1. Eating Disorder Primary Care Workshop
Jaco Serfontein

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

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

5. Victorian Fasting Girls
Sarah Jacob – The Welsh fasting girl ( ) Mollie Fancher – The Brooklyn Enigma ( ) Josephine Marie Bedard – The Tingwick Girl Therese Neumann ( ) - Bavaria

6. 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

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

8. 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

9. 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

10. 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

11. Categories and movement between diagnosesBN
ED-NOS
Fairburn & Harrison (2003). Lancet 361,

12. 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

13. 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

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

15. 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,
Prevalence rate refer to age 16 –40 years in women 15

16. 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

17. 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

18. Eating disorders in males
AN %
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

19. 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

20. Medical complications

21. 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

22. Cardiac-related
Eliana and Luisel Ramos

23. Multiorgan Failure
Christy Henrich
Ana Restin

24. Suicide
Anna Westin

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

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

34. 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

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

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

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

38. Treatment

39. 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

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

41. 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

42. 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)

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

44. 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

45. Treatment complications

46. 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

47. 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

48. 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

49. 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)

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

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

52. 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)

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

54. 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

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

56. 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

57. Sit-up/Squat test

58. 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