Anorexia Nervosa

Management of Anorexia Nervosa

Thursday, 30 June 2005

Immediate physical complications of starvation

Long term physical complications of starvation

Psychological changes of starvation

Maturational issues

Family dysfunction

Interpersonal dysfunction

Comorbid psychiatric conditions Axis 1 and 11

Active non compliance

Disability associated with chronic illness

Socio cultural issues

Early developmental/psychodynamic issues

Terminal illness

Course and outcome of Anorexia Nervosa (n=94)

Sten Theander (Sweden) published 1985

LONG TERM OUTCOME OF BULIMIA NERVOSA(1992 Keller & Hertzog)

30 people presented to an eating disorder clinic - 70% recovered at 8 weeks but 63% of the ‘recoverers’ had relapsed in 18 months.

THE SUFFERER WHO FRUSTRATES A KEEN THERAPIST BY FAILINGTO IMPROVE IS ALWAYS IN DANGER OF MEETINGPRIMITIVE HUMAN BEHAVIOUR DISGUISED AS TREATMENT(T F Main)

Management of Eating Disorders

Recognition - What is Normal Eating

WOMEN AND WEIGHT

REMEMBER - FAT IS A FEMINIST ISSUE

OBESITY IS A REVOLT AGAINS MALE DOMINATED SOCIETY

WOMEN DIET TO PLEASE MEN

OBESITY IS MORE ACCEPTABLE IN MEN

OBESE WOMEN ARE LESS LIKELY TO MARRY

EPIDEMIOLOGY OF BULIMIA NERVOSA

Normal Population Survey(Cooper et al 1983)

Recognition - Warning Signsof Anorexia Nervosa

DSM IV Anorexia Nervosa

1. Refusal to maintain body weight over a minimal normal weight for age and height. Eg. Weight loss leading to maintenance of body weight 15% below that expected to failure to make expected weight gain during a period of growth heading to body weight 15% below that expected

2. Intense fear of becoming obese even when underweight.

3. Disturbance in the way in which one’s body weight, size or shape is experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight.

4. In females, the absence of at least 3 consecutive menstrual cycles when they would otherwise be expected to occur, i.e primary or secondary amenorrhoea.

Restricting sub type:

Bingeing/Purging subtype:

Clinical Features

Dysfunctional thoughts about shape and weight which lead to the “relentless pursuit of thinness” characteristic of anorexia nervosa

This leads to control of weight and shape by rigorous dieting, laxative abuse, self-induced vomiting, fasting, excessive exercise etc.

Marked weight loss

Appetite is not lost.

Preoccupation with thoughts of food and eating.

As weight loss increases so does the body image disturbance which further drives the disorder.

Keys et al 1950 The Biology of Human Starvation

34 Conscientious objectors starved for 12 weeks then re-fed for 12 weeks.

Starvation Syndrome described

Worsened with increasing starvation

Ten of the fifteen men who reported for follow up had then placed themselves on reducing diets.

Physical Symptoms and signs of Anorexia Nervosa

Psychological Features of the Starvation Syndrome

food preoccupation, cooking, recipes, pictures

hoarding and stealing food,

eating rituals, binges,

social withdrawal,

lability and depression of mood, mood swings

poor concentration,

irritability,

loss of energy, bursts of energy and restlesssness

sleep disturbance,

obsessional symptoms,

narrowing of interests.

Diagnostic Criteria for Bulimia Nervosa

A.Recurrent episodes of binge eating. An episode of binge eating is characterised by both of the following:

(1) eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances

(2) a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months.

D. Self-evaluation is unduly influenced by body shape and weight

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Purging Type:./ Nonpurging Type:.

Diagnostic Criteria for Bulimia Nervosa (contd)

Specify type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

COMORBIDITY OF BULIMIA NERVOSA

PERSONALITY DISORDER IN BULIMIA NERVOSA

80% of people with Bulimia Nervosa meet criteria for more than three personality disorders each,After treatment the rate of personality disorder is much less, suggesting that personality disorder diagnosis is an artefact of the illness in a chronic fluctuating disorder.

FACTORS WHICH DETERMINE DEVELOPMENT OF BULIMIA IN SOMEONE WITH ANOREXIA NERVOSA

1. Prolonged dietary restraint is possible for only a small proportion of people

2. Personality factors - people with Bulimia may be more extrovert, more socially skilled and have less impulse control.

3. Age - Bulimia tends to start at a slightly later age and present to doctors in the mid-20’s.

FACTORS WHICH DETERMINE DEVELOPMENT OF BULIMIA IN SOMEONE WITH ANOREXIA NERVOSA

4. Physiological pressures - prolonged high protein, low carbohydrate diet depletes brain of L-tryptophan a precursor of serotonin. High Carbohydrate binges increases rapidly the amount of L-tryptophan within the brain.

