Eating Disorder Primary Care Workshop Jaco Serfontein

What are Eating Disorders? Complex psychological disorders Serious Physical complications Mortality increased Psychiatric co-morbidity People often ambivalent about treatment 3

AN in History Holy Anorexics St Catherine of Siena (14th Century)

Victorian Fasting Girls Sarah Jacob – The Welsh fasting girl (1857-1869) Mollie Fancher – The Brooklyn Enigma (1845-1916) Josephine Marie Bedard – The Tingwick Girl Therese Neumann (1898-1962) - Bavaria

Diagnostic Criteria - AN DSM-5: Markedly low weight (Body weight < 85% of expected in DSM-IV) Intense fear of gaining weight or persistent behaviour to avoid weight gain Weight and shape disturbance (Amenorrhea in DSM-IV) Restricting type and binge-eating/purging type

BMI 20 - 25 Normal weight 17.5 - 20 Underweight 15 – 17.5 Anorexia nervosa 13.5 - 15 Severe Anorexia nervosa 12 – 13.5 Critical Anorexia nervosa < 12 Life threatening anorexia nervosa

Bulimia Nervosa Recurrent episodes of binge eating once per week Recurrent inappropriate compensatory behaviour in order to prevent weight gain Present for 3 months Self-evaluation unduly influenced by body weight and shape (morbid fear of fatness) Two subtypes Purging type Non-purging type

NoS-FED or atypical subthreshold cases partial syndromes Disorders of eating or weight control: resembles AN or BN but do not reach their diagnostic criteria subthreshold cases partial syndromes

Binge-Eating Disorder (DSM-5) Binge eating (once per week for 3/12) Binges associated with 3 of: Eating rapidly Uncomfortably full Large amounts when not hungry Alone because embarrassed Guilty, depressed, disgusted Marked distress No compensatory behaviour

Categories and movement between diagnoses BN ED-NOS Fairburn & Harrison (2003). Lancet 361, 407-16.

The patients Anorexia nervosa Bulimia nervosa weight/shape related psychopathology not always present culturally influenced highly visible reluctant patients who deny their problems others concerned outcome poor mortality high (20% at 30 yrs; 1/3 = suicide) early-onset  shorter stature Bulimia nervosa weight/shape related psychopathology central strongly culture-bound invisible “shameful secret” ambivalent patients others unaware outcome fair mortality not raised 12

Clinical features AN BN BED Specific psychopathology strict dieting +++ +++ - self-induced vomiting + ++ - laxative misuse + ++ - over exercising ++ + - bulimic episodes + +++ +++ ritualistic eating habits ++ - - anxiety when eating with others +++ +++ + over-evaluation of shape & wt +++ +++ +

Clinical features AN BN BED General psychopathology depressive symptoms + +++ ++ anxiety symptoms + ++ + obsessional symptoms ++ + - impaired concentration +++ +++ - social withdrawal +++ + - substance misuse - + -

Prognosis 8.7% persistent psychiatric problem requiring hospital care Outpatient AN – 80% remission after 5 years Keel and Brown, 2010 Inpatient AN – 48% remission after 12 years Fichter et al, 2006 Swedish adolescent females inpatients 9-14-year follow-up study Anorexia nervosa 21.4% dependent on society for income 8.7% persistent psychiatric problem requiring hospital care mortality: 1.2% Hjern et al (2006) B J Psych 189, 428-432 Prevalence rate refer to age 16 –40 years in women 15

How common is ED? AN prevalence 0.3 – 0.9, increasing in young women BN 1-2 BED 2? Turnbull et al., 1996; Currin et al., 2005

An average GP list On an average GP list of 2000 people expect: 1-2 people with full AN 18 people with full BN 40 people with ED-NOS

Eating disorders in males AN - 5-10% BN 10-15% (0.2%) of young males BED ~20% symptomatology quite similar to females later age of onset (18-26) vs (15-18) higher premorbid weight body image dissatisfaction - lean tissue athletic pursuits / job sexuality osteoporosis more rapid & severe but more exercise, less abuse of laxatives & strict dieting, less concerned with weight, increased co morbidity of substance misuse Age of onset - females 2 yrs ahead in puberty and lower resting metabolic rate Outcome related rto age of onset has yeilded conflicting results and confounded by length of illness Overweight - up to 60% in BN and higher percentage in An than seen in females, more teasing at school Body image - not so much on thinness, diff in cultures USA men vs Austrian Athletics - partic in sports where weight restrictions, eg light weight boxers, athletic training Actors/ models Greater risk if gay ?similar emphasis on body as part of self worth, but ambivalence or avertion to sexual matter ‘asexual’/ sexual anxieties, actively suppressing sexual drive, both in hetero and homosexual Also high feminity scores on personality measures Presence of sexual fantancy and masturbation good predictor of outcome, and absence a poor outcome Personality - 71% BN have axis 2 diagnosis,of cluster B personality, borderline, narcissitic antisocial AN - spread across 3 categories of personality disorder, but high rates of OCD and/or obsessional features 18

