Eating Disorders. The expanding spectrum between primary and secondary care

Transcription

1 14 th CCMHCC Eating Disorders The expanding spectrum between primary and secondary care Dr Pallavi Nadkarni MD, MMEdSc, MRCPsych Attending Psychiatrist & Assistant Professor

2 Disclosure Grants/supports: Nil Conflict of interest: Nil

3 Eating Disorders Diagnostic enigma

4 Learning objectives Impact of ED on mental health Impact of ED on physical health Importance of collaborative care

5 Topics covered Classification of ED Statistics Clinical features Aetiology Comorbid mental health issues Medical complications Management

6 Classification AN BN EDNOS (Fairburn & Wilson 1993)

7 DSM- IV Vs 5 DSM IV DSM 5 BED EDNOS Separate ARFID - + AN/BN + +

8 Magnitude of the problem AN 45% BN 12% EDNOS 5% BN 3% AN 1%

9 Core clinical features Triad of Fear of fatness Dissatisfaction Intense loathing

10 Historical aspects Religion- St Catherine (1380) Morton (1689) Lasegue & Gull (1870 s) Pierre Janet Hilda Bruch Russell (1990 s) Minnesota experiments (Keys et al 1940 s)

11 Aetiology Genetic: MZ (65%), DZ (32%) Familial: obesity, drug use, affective disorders Personality Psychodynamic theory Social

12 Aetiology Organic basis- fmri findings, 5HT, BDNF, NE, HPA Behavioural basis

13 Ethnic variations African-American Latin- American Japanese

14 Broad comparison ED AN BN Described William Gull (1868) Gerald Russell (1979) Eating Starvation Bingeing BMI < 17.5 > 17.5 Age 16 yrs avg Early 20s M:F 1:6- community 1:10- clinical Types Restricting Purging Binge-eating/purging Non-purging PMP Cluster C Cluster B Crossover As much as 50% Fewer (? 1%) Menses Amenorrhoea x3 cycles -

15 Males Vs females Rapid osteoporosis GID Premorbid obesity M:F= 1:4 in adolescents, 1:10 adult Binge/exercise > purge (Carlat et al 1997, Andersen et al 2000)

16 Psychiatric comorbidity Affective disorders Anxiety spectrum disorders (Hudson et al, 2007) Dissociative disorders Body dysmorphic disorder Substance use Personality disorder Multi-impulsive variant: BN (Lacey 1993)

17 Depression & ED Depression Eating disorder Fatigue Lethargy Self harming High cortisol Low T3

18 Medical complications REPRODUCTIVE SYSTEM Amenorrhoea: 20% Infertility Pregnancy: Caesarean section, PPD, SGA babies Polycystic ovaries: BN

19 Medical complications PERINATAL COMPLICATIONS Nuchal cord Placental infarctions Hypotonia Cardiomyopathy Hypothermia (Favaro et al, 2006)

20 Medical complications OTHER ORGANS Pancreas Liver- NASH Endocrine- thyroid, cortisol Kidneys Bone Heart- QTc Blood Glands Skin Eyes Teeth

21 Associated disorders Orthorexia Muscle dysmorphia Anabolic steroid use

22 Interesting facts Anorexia: misnomer Bulimia: ox-hunger Reverse AN/ bigorexia nervosa

23 True or False Childhood sexual abuse is an absolute risk factor for ED. (Pope et al 1994)

24 APA (2006) NICE (2004) Management

25 Principles of treatment Therapeutic alliance Collaboration Physical complications Psychiatric issues

26 Therapeutic alliance and not treatment dictates improvement. (Krupnick et al, 1996)

27 Screening questions SCOFF: =/>2 S- sick C- control loss O- one stone in 3 months F- fat F- food dominates (Morgan et al, 1999)

28 Rating scales Yale- Brown- Cornell Eating disorder scale Eating Disorders Inventory Eating Attitudes Test

29 Vitals BMI General Systemic SUSS test Physical examination

30 Laboratory tests Haematology: low Hb, low WBCs Thyroid: low T3 Electrolytes: low Na, Ka, Mg, P, Ca, Cl alkalosis Sugars: < 60mg/dl Hepatic: high enzymes, bilirubin GI: raised amylase Gynaecology: low FSH, LH ECG: prolonged QTc, RAD, ST-T abn

31 Treatment setting- inpatient HR< 40/min BP< 90/60 mm Hg K< 3meq/l Glucose < 60 mg/dl BMI <13, <16 Dehydration Organ failure

32 Ethical issues Compulsory treatment

33 Other aspects Refeeding syndrome Drug prescribing: antidepressants, antipsychotics Psychological treatments

34 Treatment implications Purging behaviours-?? Retained ADD CPS guidance on anti-depressant

35 Novel treatments CREST = cognitive remediation & emotional skills training EABT= emotion acceptance behaviour therapy DBT MANTRA (UK) Salut-BN

36 Studies INTERBED (Germany) SWAN (Australia)

37 Prognosis Chronicity Cross-over Mortality: 6% per decade (Sullivan 2002)

38 Case vignette- 1 Alice was a perfect child. Her room was always clean & her school work was always completed on time. At age 6 she was fascinated with her Barbie doll. She would say, I wish I could look like her. At age 18, she left for college. When she returned for the summer vacation, she had lost 20 pounds. When her family pointed it out, she exclaimed, I need to lose weight, I am too fat. While her family dined, Alice ate a dry toast & drank a diet Pepsi. She exercised excessively.she began buying cookbooks & preparing family meals.

39 AN: restricting type Diagnosis

40 Case vignette- 2 Russ is a 27-year old model who is concerned about his weight & figure. He constantly fasts & exercises to maintain his weight. For the last year he has started engaging in binge eating. At least thrice a week, he visits a restaurant that serves buffet meals. He piles food on his plate. He generally eats huge portions over 2 hours. Then he goes to the bathroom and makes himself sick with his fingers. He continues his binge after which he is subsumed with guilt. He then compensates by running to burn extra calories.

41 BN: purging type Diagnosis

42 Case vignette- 3 Judy is a 23 yr old medical student who has always been concerned about her weight. She often feels an uncontrollable urge to eat junk food such as cookies & pastries. She is concerned about her weight gain. Hence she routinely chews & spits out the food rather than swallowing it.

43 EDNOS Diagnosis

44 Take home message Eating disorders: dilemma Collaborative care BMI, physical examination, lab reports Avoid bupropion

45 Thank You