5. Bulimia may be maintained by a variety of feedback loops as described.

CLINICAL FEATURES OF BULIMIA NERVOSA

Most patients conceal the problem, it may be identified because of hypokalemia, metabolic acidosis, dental erosion, peptic ulceration, dehydration, enlarged parotid glands, cardiac arrhythmias, Russell’s sign.

If you don't ask, you wont get told.

All young women with mood disorders, low self-esteem, should have their dietary and body shape and weight issues explored.

CLINICAL FEATURES OF BULIMIA NERVOSA

BULIMIA IS A DIETING DISORDER.

CHRONIC PREOCCUPATION WITH FOOD.

WORRIES ABOUT SHAPE AND WEIGHT.

REPEATED WEIGHING.

BODY IMAGE DISPARAGEMENT.

BINGEING WITH LOSS OF CONTROL.

Clinical Features of Bulimia Nervosa

THE STARVE/BINGE/PURGE CYCLE

Bulimia is a Dieting Disorder

STARVE

PURGE BINGE

WORRY ABOUT SHAPE AND WEIGHT

A Binge

1 gin and bitter lemon

Prawn cocktail

Roll & butter

2 glasses wine

1 slice roast beef

1 slice roast pork

1 slice ham

Portion potato salad

Portion red cabbage

Portion sweetcorn

Portion coleslaw

Lettuce, cucumber and tomato

Portion curried rice

Large baked potato and dressing 1/2 large bakewell tart

4 oz Black Magic

1 lb tablet

2 profiteroles, cream and chocolate sauce

1 can diet coke

1 can 7-Up

Large gin and bitter lemon

5 sandwiches and meat filling

6 pancakes and butter

7 scones with butter + jam

Bowl ice cream

2 slices date and walnut cake

1 litre fresh orange juice

3 glasses lemonade

Packet crisps

Cup of tea

2 slices fruit cake

4 biscuits

Eating Disorders for Clinical Examinations

Management of Eating Disorders

Establish severity

History (also developmental and social context)

Physical Examination

Use as an opportunity to identify aspects of their current state that they find distressing. Feedback of all relevant signs and symptoms and findings related to weight loss and weight control. Combine information gathering, education and engagement.

BMI

BDI BITE BSQ SAS

Investigations

FBE & ESR

U&E, LFT,TFT,Ca&P, Gluc.

ECG, BMD, Creatinine Clearance

Ovarian and Uterine US., repeating according to need.

BODY MASS INDEX

BMI(QUETELET INDEX)

Anorexia Nervosa Treatment

Setting

Inpatient setting reserved for severely underweight with health problems, suicide risk, or failure of outpatient treatment.

Day hospital treatment may provide alternative

Outpatient treatment adequate for most Anorexia Nervosas

If inpatient treatment provided, emphasis should be placed on maintenance of healthy change on return to outpatient environment.

Development of AN

Abnormal eating, body image and self attitude

Diagnosable Disorder

Self maintaining disorder independent of precipitants and vulnerability factors

AN as the identity of the person.

FOR AN Management of Eating Disorders

Health Education for patient and family

Psychological and physical consequences of starvation

Complications of vomiting, and laxatives

Mortality rates and prognosis

Eating disorders as illnesses that effect people - get some distance from the disorder in order to change it.

Binge Vomit Diet cycle, BN as dieting disorder, efficacy of laxatives, vomiting

Management of Eating Disorders

Health Education for patient and Family

Focus on recovery of health rather than recovery of weight.

Focus on reversal on unwanted aspects of the condition, ask person to set goals of therapy.

Focus on regaining control from the disorder.

Focus on reality checking rather than fears, fantasies and opinions

"I feel fat therefore I am fat"

Refer family and sufferer to local support groups. eg ANBNF 9885 0318

Management of Anorexia Nervosa

Immediate physical complications of starvation

Long term physical complications of starvation

Psychological changes of starvation

Maturational issues

Family dysfunction

Interpersonal dysfunction

Comorbid psychiatric conditions Axis I and II

Active non-compliance

Disability associated with chronic illness

Socio-cultural issues

Early developmental/psychodynamic issues

Terminal illness

FOR AN Psycho social treatment

Education and CBT can begin before refeeding but education will need to be repeated.

Involve family from the start:

education

support

family treatment - short duration, young??

Management of Eating Disorders

Initial management of nutritional deficits and problems associated with weight control behaviours

Begin to record a daily food diary

Obtain agreement to maintain weight at prsent level

Introduce simple behaviour changes from ‘Principles of Normal Eating’

In AN obtain agreement to gradually introduce a weight restoration programme in consultation with a dietitian

In BN introduce a none dieting approach to none binge food intake. Plan this the day before.

? Use of supplements

Nutritional rehabilitation

Reversal of biological and physical concomitants of starvation is early and central goal.

Emphasis taken away from weight and placed on health and well being.

