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Eating Disorders
Information for relatives and friends
Dr Harry Millar
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• What are eating disorders?
• What are the effects on families and friends?
• What help is available?
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What are Eating Disorders?
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Anorexia Nervosa
• Body weight < 15% below expected or BMI 17.5 or less
• Self induced weight loss• Eating restraint• Self induced vomiting,laxative abuse, excessive
exercise, abuse of appetite suppressants / diuretics
• Body image distortion• Amenorrhoea (Loss of sexual libido in
men)
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Body Mass Index (BMI)Weight in Kilograms/Height in metres squared
e.g. 70Kg weight 1.8Metre height70/1.8x1.8=70/3.24=21.6
e.g 37 Kg weight 1.7 Metre height37/1.7x1.7=37/2.89=12.8
Healthy range 20-25 approx
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Anorexia Nervosa
• Body weight < 15% below expected or BMI 17.5 or less
• Self induced weight loss• Eating restraint• Self induced vomiting,laxative abuse, excessive
exercise, abuse of appetite supressants / diuretics
• Body image distortion• Amenorrhoea (Loss of sexual libido in
men)
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F50.2 Bulimia NervosaGreek: Bous=Ox Limos=Hunger
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Bulimia Nervosa (F50.2)
• Persistent food craving pre-occupation, and binge eating
• At least one of • Self induced vomiting, laxative abuse, starvation,
abuse of appetite suppressants, thyroid drugs, diuretics
• Morbid dread of fatness
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Other Eating Disorders
“Atypical” or Eating Disorder Not Otherwise Specified (EDNOS)– One or more of key features absent– Otherwise can be typical picture– Includes Binge Eating Disorder
• Overweight binge eaters• No compensatory behaviours
Patients often move from one group to another
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Fairburn CG and Harrison PJ. Lancet 2003
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Symptoms • Fear of uncontrolled eating and weight gain
• Binge eating and compensatory behaviours
• Distorted body image perception, mirror gazing
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Distorted Body Image
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Symptoms • Fear of uncontrolled eating and weight gain
• Binge eating and compensatory behaviours
• Distorted body image perception, mirror gazing
• Pursuit of thinness
• Food preoccupation, avoidance, restricted choice
• Anxiety eating in company
• Guilt after eating
• (True loss of appetite)
• Overactivity
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Non specific symptoms
• Depression, low self esteem and self blame
• Lack of assertiveness
• Obsessional, rigid and inflexible thinking
• Thinking slowed
• Social withdrawal and irritability
• Self harm
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Physical featuresAnorexia nervosa• Emaciation, Cold
extremities, Lanugo• Slow Pulse, low BP• Anaemia/leucopaenia• Hypothermia• Osteoporosis• Oedema• Constipation• Infertility
Bulimia nervosa• Electrolyte abnormalities• Dehydration• Parotid enlargement• Hoarse voice• Damaged tooth enamel• Loss of bowel tone• Vomiting blood• Finger Scars - Russell’s
sign
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Effects on Families and Friends
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Effects on families• Extreme level of burden – greater than
schizophrenia• Perplexed about cause
– Often self blame by parents– Frustration at other’s lack of understanding
• Including professionals
• Fear of long term effects– Physical, mental, and social
• Helplessness and hopelessness– Uncertainty about how much daughter can help herself– Tried everything – nothing makes any difference– Feeling controlled by the illness– Interference with family life– Difficult to make plans
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Responses in the family
• Sadness up to severe depression• Extreme anxiety – fear she will die• Spending hours over meals, shopping etc.• Anger and hostility• Fear of stigma• Wishful thinking• Externalising the illness
– The anorexia as an enemy or alien possession
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Help for Eating Disorders
• Community, voluntary and self help
• Primary care
• Specialist care
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Community/self help
• Books
• Web sites
• Support services– beat– NEEDS– NHS services– SEDIG
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Books – See beat web siteclick on books from Amazon
• Eating Disorders: helping your child recover– S Bloomfield, 2006, Eating Disorders Association
• Understanding eating disorders– R Palmer, 2005, Family doctor publications
• Anorexia nervosa. A survival guide for families friends and sufferers– J Treasure, 1997, Psychology Press
• Skill based learning for caring with a loved one with an eating disorder : the new Maudsley method– J Treasure, G Smith and A Crane, 2007, Routledge
• Anorexia and Bulimia in the family– G Smith, 2004, Wiley
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Eating disorders: anorexianervosa, bulimia nervosa andrelated eating disordersUnderstanding NICE guidance: a guide forpeople with eating disorders, their advocatesand carers, and the public
Eating Disorders in ScotlandA Patient’s Guide
NICE and QIS Guidance
• NICE
• QIS
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Some useful web sites• http://www.something-fishy.org – Full of excellent information
including a chat room.• http://www.grrr.demon.co.uk/eat.html – Lucy Serpell’s eating
disorder resource page has many links.• http://www.anred.com/toc.html - Information about anorexia
nervosa, bulimia nervosa, binge eating disorder, and other less-well-known food and weight disorders.
