EATING DISORDERS PSYCHIATRIST. Epworth Clinic Camberwell BETRS, St Vincent s Health

Transcription

1 EATING DISORDERS Dr Karen Gwee PSYCHIATRIST Epworth Clinic Camberwell BETRS, St Vincent s Health 1

2 What is an eating disorder? An eating disorder is an unhealthy relationship with food and weight that interferes with many areas of a person s life. One s thoughts become preoccupied with food, weight or exercise. A person who struggles with an eating disorder can have unrealistic self-critical thoughts about body image, and his or her eating habits may begin to disrupt normal body functions and affect daily activities. Eating disorders are not just about food and weight. People begin to use food as a coping mechanism to deal with uncomfortable or painful emotions or to help them feel more in control when feelings or situations seem over-whelming. National Association of Anorexia Nervosa and Associated Disorders 2

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9 DSM V Diagnoses Anorexia nervosa Bulimia Nervosa Binge Eating Disorder OSFED (Other specified feeding and eating disorder) Atypical AN Subclinical BN and BED Night eating disorder Purging Disorder UFED ARFID 9

10 GP role Assessment and early diagnosis Ongoing medical monitoring Manage mild or less complicated cases Manage chronic cases, SEED Refer to MDT dietician, psychologist, psychiatrist, psychotherapist, MH nurse Refer to specialist care for intensive interventions, e.g. DPP, IPU, AMHS Provide support to patient and family 10

11 Screening High index of suspicion High risk populations Adolescents Women during key transition periods Medical conditions DM, PCOS Professions/interests where weight and shape is important People seeking help for weight loss FHx ED Screening tools Open, non-judgemental questions Questionnaires (SCOFF and ESP) 11

12 SCOFF S Do you make yourself Sick because you feel uncomfortably full? C Do you worry you have lost Control over how much you eat? O Have you recently lost more than 1 stone in a three-month period? F Do you believe yourself to be Fat when others say you are too thin? F Would you say Food dominates your life? Yes to >2 needs further Ax Further 2 questions have high sensitivity and specificity for BN: Are you satisfied with your eating patterns? Do you ever eat in secret? 12

13 Eating Disorder Screen for Primary Care (ESP) Are you satisfied with your eating patterns? (A no to this question is classified as an abnormal response). Do you ever eat in secret? (A yes to this and all other questions is classified as an abnormal response). Does your weight affect the way you feel about yourself? Have any members of your family suffered with an eating disorder? Do you currently suffer with or have you ever suffered in the past with an eating disorder? 13

14 Medical Assessment Exclude underlying medical causes for weight loss/gain Physical examination Vital signs including postural BP/HR Weight/height/BMI Hydration status Systems review or targeted examination as indicated Complications or signs of the ED Signs of starvation/malnutrition Dehydration, dental erosions, GIT, purging related signs Obesity, metabolic syndrome 14

15 Risk Assessment Medical risk ED have high medical mortality: AN> EDNOS, BN not elevated Suicide risk 1 in 5 pts with AN who died prematurely Completed suicides in BN lower than AN BED probably elevated risk but insufficient studies Non lethal suicide attempts 23-35% BN 3-20% AN RF of suicidality Comorbidities: BPD, substance abuse, excessive exercise, alexithymia Adolescents 15

16 Self-harm BN, binge-eating or purging behaviours Complex PTSD Obsessive compulsive, perfectionistic Adolescents Comorbidity common and affects risk: Depression Anxiety Personality Disorder 16

17 Investigations Bloods FBE, U&E, LFT, Cr/Ur, TFT, CPM, FBSL/RBSL, F lipids ECG BMD Liver U/S, sleep study 17

18 Case study 1 35 year old mother of two Hx of recurrent depression and anxiety on Sertraline. Had a recent depressive relapse that was managed by increasing Sertraline to 100mg mane. Obese BMI 31 seeking weight management advice. Would you screen this woman for an ED? 18

