Eating Disorders Lecture - part 2 Flashcards
Co-morbidity with eating disorders
- More than half of those with AN have another mental illness
- 88-97% with BN have another mental illness
- Most common co-morbids include mood and anxiety disorders - depression, OCD, social anxiety
- Strong association with AN and autism spectrum disorders
- Substance abuse
- Can be part of EUPD - method to regulate emotions
Where do eating disorders often originate from? - emotion wise
- Coping mechanism for different emotions - distraction, numbing
- Can help someone feel protected, more confident and less anxious - get compliments initially
- Can provide a sense of feeling special
- May present a barrier to engaging with treatment - feels part of self, people want to look after you more
Causes of eating disorders
- Genetics
- Biological vulnerability
- Biological stress
- Psychological vulnerability
- Psychological stress
- Social/cultural
Biological pre-disposing factors for eating disorders
- Genes
- Neurotransmitters - dopamine, serotonin, noradrenaline
- Hormones
- Physical illness/allergies eg always had to look at labels, T1DM
- FH depression, anxiety, addiction
Psychological predisposing factors to eating disorder
- Low self esteem
- Feelings of ineffectiveness or lack of control
- Self identity
- History of depression/anxiety/mood intolerance
- Personality traits - perfectionism, obsessional
- Interpersonal style - struggle to recognise cues and emotional states of others
- Emotional processing - difficulty recognising own emotional state, expressing emotions and difficulty handling stress
- Thinking style - cognitively rigid, all or nothing thinking, can’t see bigger picture
Social/environmental pre-disposing factors of eating disorders
- History of bullying - esp about weight
- Trauma - all forms abuse
- Stressful life events - grief, loss
- Difficult interpersonal relationships - conflict within family, high expectations, stressful family circumstances, overprotection
- Taking part in competitive sports - dancing, gymnastics
- Growing up in household that places value on appearance and dieting
But families not to blame
Precipitating factors of ED
Biological:
* Puberty
* Physical illness/trauma
* Dieting and weight loss
Psychological
* Low mood/anxiety
* Sense of lack of control in other areas of life
Social/environmental
* Interpersonal problems - loneliness
* Transitions - taking on new role and new expectations eg moving to uni, new job
* Grief/loss
* Social media/diet culture
Perpetuating factors of eating disorders - biological
- Effects of starvation - energy, euphoria
- Reduced sex drive - can be positive in terms of avoidance eg previous sexual abuse etc
Psychological perpetuating factors for ED
- Feelings of control, protection and safety
- Sense of identity
- Numbing emotions
- Sense achievement
Perpetuating factors ED social/environmental
- Reinforcement from others - positive comments
- Eliciting care from others
- Ability to avoid transitions, events and responsibilities
- Social media/the media/diet culture
What happened with Minnesota study?
- Semi starved healthy men
- Initially preoccupied with food
- Then became agitated and found it difficult to rest
- More tired and withdrawn as weight dropped
- Very focused on their bodies - were not previously
- Some became worried about weight gain
- Many binged once able to eat, struggled to put weight on
Something with starvation changes brain and the way it functions - rigid
Psychological effects of starvation
- Brain structure and self regulatory system (in forebrain) changes
- Anxiety and intense negative emotions increase (lose neurones)
- Both negative and positive emotions are numbed
- Coping ability reduces
- Thinking –> rigid, habits and routines become more rigid
Functioning of self regulation system during starvation
Decreased effect:
* Social situations thoughts
* Emotional regulation
* Decision making
* Flexibility
* Abilty to plan
Increased effect:
* Compulsive behaviours
* Avoidance
* Anxiety
* Sensitivity
People without ED vs people with them reaction to hunger
Without ED:
* Hunger –> irritable –> seek food
* Satiety –> sense of pleasure and reward (enjoyable)
With ED:
* Hunger –> sense of calm
* Eating/satiety –> anxiety and guilt
Assessment of ED - 3 aspects
- Psychiatric assessment
- Medical
- Risk - psych and physical
Eating disorder history
- History of ED
- Current pattern eating
- Mechanisms of weight control
- Attitudes to weight and shape
- Current mood symptoms
- Current anxiety symptoms
Aspects of psych assessment of ED
- What’s happening?
- When did it begin?
- Symptoms?
- Why unwell?
- Feelings about illness?
- What help do they want/need?
History of eating disorder - assessment
Current pattern of eating history - ED assessment
Mechanisms of weight control history - ED
Where do they get pills from? - part of Risk
Attitudes to weight and shape - ED assessment
Physical symptoms to check for in ED assessment
- Refeeding syndrome can cause oedema
Driving rules and BMI
- Advise not to drive if BMI under 15
Risk assessment - ED assessment
- Current/past deliberate self harm
- Current and past suicidal thoughts inc plans and intent
- Risk to others inc children
- Risk from others
- Other risks - eg hypoglycaemia and falls etc
- Driving -
Physical examination - BMI and traffic light system grading of physical risk
- Red - BMI under 13 or rapid weight loss of more than 1kg per week in undernourished patient
- Amber - BMI 13-14.9 or recent weight loss 0.5-1kg per week in undernourushed patient
- Green - BMI more than 15 or recent weight loss of less than 0.5kg per week or fluctuating weight
General exam signs of ED
- Cachexia
- Signs of dehydration
- Lanugo hair
- Russells sign
- Salivary gland enlargement
HR for adults with ED
- Red - less than 40bpm
- Amber - 40-50
- Green - more than 50
BP physical examination risk of ED
- Red - standing BP under 90, associated with recurrent syncope, postural drop over 20mmHg or increase in HR over 30bpm
- Amber - standing BP more than 90, occassional syncope, postural drop 15mmHg or increase in HR up to 30
- Green - normal standing BP, normal CV orthostatic changes, normal rhytym
Temperature physicla signs ED risk
- Red - under 35.5 or under 35 axillary
- Amber - under 36
- Green - above 36
Hydration status physical examination ED risk
- Red - fluid refusal, severe dehydration 10%
- Amber - severe fluid restriction, moderate dehydration (5-10%)
- Green - minimal fluid restriction, no more than mild dehydration (<5%)
Testing muscle power SUSS test
- Red - unable to sit up from lying flat or to get up from squat at all or only by using upper limbs for help
- Amber - unable to sit up or standd from squat without noticable difficulty
- Green - able to sit from lying flat and stand from squat with no difficulty
Inv for ED
Bedside:
* Full obs - as above
* ECG
* Blood glucose
Bloods:
* FBC
* U&E
* LFT
* Bone profile
* TFT
* Mg
What happens to thyroid in biological adaptation to low weight?