• www.anitt.org.uk/ - Click on downloads for care pathways for anorexia nervosa
• http://www.iop.kcl.ac.uk/iopweb/departments/home/default.aspx?locator=308 - Institute of Psychiatry
• www.patient.co.uk – Links to information and other sites
• http://www.rcpsych.ac.uk/ Royal College of Psychiatrists
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• Beat– Helplines, 01603 621 414 - under 18, 01603 765 050– www.edauk.com
• Local NEEDS Group – Meetings first Monday of month– 01224 557652 - Answering service– www.needs-scotland.org
• North of Scotland Managed Clinical Network (MCN)– 01224 557858– www.eatingdisorder.nhsgrampian.org
• Grampian Eating Disorders Service– 01224 557392
• Scottish Eating Disorders Interest Group (SEDIG)– www.sedig.members.beeb.net
Sources of information, advice, support
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Primary care
• Usual first point of contact for professional help– variable response
• Have continuing responsibility even if patient is seeing a specialist– During normal hours your practice– Out of hours
• NHS 24 – 08454 242424– G-Meds
• A and E• Can access psychiatric services via them
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Specialist Care
• Can be – General Medical if uncertain diagnosis or physically
unwell – General Psychiatric if urgent or emergency worry
about mental state e.g. depression and suicidality– Specialist Eating Disorders (Psychiatric)
• For Advice• For Assessment and advice• For Treatment
– Usually multiprofessional mental health team– Most patients will just see one or two team members
but other team members may advise
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Grampian Eating Disorder Service
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Staffing
• Consultant Psychiatrist 0.5• Psychologist 0.8• CBT therapists 3.0
– Nurses 1.6– OT 0.4– Psychologist 0.8
• Dietitian 1.0• Secretaries 1.0
?social work, general medical, junior psychiatrist
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Referral to Triage Assessment
• Referral received (usually from GP)↓
• Referral documented↓
• Clinical Meeting↓
• Referral accepted / not accepted↓
• Opt in procedure with standard letter and questionnaires↓
• Scoring of questionnaires↓
• Triage assessment clinic↓
• Suitable / unsuitable for EDS↓
• Waiting Lists for Treatment
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Assessment
• Opt in questionnaires• Risk assessment/prioritisation
– But don’t do emergency/urgent– GP and General Medical/General Psychiatric
Services• Triage Assessment
– Extended assessment– In patient assessment
• Therapy Assessment• Physical Assessment
– In abeyance
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Telelinks
• Peripheral clinics– Orkney– Shetland, Lerwick and Unst– Peterhead– Fraserburgh– Aboyne– Stonehaven– Elgin– Turriff
• Priory Hospital• Management meetings
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Treatment/Management• Individual therapy
– Maybe alongside group treatmentse.g.Self esteem, body image
• Group treatments– Bulimia group– Overeaters group
• Video therapy• Dietetic input (alongside other therapy)
– Nutritional education - 6 group sessions– Individual sessions
• Medical– Medication– Monitoring
• Family support
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Specialist Treatment Strategies• Engage the patient
Motivational Interviewing
• Psychological treatments
• Drug treatments
• Hospital admission
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Psychological TreatmentsAnorexia Nervosa
• Individual Psychotherapy OP.– continuity of care with single therapist who
can co-ordinate other aspects of treatment.– long term follow up.
• Family therapy / counselling
• Group therapy - usually an adjunct– psychoeducational /nutritional/cooking– psychodynamic / CBT
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Psychological TreatmentsBulimia Nervosa
• More effective than drug treatment
• Cognitive Behavioural Therapy (CBT)– 10 to 18 sessions of one hour (Video?)– response rates of 60-80%
• Other techniques eg Interpersonal therapy (IPT) but less available
• Individual/Group treatments
• Self help/Guided self help/Internet/CD/
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Drug treatmentAnorexia Nervosa
• No drugs affect the course of illness.• Some drugs may help particular
symptoms:– Depression - antidepressants– obsessionality – anti–obsessional drugs i.e.
clomipramine in low dose / Selective Serotonoin Reuptake Inhibitors (SSRIs)
– dietary supplements eg. calcium / oestrogen– ? Antipsychotics e.g. Olanzapine
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Drug treatmentBulimia Nervosa
• SSRI’s– direct but modest anti-bulimic effect– Fluoxetine best tested– Paroxetine and Fluvoxamine don’t work– Need high doses 60mg Fluoxetine
• Other drugs as per A.N.
• Potassium supplements if low potassium
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Hospital Admission• What are the aims?
– to save life– to treat the disorder– to relieve anxiety (doctors / patient / relatives
• Medical of Psychiatric
• Voluntary or compulsory