CARE BUNDLE Robyn Girling-Butcher Senior Clinical Psychologist Child, Adolescent & Family Service Mental Health MidCentral DHB
Principles of Care AN has highest death rate of any mental health disorder and very high levels of morbidity Medical and psychiatric risk so assess for both Psychotherapy is not effective with starving patients; prioritise re-feeding for the underweight and regular eating for those with chaotic intake Models of Treatment Maudsley Family Based Treatment CBT / CBT-E for Bulimia/ + some EDNOS cases
Anorexia Lifetime prevalence 0.5-2%(<1 in 10 are males) Mortality 8.8% in 12 years (2006 US data) Most deaths in first 2 years or after 15 years Longer first admission = lower mortality <20% develop severe & enduring illness(seed) Smallest diagnostic group of the eating disorders Bulimia Lifetime prevalence 2-4% (1 in 10 are males) Usually found to be 3 to 6 x more common than AN EDNOS Lifetime prevalence 2-10% >50% EDs are EDNOS, by far the most common eating disorder However transmigration rates across diagnoses observed to be very high since these disorders first emerged
Eating Disorders now Feeding & Eating Disorders Anorexia Nervosa amenorrhea criterion removed Bulimia Nervosa Binge eating & compensatory behaviour frequency threshold reduced from twice to once weekly for past 3 months Binge Eating Disorder Previously part of EDNOS, now a separate diagnosis New Diagnoses (replacing EDNOS) Other Specified Feeding or Eating Disorder /OSFED Subclinical, noting why criteria not met, e.g. atypical AN Unspecified Feeding or Eating Disorder / USFED Subclinical cases in which reasons full criteria not met are either not stated or unknown e.g. insufficient information
Threshold changes for AN and BN, and dissolution of EDNOS mean large numbers of existing and new cases will receive a different diagnosis than they would under DSM-4 E.g. previous EDNOS case now diagnosed as AN Comparison of incidence/prevalence pre and post DSM 5 will be difficult likely to see significant increase in AN and BN rates, while OSFED rates expand over time (as per EDNOS) Dissolution of Eating Disorders as a category in which socio-cultural factors were accepted as being a significant contributing factor; now joined with feeding disorders such as Pica
80% of people with eating disorders also have another mental health disorder 60% Mood Disorder: e.g. major depressive dx 40% Anxiety Disorder: e.g. social anxiety; OCD 30% Substance Use Disorder: alcohol use has the highest correlation with suicide 1. Borderline Personality Disorder: proxy for attachment disorders and/or trauma history
AN has highest mortality of any psychiatric illness from 5-20% Risk of premature death is 6-12 times higher in women with AN than in the general population Common medical events include heart failure, myocardial infarction & fatal cardiac arrhythmia However suicide contributes to the high mortality rates; self-harm also not uncommon Risk of death from Re-feeding Syndrome
Originally described in Japanese prisoners of war at the end of WWII, in whom re-feeding after prolonged starvation precipitated cardiac failure Severe electrolyte and fluid shifts associated with refeeding after acute or chronic starvation Rapid intracellular update of electrolytes (phosphate, potassium, magnesium) resulting in low circulating levels, causing organ failure and cardiac events Re-feeding syndrome remains a significant contributor to mortality rates in AN. Primary care clinicians particularly should consider the risks of agreeing to re-feeding in the community without close medical monitoring Phosphate now routinely added during re-feeding regardless of levels, and levels monitored every 1-2 days
Medical Assessment (best by GP prior to MHS assessment) Weight, height, BMI or percentiles, weight history Menstruation history General health overview & medications Lying and standing blood pressure & pulse; temperature Blood tests; ECG if bradycardic or purging 4+ times per week, and/or reporting any cardiac symptoms Brief Initial Assessment and/or Specialist Eating Disorder Assessment Presenting concerns and history Eating disorder behaviours and cognitions Overview of physical health status; physical symptoms Summary, impression and plan Dietitian Assessment Meal planning; manage risks of re-feeding; regular review Nutritional deficits may need addressing, e.g. low iron
Template for brief assessments for eating disorders across services, and for comparison across referrals for individual clients Can be used by any clinician with brief preparation Can be completed in a single session Covers the physical and psychological criteria for DSM 4 and 5 diagnoses Provides enough information to identify risk factors, to provide risk feedback to client and assist service in prioritising triage and treatment
Have there been any recent changes to your normal eating pattern? Describe current daily intake (food & fluid) Recent or longer term vegetarianism or veganism Omitting dairy, sugar, gluten, carbohydrates Food intolerances or allergies Have you been reducing or restricting your food intake? Dieting or calorie counting, avoiding fat foods Missing full meals and/or snacks Fasting (no solid food in a day check fluids)
Are you having episodes of bingeing on food? Objective versus subjective bingeing Do you feel like your eating is out of control Do you eat more than the quantity of a 3 course meal within any 2 hour period Do you keep eating even when you are full Do you eat unprepared food such as raw or frozen food (eg., cake mix; uncooked food) Do you take other people s food to binge Is any vomiting occurring? In order to control your weight and/or involuntary Duration (onset) and frequency (daily/weekly etc) Have you ever noticed blood in the vomit?
