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

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

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

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

Non-Negotiable

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

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

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).

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.

Epidemiology Prevalence – 0.7% (school & college girls) Incidence range from 0.37 – 4.06 per 100 000 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 DF1153721 locus. London figures, in text are much smaller.

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

Symptoms - AN

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)

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.

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.

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: 0117 3236113