19 History 20 year history of binge-eating 1x/week, no purging behaviours Overweight child, bullied about weight, thin parents who commented on weight Age 15 went to Weight Watchers, wt loss of 16kg from 64 to 48kg Dieting continued but had one cheat day Bingeing started once a week Age 17 became depressed and binged more Highest weight 86kg Ongoing healthy eating, exercises 3-4 times a week Binges once a week shame/guilt/disgust Importance of appearance and weight What next? 19

20 Case Study 2 22 year old single woman Studying childcare 3 year history: Bingeing 2x week Purging 2x week Restrictive intake to compensate Body image dissatisfaction BMI 20 Comorbidities Alcohol abuse 1 bottle of vodka decreased conscious state multiple presentations to ED Would place herself in sexually unsafe situations to obtain money for alcohol Borderline personality traits though no formal diagnosis 20

21 What would you do next? Dx, Medical Ax, Risk Ax, Ix What are you concerned about? Risk Medical risk with alcohol abuse Electrolyte disturbance secondary to purging SH/suicide risk ass/w BPD Sexual disinhibition (physical, psychological, safety) Multiple conditions BN, Alcohol abuse, BPD Family Would you refer on? 21

22 BULIMIC DISORDERS - BED Diagnosis Binge eating is eating a large amount of food in a discrete time period with a sense of lack of control over eating. The binge eating episodes are associated with >3 of: eating much more rapidly than normal eating until feeling uncomfortably full eating large amounts of food when not feeling physically hungry eating alone because of feeling embarrassed by how much one is eating feeling disgusted with oneself, depressed or very guilty afterward Marked distress regarding binge eating is present Occurs, on average, at least once a week for three months 22

23 BED more prevalent In obese population, particularly those seeking treatment (1.3 to 30.1%). With increasing BMI In T2DM (10% had ED, majority BED) Psychopathology BN > BED > obesity Two management approaches: Obesity specialist (weight) vs ED specialist (binge eating) 23

24 BULIMIC DISORDERS - BN Diagnosis - Recurrent binge eating. - Recurrent compensatory behaviour to prevent weight gain, e.g. selfinduced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. - Occurs on average, at least once a week for three months. - Self-evaluation is unduly influenced by body shape and weight. - Does not occur exclusively during episodes of Anorexia Nervosa. Dieting disorder Normal weight or overweight/obese 24

25 General Principles of Management Engagement Psychoeducation Managing risk Patient centred informed decision making Recovery centred practice Least restrictive context Involve family members, significant others and carers Multidisciplinary approach Stepped care Integrated care Cultural awareness 25

26 Treatment for BED/bulimia nervosa Community treatment generally appropriate Psychotherapy +/- nutritional rehabilitation CBT-E (Fairburn) effective treatment for older adolescents/adults with BN and BED Transdiagnostic Core pathology: overevaluation of shape and weight and their control Good efficacy cf control and other psychotherapies Reduces binge eating and purging. Low relapse rates Guided self-help CBT for BN (Hay 2013) Treating Bulimia Nervosa and Binge Eating:A guide to Recovery (Cooper 1995) administered by GPs 8x1/2 hour sessions (Banasiak et al 2005). Overcoming binge eating (Fairburn, 2013). Unguided self-help may be effective in BED Other delivery modes: internet, telemedicine, group therapy 26

27 Requirements for CBT Motivation Cognitive capacity Emotional stability Commitment and energy Contraindications: Medical instability Suicidal ideation or behaviour Severe depression Substance use disorder Psychosis Major life events/crises Competing commitments 27

28 Other psychotherapies Weaker evidence for: IPT and DBT in BN and BED Mindfulness in BED (Kristeller ane Wolever, 2011) Mixed findings for FBT 28

29 Weight management for BED Many people with bulimic illness will seek weight loss treatment Behavioural weight loss Effective in the short-term but likely to require psychotherapy to prevent recurrence Dietary restriction did not appear to worsen ED symptoms but disinhibition and hunger remained a problem (Yanovski 1994) Epworth Weight Management DPP Ax by obesity expert Psychiatric Ax prior to referral to DPP Option for individual therapy during, prior or after DPP with psychiatrist DPP multidisciplinary (dietician, exercise physiologist, psychologist, doctor) 29