Are you using laxatives or any other substance to help with bowel function or purge food? Source (OTC or prescribed; internet) type, dose, frequency (within prescribed limits?) experiencing diarrhoea (risk of loss of potassium) Are you using any other medications for weight control? Source, type, dose, frequency Over-using thyroxin; omitting insulin; buying others diuretics; and street amphetamines all used for their weight-reducing effects
What kinds of exercise do you do? Type; frequency; duration; include school PE & sports Check on walking and other less obvious exercise, such as physically demanding work roles What is your current fluid intake? 1-2 litres sufficient in most NZ climates/seasons Insufficient (under 500mls/24 hrs = kidney failure) Excessive (> 2 litres; medically dangerous > 4 litres) Do you monitor your weight? Scales; location; frequency of use Other ways (clothes; mirror; seeking reassurance)
Excessive fear of weight gain or being fat How much time do you spend worrying about your weight/shape? Body image disturbance Do you think you are in the normal weight, overweight or underweight range? Check logical versus feeling sense. What would family or friends say? Undue influence of weight and shape of self-evaluation How much does weight/shape influence how you feel about yourself? Is it the most important thing in how you feel about yourself? Unable to recognise seriousness of risk factors Minimizes or denies risk Ignores mental health and/or medical advice
Collate most of this information from the Medical Assessment Form from the GP Weight/height/using BMI and percentiles Percentiles for under 18s; BMI 18+ Lowest and highest weight/weight change Rate of weight loss important; > 1kg/week = risk Menstrual history including contraceptives Menstruation can t be used as physical measure of safety Current medications May affect weight or indicate chronic illness Current physical symptoms Important to determine risk
Brief Initial Formulation Summarize main presenting issue Consider predisposing, precipitating, perpetuating (maintaining) and protective factors Diagnostic impression including co-morbidity Note primary versus secondary concerns Initial Planning Identify professionals to be involved in treatment (MH; primary care, school, dietitian)
Psychological assessment and formulation informs treatment Therapeutic relationship critical for engagement and motivation for treatment Clinical formulation, including co-morbid presenting issues Psychoeducation (client and family) might include: What is a normal weight range and eating pattern Signs, symptoms and effects of low blood sugar Short and long term consequences of eating disorders Psychiatric assessment & medication if required Motivation to change: Stages of Change model Pre-contemplation: what problem? Contemplation: yes, but. Preparation: how do I do this? Action: I m doing it! Maintenance: how do I keep doing it? Relapse: oops, I did it again
Prevent mortality death from starvation medical complications (electrolyte imbalances from purging or re-feeding syndrome leading to arrhythmias) Establish healthy eating patterns and eating behaviours Ongoing monitoring of physical and mental health issues Increase insight into contributing factors Body image/self-esteem Family issues/stressors Trauma/anxiety Maturation fears/developmental tasks Unhelpful & distorted thinking Relapse planning; quality of life; self-care
Maudsley Family Based Treatment (Evidence based intervention shown to be effective) Three stage model which prioritises physical wellbeing and assists parents to re-feed at home Preferably has two therapists Dietitian & medical reviews as needed Externalising the illness from the young person Calm, Consistent and Collaborative approach
Phase 1: Re-feeding the young person Engagement with young person and family Improving parents control to enable feeding and weight restoration Reduce activity levels, assess for and monitor safety Identifying additional supports for the young person and family Identifying family dynamics contributing to ED such as coalitions, authority structure, conflicts. Phase 2: Negotiations for a new pattern of relationships Getting to and maintaining healthy weight range Returning decision making to the young person Model problem solving to the family Resuming appropriate adolescent developmental tasks Phase 3: Adolescent issues and finishing therapy Establishing more appropriate family boundaries Addressing underlying psychosocial issues relapse prevention planning Address quality of life and future goals
MDT s Eating Disorder specific MDT once a month attended by Paediatrician and Dietitian working with Eating Disorders Peer Group Discussions Peer group discussion also monthly in small groups to talk about ongoing eating disorder work Peer group discussion - 3 to 5 people Mix of professions and experience enables more experienced clinicians to share knowledge and expertise CREDS Central Regional Eating Disorder Service supervision days
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