- Adjusts free T4 to reduce its metabolic requirments - sick euthyroid syndrome
- = reduced resting metbolic rate, reduced temp and bradycardia
- Do not treat with thyroxine - make worse
Anorexia nervosa effects on body - medical complications
Medical complications of bulimia
Often advise to use mouthwash after vomitting to reduce risk of acid dam
Managing medical emergencies in ED
- Use traffic light system to assess risk
- If need help - ask
- Use MEED guidelines - medical emergencies in eating disorders
Cause of refeeding syndrome (starvation and refeeding) - biochemical
Biochemical changes you get with refeeding syndrome
- Hypophosphataemia
- Hypomagnesaemia
- Hypokalaemia
- Vitamin deficiency
- Fluid retention –> oedema
Refeeding syndrome consequences
- Sodium retention and extracellular fluid expansion + thiamine deficiency –> congestive cardiac failure
- Cardiac arrythmias from deficiencies of K+, phosphate and Mg
- Neuro - delirium, neuropathy, seizures
- Respiratory failure - poor ventilation function
- Rhabdomyolysis - low phosphate causes muscle weakness and myalgia
- Thrombocytopenia and impaired blood clotting - low phosphate
Management of refeeding syndrome
- Specialist management - with dietician
- Close blood monitoring - daily
- Oral supplements and IVs may be needed
Management of anorexia nervosa - general points
- Psychoeducation about disorder
- Monitor weight, MH, physical health and risk factors
- Involve family/carers
- Aim to keep healthy weight/BMI
- Offer dietary advice as part of MDT - encourage multivitamins, meal planning and regular eating. Not more than 4hrs without eating etc
Psychotherapy for adults with anorexia
- Individual CBT-ED
- Individual maudsley anorexia nervosa treatment for adults - MANTRA
- Individual speciliast supportive clinical management - SSCM
- Individual docal psychodynamic therapy (FPT)
Psychotherapy for children with anorexia
- Anorexia family focused therapy (FT-AN) - first line
- Individual CBT-ED
- Individual adolescent focused psychotherapy for anorexia nervosa (AFP-AN) - 2nd line
Management bulimia nervosa - adults
- Guided self help in milder cases
- Otherwise - 20 sessions individual CBT-ED
Treatment for bulimia nervosa - children and young people
- Bulimia nervosa focused family therapy - FT-BN
- Individual CBT-ED (second line)
Treatment for binge eating disorder
- Stabilise eating and stop bingeing - not aimed at losing weight
- Guided self help programme - 1st line
- If ineffective after 4 weeks - group CBT-ED
- If not available, consider individual CBT
Same in children
Treatment of OSFED
- Treatment for eating disorder it most closely resembles
Aim of therapy for ED
- Shift motivational position - hard work, so need motivation
- Restore healthy weight
- Help cope with life and express selves without resort to dietary restriction
- Get lifes back on track
Why is anorexia so difficult to treat?
- Egosyntonic - feels right
- Frightening - to gain weight, buy larger clothes
- Ambivalence - want to get better but also don’t want to. Sometimes seen as seperate unhelpful part of person
When do we admit those with ED?
- Last resort usually
- Wants change but not progressing as outpatient
- OR immediate danger
- OR no adequate treatment locally
We can admit someone and detain them under MHA and feed against wishes if really necessary - always better to avoid this if possible
Capacity and use of MHA in eating disorders
- If they are at medical risk and refuse - need to be assessed for capacity and treated under appropriate criteria (common law in emergency if lack capacity or MHA)
- Impairment is often in their ability to rationally balance consequences of treatment that results in weight gain against their extreme fear of gaining weight
- If unsure - speak with MH liason team, ED consultant specialist
Outcomes of bulimia
50-70% recover completely
Rest have relapse and remitting course
Outcomes anorexia nervosa
- Around half fully reover
- 33% improve
- 20% remain chronically unwell
- Best chance of recovery is within 3 years of onset and when younger, first episode
- Outcome poor if disease lasts 10yrs or longer
- Average duration is 8yrs
Mortality rate AN
- Higher than any other MH disorder
- 4 in 5 related to physical causes
- 1 in 5 related to suicide
What predicts good outcome from ED?
- Motivation to change
- Short duration of illness
- Lower level of severity
- Onset during adolescence - brain neuroplasticity
- Good family function/support
- Lack of co-morbid conditions
Charities help for ED
- First steps
- Beat eating disorders