30 Pharmacotherapy SSRIs at high dose TCAs effective for BN but SEs limit use Topiramate effective for BN and BED, SEs paraesthesias and taste perversion Likely ST efficacy, no LT trials Probably less effective than pharmacotherapy + CBT Indications: If they have a comorbid condition, e.g. depression Limited response to psychotherapy If psychotherapy not available For BED, recent FDA approval for Vyvanse (lisdexamphetamine) 50-70mg/day 30

31 Prognosis BED better outcome than BN Pre-treatment poor prognostic factors ass/w BN (NICE 2004): Features of borderline personality disorder Concurrent substance misuse Low motivation for change History of obesity. When to refer to a psychiatrist? Complex patients with multiple comorbidities Comorbid conditions not responding to treatment BN not responding to community treatment Patients at risk, e.g. pregnant, suicidal 31

32 Case study 3 25 year old woman 10 year history of restrictive intake, excessive exercising. Periods of purging. Cx amenorrhoea, osteoporosis. Treated in an IPU and DPP in the past. Restored weight but on discharge, did not follow-up with community team and gradually lost weight over months. Presents with LOW of 10kg over the past 1 year, BMI 15. How would you Ax her further? How would you manage her? When would you refer on and to whom? 32

33 Case study 4 35 year old woman 20 year history of AN, restrictive subtype Maintains BMI 15.5 Cx amenorrhoea, osteoporosis, chronic symptoms of starvation Mood low, anxious (chronic) No risk of SH/suicide Lives with family, unable to work, no social network How would you manage her? Is your approach different from the previous pt? 33

34 Anorexia Nervosa Diagnosis Persistent dietary restriction leading to low body weight Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though significantly low weight). Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight. Restricting or bingeing-purge subtype 34

35 Management of AN Medical stabilisation and monitoring MDT - specialist dietician, GP/physician, psychiatrist, psychologist, AMHS/CYMHS, specialist ED service Nutritional rehabilitation and weight restoration Awareness of refeeding syndrome Settings outpatient, DPP, medical ward, psychiatric IPU, EDU Consider IP Life-threatening medical complications Low BMI Uncontrolled symptoms that increase risk SEED Focus on improving QOL ED maintained or addressed slowly Management of risk and complications 35

36 RANZCP eating disorder guideline 36

37 RANZCP guideline 37

38 Psychotherapy SSCM - specialist supportive clinical management Focus on normalising eating and weight restoration Addresses life issues as they present and impact on ED CBT-E (Fairburn) Guided self-help CBT probably not useful MANTRA Addresses cognitive maintaining factors, e.g. obsessional and anxious/avoidant traits Motivational enhancement CAT IPT Focal psychoanalytic and psychodynamic therapies FBT for children and adolescents. Family interventions for partners or family members probably helpful 38

39 Pharmacotherapy Treat comorbid conditions such as depression and anxiety once starvation has been addressed unless there are significant risks Antipsychotics e.g. Olanzapine, Quetiapine may be helpful Caution as AN may place patients at greater risk of SEs Lack of evidence for medications to reverse bone density loss 39

40 Prognosis 41% relapse, highest risk in first 4-9 months after treatment Higher relapse with AN, BP subtype % have full or partial recovery at a mean of 6.4 years (Steinhausen 2002, Strober) 20% have chronic illness 5% mortality rate 2.9% crude mortality rate in European cohort (Steinhausen 2003). Poor prognosis ass/w: Lower BMI, more psychosocial impairment, B-P subtype 40

41 Take-home messages Consider an ED in at risk populations Screen for ED Engage the patient and see them regularly Ax and manage ongoing medical risk Manage mild-moderate ED Refer to MDT with specialist skills in managing ED or specialist public ED service when appropriate 41