What causes AN? Complex psychological illness with no single cause Combination of biological, psychological and sociocultural factors First degree relatives of AN have a ten-fold increased lifetime risk of developing AN (Pinheiro, 2009) Anorexia – specific heritability Bulimia – general heritability

Medical complications

Etiology Starvation Fluid and electrolyte disturbance Direct local damage due to eating disorder behaviour Endocrine changes Changes in liver function Refeeding Give examples 21 21

Cardiac-related Eliana and Luisel Ramos

Multiorgan Failure Christy Henrich Ana Restin

Suicide Anna Westin

Biochemical abnormalities Could have any abnormality, hypo >> hyper ↓K ↓ Na ↓Mg ↓glucose

Refeeding syndrome Refeeding of severely malnourished AN (esp parenteral) and bingeing Severe intracellular shifts in fluids and electrolytes, esp PO4 (also Mg, K, Thiamine) PO4 nadir in first week Decreased PO4 = decreased ATP Very low PO4 directly cardiotoxic Clinical Muscle weakness Cardiac - arrhythmias, failure, pericardial effusion Neurological – delirium (can occur > 1week and after PO4 has recovered), coma, death Haematological – leukocyte dysfunction, haemolytic anaemia, platelet dysfunction

Osteoporosis (oestrogen, cortisol, GH, IGF-I) Early, frequent and serious complication of ED Increased resorption (as result of decreased oestrogen and increased glucocorticoids) and decreased deposition (low IGF-I) No correlation with calcium intake, exercise or HRT 40% of women with AN has osteoporosis (>2.5 SD) 92% of women with AN has osteopenia (>1 SD) (Vestegaard et al, 2002) 7x higher fracture rate than healthy women of same age Treatment Refeeding Weight bearing exercise? HRT? Bisphophanates? Mention positive trial with oestrogen and IGF-I. Few studies on DHEA. 27 27

Direct local damage related to binge-eating and purging Parotid swelling Oesophageal damage GER reflux GI bleed Post-binge pancreatitis Acute gastric dilatation Colonic volvulus prolapse Follow path of food – hand, mouth, parotid, oesophagus – oesophagus tears, rupture, oesophagitis, ulcer, other rare intestinal complications 28 28

Gastrointestinal system - chronic Due to starvation Abnormal oesophageal motility Delayed gastric emptying Increased colonic transit time Laxative abuse -> colonic autonomic nerve degeneration Liver Fatty infiltration (lipogenesis > lipolysis) Increased ALT (less than 4x), benign Rarely can progress to Nonalcoholic steatohepatitis (higher risk in older, dual diagnosis, obesity and AST/ALT>1) Talk about physical discomfort and pain when refeeding and psychological 29 29

Cardiovascular System 1/3 of deaths in adults with eating disorders Starvation related Hypotension and bradycardia Mitral valve prolapse Fluid and electrolyte balance related (and severe starvation) Arrhythmias (prolonged QTc) Refeeding Cardiac failure Eating disorder behaviour related Ipecac related cardiomyopathy

Endocrine System Reproductive Low FSH, LH, oestrogen, testosterone Adrenal High cortisol Growth hormone axis High GH, low IGF-I Thyroid Axis Low T3/T4, normal or reduced TSH ‘sick euthyroid’ Appetite Low leptin, high ghrelin and peptide YY Osteoporosis is not only oestrogen related, also mention other hormones. Also IGF1 decreases due to decreased liver production – this leads to increased GH (negative feedback system). Also GH resistance. 31 31

Haematology Anaemia Mild leukopenia Thrombocytopaenia Decreased ESR Talk here about difficulty in identifying infection (no fever, no raised WCC) and other markers (like drop in albumin) that might indicate infection. 32 32

Nervous System Starvation related: Pseudoatrophy, enlarged ventricles Cognitive impairment Peripheral neuropathy

Skin and Hair Self-injury Dry skin Skin breakdown, pressure sores Carotenemia Dry, brittle hair Hair loss Lanugo Carotenemia due to decreased liver clearance. (and relative increased intake). Talk here about how complications that are not medically serious can be the ones that cause most distress to patients. Also talk about anorexia being a great pretender, presenting indifferent forms to various clinicians. 34 34

Comorbidity with Diabetes Type I AN – no increase BN – 3X increase EDNOS – 2X increase Type II BED most prevalent

