Answer 3

mid teens to mid twenties

Question 4

what screening tool is used for eating disorders?

Answer 4

SCOFF Questionnaire

Question 5

SCREENING TOOLS:
SCOFF Questionnaire

If patients score 2 or more positive answers, then an eating disorder is likely:

what are the questions?

Answer 5

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?

Question 6

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

Answer 6

fatness

calories

compulsive

anxiety

physical

psychological

Question 7

F50.0 Anorexia Nervosa:

what is it?

Answer 7

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

Question 8

when can someoneb be classed as having Anorexia Nervosa?

Answer 8

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

Question 9

F50.0 Anorexia Nervosa:

what symptom are seen?

Answer 9

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

Question 10

F50.2 Bulimia Nervosa:

what is it?

Answer 10

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

Question 11

If binging and purging but of normal weight = ???

If binging and purging and less than 17.5 = ???

Answer 11

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

Question 12

what are the Signs and Symptoms of bulimia nervosa?

Answer 12

Gastric contents coming into mouth causing mouth sores

Upper GI symptoms

Tends to be history of impulsivity in this group

Question 13

what is a Binge Eating Disorder?

Answer 13

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

Question 14

how do you treat binge eating disorder?

Answer 14

CBT approach and treated in outpatient setting, in context of group work normally

Question 15

AVOIDANCE OF CALORIE INTAKE:

how is it done?

Answer 15

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

Question 16

Research in GI medicine has shown an improvement in ______ and ______ function but no significant improvement in ________ function even after a prolonged period of refeeding

Answer 16

gastric

colonic

oesophageal

Question 17

GETTING RID OF CALORIES:

how is it done?

Answer 17

• 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

Question 18

what are some OTHER EATING DISORDER BEHAVIOURS?

Answer 18

‘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

Question 19

THESE BEHAVIOURS ARE NOT JUST HANDICAPS TO WEIGHT GAIN - THEY DAMAGE THE QUALITY OF ____ – AND THEY MAINTAIN THE DISORDER

—

Answer 19

LIFE

Question 20

WHY DO ‘EATING DISORDERS’ MATTER?

Answer 20

Psychological consequences

Social consequences

Physical consequences

Question 21

Why do Eating disorders matter? -
What are the Psychological consequences?

Answer 21

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

Question 22

Why do Eating disorders matter? -
What are the Social consequences?

Answer 22

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

Question 23

Research (& experience) shows recovered sufferers put the highest value of all on the recovery of their ___________ ____

Answer 23

interpersonal life

Question 24

Why do Eating disorders matter? -
What are the Physical consequences?

Answer 24

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,

Question 25

CAUSES:

predisposing,

precipitating

and perpetuating factors

what do these terms mean?

—

Answer 25

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

Question 26

what is the HYPOTHESESIS on how it occurs?

Answer 26

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

Question 27

what are the Causes of anorexia?

Answer 27

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

Question 28

what are some precipitating factors of anorexia?

Answer 28

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

Question 29

what are Perpetuating factors of anorexia?

Answer 29

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)

Question 30

does anorexia cause death?

Answer 30

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

Question 31

Death is not the only outcome:

what is the other outcome?

Answer 31

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

Question 32

How can we help?

NICE guidelines (2017)
 & QIS recommendations (2006)

Answer 32

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

Question 33

What is our approach ?

Answer 33

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

Question 34

Human rights

Answer 34

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)