Eating Disorders. what do GPs need to know? John O Brien May 2016

Transcription

1 Eating Disrders what d GPs need t knw? Jhn O Brien May 2016

2 Overview Eating, weight and eating disrders Case scenari Hw t spt them When t refer Management pre and pst referral

3 Eating and weight Adlescence Time f change in weight, eating habits, dieting Identity develpment Dissatisfactin with bdy Cmmn time fr independence frm family eating Dieting Lts f peple diet r are bsessed with weight, few have eating disrder Obesity Culture & fashin Physical Disrders and ther factrs can affect appetite and weight

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5 Eating Disrders Mrbid preccupatin with weight and shape Distrted r chatic (eating) behaviurs Can be chrnic 90% are female dn t frget the bys Often present in adlescents/ yung adults dn t frget the later presentatin All ethnic grups Scial, genetic, psychlgical ( ideal weight, temperament ) factrs Different mechanism t fd fads, fd phbia, besity Families and systems are imprtant

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7 Anrexia Nervsa Self induced weight lss, and sustained Bdy image distrtin, fear f gaining weight, intrusive vervalued ideas Impse a lw weight threshld Restricting type r binge/purge type (DSM) +/- vmiting, purging, excessive exercise, appetite suppressants, diuretics Undernutritin Metablic/ Endcrine (hypthalamic- pituitary- gnadal axis e.g. amenrrhea) Disturbances f bdy functin Delayed r arrested grwth/ puberty Mst cmmn in girls and yung wmen, 0.5% girls 3 rd mst cmmn chrnic illness f adlescence Can have an atypical presentatin: E.g. weight lss and weight reducing behaviur but n dread f being fat Can kill

8 Bulimia Nervsa Excessive preccupatin with eating and cntrl f bdy weight Over-cncern with bdy shape, dread f fatness Overeating in shrt perids f time fllwed by vmiting, use f purgatives, starvatin perids, appetite suppressants, thyrid preparatins, diuretics, excessive exercise Purging type/ nn purging type (DSM) Vmiting giving rise t electrlyte disturbance and physical cmplicatins Endcrine disturbance 1-3% prevalence Can appear similar t AN, and smetimes earlier episde f AN Dn t frget atypical presentatins

9 Vs AN Lw weight Presents early Rarely seeks help Often early t mid teens nset Can be pre-menarcheal Can affect bys Can be chrnic N previus illness depressin, anxiety, OCD Pr prgnsis withut early interventin BN Nrmal weight Presents late May seek help Often late teen nset Rarely pre-menarchael Usually affects girls Usually fluctuating curse Previus AN (mnths/yrs befre) depressin, S/H, substances Up t 60% respnse t Tx

10 Others EDNOS: ED that desn t meet criteria fr AN, BN. subthreshld AN/BN, mixture f AN and BN Very atypical eating behaviurs nt characterised by AN/BN Binge eating : sme will call it a disrder but is a pattern f episdes f uncntrllable eating ften hidden assciated shame, depressed md Others: Psychgenic vereating Psychgenic vmiting Pica in adults

11 Case discussin

12 Hw t spt them?

13 Hw t spt them? GPs likely t have sme ED patients n their case lad but may nt have identified them as ften hidden : patients secretive nature and reluctance t seek help It may be smene else wh spts it fr yu get the cllateral histry frm them Need t spt them as early interventin very imprtant fr prgnsis

14 Hw t spt them? Can be difficult: Reluctant attender t clinic- its just a lifestyle chice, nt an illness Physical symptms Resists examinatin and bservatins Cvers bdy Secretive/ evasive May be distressed when asked abut eating Risk factrs (esp. if in adlescence): Female but dn t frget abut bys Repeated dieting Early puberty Temperament Perfectinism Teasing abut weight Lw self esteem Lss & majr life events Family dysfunctin

15 What shuld I d? Take a gd histry yu can make diagnsis frm this! What shuld I ask? Hw d yu feel abut yur weight? D yu wrry abut yur weight? Des anyne else wrry abut yur weight, eating r exercising? D yu think yu have any eating difficulties? Hw much wuld yu like t weigh? (and hw sn?) What d yu think abut the lk f yur bdy? Have yu made any changes t yur diet? Are yu restricting yur diet? Hw ften and hw much exercise? Have yu been making yurself sick? Have yu been using any ther drugs?

16 What else shuld I explre? Mental state Anxiety Depressin S/H suicide OCD ASD Psychsis Past Psychiatric histry Eating Premrbid persnality Past Medical histry Family histry Substances, ther drugs Change in functining Life events trauma & abuse Systemic factrs Family, parents, siblings Schl Friends Scial media pr-ana pr-mia

17 Physical examinatin Signs f malnutritin and purging Thinning hair Partid gland swelling Enamel ersin Hypthermia Bradycardia Lanug hair Dry skin Hyptensin Underweight Cld (blue/dark) hands/ feet Pr capillary return Insensitivity t pain Cnstipatin Amenrrhea Measurements & investigatins Weight Height BMI (centile) BP & pulse (pstural drp) ECG Temperature Sit up/ Squat test Bld tests: FBC, UEs, PO4, LFT, Albumin, CK, Glucse, Mg, Ca, TFT, serum prteins, FSH, LH, GH Bne scan Pregnant? Diabetic?

18 Management

19 Management Therapeutic relatinship imprtant Feedback findings Cntinue t mnitr risk Mental state examinatin Establish a weight mnitring plan Prvide family/ carers with infrmatin, encurage their invlvement Lw threshld fr referral/ discussins with clinicians in secndary care Plan t mnitr whilst awaiting assessment

20 What happens after referral? Majrity will be managed as utpatients/ day hspital (6/12+): MDT management medical, dietician, psychlgy Meal planning Family invlvement Medicatin e.g. SSRI Small prprtin will require inpatient admissin Very rapid weight lss, BMI well belw 2 nd centile, suicidal, physical cmprmise Meal planning, bservatins, Gal t establish weight gain May require use f MHA Family invlvement, family supprt Medicatin Discharge back t GP Shared care agreement Wh is mnitring, hw ften? Cntingency/crisis/ relapse preventin plans

21 Summary key pints Early detectin/ interventin gives better prgnsis Assess mental health, physical health and RISK Have a cntingency plan nce referred What s ging n in their system? The mst effective screening test is the GP thinking abut it

22 Useful resurces NICE guidance MARSIPAN: RCPsych BEAT UK eating disrder charity BMJ : eating disrders and weight prblems pr websites