Diabetes Insulin purging women > men Poor glycaemic control Early diabetic retinopathy Medical complications of ED higher Higher rate of other psychiatric diagnoses Treatment similar

How would you recognise the following? Vomiting Water loading Over exercise Infection in low weight AN Refeeding syndrome

Treatment

NICE guidelines (2017) recommend Support should include: NICE OVERVIEW NICE guidelines (2017) recommend Support should include: Psychoeducation Regular physical health monitoring Multidisciplinary Involve family and carers IPT is an alternative, but takes 8-12 months to achieve comparable results 39

Evidence based, disorder-specific psychological treatments Anorexia Nervosa Restricting EDNOS

Evidence-based psychological treatments for anorexia Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) Specialist supportive clinical management (SSCM) Next step if unsuccessful or unacceptable Eating-disorder-focused focal psychodynamic therapy (FPT) Only 30% of adult cases are recovered at 1 year, 40-50% at 5 yrs Limited evidence of fluoxetine in relapse prevention All better than treatment as usual or dietary counselling alone E.g. CBT-E typically 40+ sessions focussing on food avoidance / anxieties, weight restoration, weight/shape concerns, interpersonal, intrapersonal and systemic maintaining factors

Children & adolescents Family interventions (first line or relapse prevention) produce recovery rates of 60-70% at 1 year, 70-90% at 5 yrs classical family therapy not necessary (Eisler et al. 2003)

Evidence based, disorder-specific psychological treatments Bulimia Nervosa EDNOS Binge Eating Disorder

Stepped care approach Explain that treatment limited effect on body weight Bulimia-nervosa-focused guided self-help Individual CBT-ED Regularising eating Reducing compensatory behaviours Introducing emotional regulation skills Problem solving skills Addressing weight and shape concerns – anxieties, perceptual biases, attitudes etc Medication should not be offered as sole treatment

Treatment complications

Maintaining Factors of AN Predisposing traits Perpetuating consequences Emotional avoidance Obsessive compulsive traits Interpersonal Relationships Beliefs about The value of AN in the Person’s life

The Pros and Cons of anorexia nervosa (Serpell et al., 2002, 2003) 3 most important pro-anorexic beliefs were: Anorexia nervosa keeps me safe helps to communicate distress stifles emotion

Iatrogenic Maintaining factors Overprotection Over zealous use of inpatient treatment. Excluding or disempowering the family. Criticism or confrontation-coercive treatments MHA Use of loss of privilege systems Accommodation Use of treatment without nutritional direction/expectation of change. Engaging in bargaining of treatment goals with the persuasive patient. Enabling Services palliating loneliness and isolation. Providing the opportunity for further striving competing and calibrating against others. Treasure et al., 2011

Difficulties Secretiveness – highly functional, denial, difficult to detect Ambivalence – engaging with services, about what recovery or treatment entails Reactions of others (including services) – high expressed emotion, overly controlling, accommodating, dismissing Physical & psychological complications of illness Psychiatric and physical co-morbidity (e.g. PD / Diabetes)

Treatment considerations Collaborative and motivational approach vs MHA Engagement and disengagement Recovery and prognosis Risk management Shared care Medication

Recognition and Initial Management of Eating Disorders Screening The King’s College Risk assessment

Screening – The SCOFF questionnaire 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 in a 3 month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? 2 or more out of 5 predicts an ED with 100% sensitivity and 87.5% specificity Morgan et al (1999)

King’s College Medical Risk Assessment Medical Risk –Psychiatric Risk Psychosocial Risk Insight/Capacity and motivation

Surgery: St Stephen’s Gate Medical Practice NHS Number: XXXXXXXXXXXX Medical monitoring request This box is shared with commissioners and should not contain any identifying information Frequency FBC, u&e, LFT, Ca, PO4, Mg, muscle CK, random glucose X Every two weeks Brief essential examination (weight, pulse, lying/standing blood pressure, core temperature, squat test) Weight only   Additional requests: Please do an ECG at baseline u&e only

Medical Monitoring Brief Essential Examination – BMI alone is not enough because it is not reliable Special Investigations – Bloods, ECG, Dexa Scan, etc

Brief Essential Examination BMI (single layer of clothing, no shoes/mobiles/wallets/heavy jewelery etc) Sitting/standing blood pressure Pulse rate Peripheral circulation Core temperature A measure of muscle strength – squat test

Sit-up/Squat test

Investigations FBC, u&e, bicarb, LFT, Ca, PO4, Mg, CK, gluc Bonescan if >1 year amenorrhoea ECG if BMI<14 or if on drugs that can affect QTc Any other physical investigation pertinent to physical state, eg, TFT