Eating Disorders

Information for relatives and friends

Dr Harry Millar

• What are eating disorders?

• What are the effects on families and friends?

• What help is available?

What are Eating Disorders?

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)

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

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)

F50.2 Bulimia NervosaGreek: Bous=Ox Limos=Hunger

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

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

Fairburn CG and Harrison PJ. Lancet 2003

Symptoms • Fear of uncontrolled eating and weight gain

• Binge eating and compensatory behaviours

• Distorted body image perception, mirror gazing

Distorted Body Image

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

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

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

Effects on Families and Friends

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

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

Help for Eating Disorders

• Community, voluntary and self help

• Primary care

• Specialist care

Community/self help

• Books

• Web sites

• Support services– beat– NEEDS– NHS services– SEDIG

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

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

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

• 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

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

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

Grampian Eating Disorder Service

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

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

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

Telelinks

• Peripheral clinics– Orkney– Shetland, Lerwick and Unst– Peterhead– Fraserburgh– Aboyne– Stonehaven– Elgin– Turriff

• Priory Hospital• Management meetings

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

Specialist Treatment Strategies• Engage the patient

Motivational Interviewing

• Psychological treatments

• Drug treatments

• Hospital admission

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

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/

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

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

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

Mother of 220lbs heavier than 1966