Education re causes, course and consequence of Anorexia Nervosa and with particular emphasis on reversible complications.

Emphasis on problems identified by patient produced by starvation or reversal on these.

Thorough physical examination and investigations to allow frequent and accurate feedback to patient of current health status

NB: creatinine clearance

Dietitian input important

Emphasis on self control and self monitoring

Avoid target weights, restoration of health is the goal eg. In long term return to menstruation

Use BMI rather than absolute weight

Requires highly experienced staff

Assessment and management of psychological issues

Simple anxiety management, geared to mastery and controlling fear of fatness

Relaxation tape

Breathing Control

Avoiding avoidance

Simple self talk

Distraction

Use of information to substitute opinion with fact

"I feel fat, therefore I am fat"

"If I eat I'll lose control and blow up like a balloon"

EXAMPLE OF ANOREXIC/BULIMIA THOUGHTS

As classified by Cognitive Therapy

MAGNIFICATION, or overestimation of the likelihood of a disaster occurring because of some trivial incident.

Examples

I will be laughed at openly if I venture outside because I have put on so much weight.

If I eat normally, I will get fatter and fatter until I look like a pig.

If I don't stop this very soon, I will kill myself.

DICHOTOMOUS REASONING, or all or nothing thinking, or thinking in extremes.

Examples

If I am not in complete control, I lose control of every aspect of my life.

I am only acceptable as a human-being when I am thin.

My life is meaningless unless I can look perfect

That's it I've blown it I've eaten 1 chocolate, I may as well make the most of it.

COGNITIVE RESTRUCTURING - EATING DISORDERS

(1) Eliciting thoughts (not usually difficult)

- homework tasks

- record thoughts

- provoke in treatment

(2) Dieting/eating behaviour

- bingeing

- vomiting

- starving

(3) Weight and size

- magical 99lbs, 7st 13 lbs

- size 8 or 10

(4) Body image

- avoidance

- colour blind

(5) Self esteem

(6) Explore meaning of terms

eg fat (markedly over-defined

ADAPTING CBT FOR ANOREXIA NERVOSA

1. The idiosyncratic beliefs regarding shape and weight.

2. The interaction between physical and psychological components of the disorder.

3. The patients desire to retain certain focal symptoms.

4. The development of motivation for treatment.

5. The evolution of a trusting therapeutic relationship.

6. Prominence of fundamental deficits in self concept and self esteem.

7. Longer duration of treatment.

Components of Therapy proven to be of some value include:

Self monitoring

change in eating pattern

education

self control (cue restriction)

cognitive restructuring

focus on relationships (IPT)

exposure with response prevention (ERP)

self help

behaviour therapy and anxiety management

distraction

alternate behaviours

How to Break the Vicious Cycle

Stressful Situation

eg Starving, Dieting, Worrying about Weight & Fatness

Threats to Self-Esteem

Challenge Thoughts

Alternative Helpful Behaviour

Relaxation

Distraction

Elastic Band

Flash cards

Problem Solving

PONE

Where does CBT fit into a Comprehensive Treatment Regime for Bulimia Nervosa? (A tiered approach to Treatment)

Use of Antidepressants

AN after weight restoration

BN if severe co-morbid depression

Role of Prozac

Support, ventilation, problem solving, here and now approach

Tool Box Patient as co-therapist

Pharmacotherapy for AN

Treat comorbid illnesses appropriately

OCD, Depression, Psychosis

ADPs will not work until BMI > 16-17

SSRI's - Fluoxetine has a role in maintenance of weight gain post re-feeding-why?

BZDs useful as anxiolytics pre meal in some patients

Antipsychotics

Is AN a psychosis?? The Graham Burrows experience!

Increase appetite but this may make things worse

HRT to re-establish ovulation and bisphosponates for osteoporosis

Management of Treatment Resistance

Develop collaborative alliance

Provide psycho-education

Set Realistic goals

Promote autonomy

Ensure balance between containment and flexibility

Involve the family

Consider pros and cons of imposing treatment

Ensure non punitive treatment

Obtain support

Treatment resistance is an evolutionary process

Mobilisation of community supports

Influence mental health referral and explain course of treatment

Help to decide if and when more intensive therapy is necessary

Shared care with Specialist referee

The Chronically Underweight

15% of all Anorexics develop a Chronic Illness

Can be considered treatment-resistant

Aim to maintain in community

Minimise physical complications

Maintenance of maximum tolerable weight

Encourage development of alternative coping strategies

Consider support in a group setting

POOR PROGNOSIS

Outcome of Anorexia NervosaHerzog et al (1988)

Mortality 0%-22% of patients

Underweightness 15%-43%

Amenorrhoea 4%-42%

Food restriction continued in 23%-67% of patients followed up.

SUMMARY

Establish Diagnosis

Assess stage and severity

Primary care Vs Specialist referral