1. Mental Health Network -Eating Disorders
Introduction to STEPs
Motivational Work
Eating Disorders
Questions
Lydia Pym - Occupational Therapist
Nadia Freyther – Community Nurse
STEPs Eating Disorder Service

2. STEPs Eating Disorder Service
Adult Service offering specialist service interventions and consulting to a wide geographical area
Commissioned to work with people with a diagnosis of Anorexia, Bulimia and EDNOS, excluding Binge Eating Disorder
10 Bed In-patient unit, 8 place Day Therapy programme* Out-patient and Community services
Multidisciplinary Team
Variety of treatments
Supporting Carers

3. Prochaska & DiClemente’s Six Stages of Change
How and why did we develop our current model of working?

4. Motivational Work Listen Step back Learn Be curious Invest less
Is it any good?
Benefits Staff, team and Clients

5. Non-Negotiable

6. 1. Clearly defined from the outset – no surprises 2
1. Clearly defined from the outset – no surprises 2. Agreed by staff & clients if possible 3. Not arbitrary, but with good justification 4. Consistently applied by all staff

7. Anorexia nervosa (F50)
Weight loss leading to body weight at least 15% below normal weight for age & height (BMI below 17.5)
Weight-loss is self-induced by avoidance of ‘fattening foods’
Self-perception of being too fat & intrusive dread of fatness
Widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis
- amenorrhea in female
- loss of sexual interest in males
Restricting type & Purging type (DSMIV)
Diagnostic criteria
Anorexia nervosa was named in 1868 by the English physician William Gull. He emphasized the psychological causes of the condition, the need to restore weight and the role of the family.
Dread of fatness persists as an intrusive overvalued idea, and patients impose a low weight threshold on themselves.
BMI – weight / height ^2

8. Bulimia Nervosa (F50.2)
Recurrent episodes of overeating (at least twice a week over a period of 3 months) in which large amounts of food are consumed in short periods of time
Persistent preoccupation with eating, & strong compulsion to eat
Self-perception of being too fat with an intrusive dread of fatness
Attempts to counteract the fattening effects of food by one or more of:
Self-induced vomiting
Self-induced purging
Alternating periods of starvation
Use of drugs (appetite suppressants, thyroid preparations or diuretics, failure to take insulin)
Patients have a profound loss of control over eating. An episode maybe precipitated by stress or by breaking of self-imposed dietary rules. Large amounts are consumed (>2000 calories per buinge). Usually carried out alone, and may relieve tension/ stress but usually followed by guilt or disgust.
The DSM-IV-TR recognizes 2 major variants of bulimia nervosa, as follows: purging and nonpurging (ie, bingeing with use of nonpurging compensatory measures such as excessive exercise, stimulant substances, or fasting).
The syndrome of bulimia was first described by Russell (1979).

9. Atypical eating disorder
Do not meet criteria for AN or BN but are clinically severe (atypical anorexia nervosa (F50.1) & atypical bulimia nervosa (F50.3))
Sub-group – binge-eating disorder (DSM IV)
Recurrent bulimic episodes in absence of other diagnostic features of BN, particularly counter-regulatory features such as vomiting
May be evidence of depression, unhappiness with weight but less significant vs BN
Higher spontaneous remission rate, txt CBT
AN atypical – may not for example have amenorrheoa, or current weight maybe within normal range.
BN except frequency of behaviour is less, or use of inappropriate compensatory measures after small amounts of food.

10. Epidemiology Prevalence – 0.7% (school & college girls)
Incidence range from 0.37 – 4.06 per
Female-to-male ratio of 10:1
Primarily white (>95%) & adolescent (>75%)
High concordance rates for monozygotic twins (55%)
Prevelence – number of cases at any point in time.
7% increased incidence - may be related to an area on chromosome 1p at the DF locus.
London figures, in text are much smaller.

11. Causes
Complex condition - biological, psychological, and social factors
Developmental condition
Predisposing - Female sex, family history of eating disorders, character (low self-esteem & perfectionism) & family dynamics
Precipitating – cultural & peer group group pressure, peer acceptance for dieting & weight loss, autonomy conflicts
Perpetuating – secondary gain (attention), biological factors (starvation)
Certain groups increased at risk - dancers, long-distance runners, skaters, models, actors, wrestlers, gymnasts
Family dynamics – enmeshment, over-protectiveness, rigidity and lack of conflict resolution.
Cultural & peer group pressure – notion that thin is desirable
Peer acceptance – dieting and weight loss
Autonomy conflict – struggle for control, for sense of identity and effectiveness with relentless pursuit of thiness as final step in effort

12. Symptoms - AN

13. Symptoms - BN
Often look ‘normal size’ & frequently have no signs of illness
Bilateral parotid enlargement - noninflammatory stimulation of the salivary glands
Self-induced vomiting causes problems with teeth and Russell sign.
Russell sign – callosities, scarring and abrasions on knuckles secondary to repeated self-induced vomiting.
Teeth – loss of enamel, periodontal disease, and extensive dental caries
Nonspecific findings may include; bradycardia, hypothermia,hypotension. Oedema is found more often among patients with a history of diuretic abuse, laxative abuse, or both or in patients with significant protein malnourishment causing hypoalbuminemia.
Repeated vomiting may lead to several complications. K+ depletion is particualry serious (cardiac aryhtmia, renal damage)

14. Prognosis Full recovery more common in those with a short history
Some may be left with atypical ED or BN
20% make a full recovery
60% fluctuating course
20% remain severely ill
Most severe cases – 15% mortality (suicide & cardiac complications)
BN – COMORBIDITY WITH DEPRESSION AND ALCOHOL USE
Assessing and Managing risks – bloods, weight, Squat tests, driving, cognitive function, mood, DSH, suicidal ideation.

15. Referring to STEPs BANES
If already in secondary mental health services the referral is direct to STEPs.
GP refers to PCLS.
PCLS and STEPs offer a joint assessment.
Decision about treatment is usually made at assessment.
What we can offer, treatment, joint working, supervision, teaching.

16. Thank you for listening Any questions?
Please contact us at:
STEPs Eating Disorder Service
Clifton Building
Southmead Hospital
Westbury-on-Trym
Bristol
BS10 5NB
Tel: