EATING DISORDERS Dr Jessica Morgan Consultant Psychiatrist

Characterised by an unhealthy and distorted attitude towards eating, shape and weight. Three main diagnostic groups: Anorexia Nervosa (AN) Bulimia Nervosa (BN) Eating Disorder Not Otherwise Specified (EDNOS) AN and BN basically distinguished by the patient’s weight.

DIAGNOSTIC CRITERIA FOR AN (ICD-10) BMI  17.5kg/m 2 Weight loss self induced Body image distortion Fear of fatness Drive for thinness Self esteem largely determined by shape and weight Body image misperception Amenorrhoea In DSM IV further subdivided into: Restricting type Binge eating/purging type

DIAGNOSTIC CRITERIA FOR BN (ICD-10) Fear of fatness Craving Bingeing Purging In DSM IV further subdivided into: Purging type Non-purging type

EPIDEMIOLOGY ANBN Point Prevalence0.28%1-2% Incidence per 100, per year Over representation ofFashion modelsFemales Ballet dancers Females (10:1)

AETIOLOGY SUGGESTED RISK FACTORS ANBN  Social Class INoFemale Personality Traits  Self esteem  Self esteem PerfectionisticImpulsive ObsessionalityBorderlineFH of affective Dx Sexual abuseSexual abuse ++ Genetic (MZ:DZ=10:1)Genetic  Premorbid weight

AETIOLOGY: MAINTAINING FACTORS AN Praise (early stages) Family dysfunction (later stages) Starvation syndrome Physical Psychological Depressive Symptoms   self-esteem further

AETIOLOGY: MAINTAINING FACTORS BN Negative self-evaluation Characteristic extreme concerns about shape and weight Intense and rigid dieting Binge eating Negative affect Self-induced vomiting/laxative misuse Perfectionism and dichotomous thinking Perfectionism and dichotomous thinking

PHYSICAL SIGNS AN Emaciated Dry skin Lanugo hair Cold and blue extremities Ankle oedema  BP  Pulse  Temperature Dehydration BN Russels sign Parotid swelling Erosion of tooth enamel

LABORATORY ABNORMALITIES FOUND IN ANOREXIA NERVOSA Metabolic Metabolic alkalosis Hypokalaemia Elevated plasma amylase Hypercholesterolaemia Haematological Leucopenia Relative lymphocytosis Endocrine Low plasma gonadotrophins Low plasma gonadal steroids Elevated plasma growth hormone Low plasma triiodothyronine Elevated plasma cortisol

MEDICAL COMPLICATIONS OF ANOREXIA NERVOSA Cardiovascular Bradycardia Hypotension Cardiac arrhythmias Oedema Cardiac Failure Neurological Seizures Metabolic Hypoglycaemia Dehydration Tetany Dental Erosion of enamel Caries Gastrointestinal Salivary gland enlargement Delayed gastric emptying Acute gastric dilatation Superior mesenteric artery syndrome Constipation Acute Pancreatitis Endocrine Amenorrhoea Skeletal Reduced growth Osteoporosis and pathological fractures Other Hypothermia

PROGNOSIS (10 year FU after clinical referral) ANBN Death10%  1% Persisting index disorder10%10% Subthreshold disorder15%20% Crossover15%  1% No clinical ED50%70% Poor prognosis indicators: Longer duration of illness Previous treatment Lower minimum weight Personality and social difficulties Distorted family relationships Purging subtype Later age of onset Comorbidity

MANAGEMENT AN Principles: To restore weight and healthy eating habits and reverse the maintaining factors. engagement education Components:dietary advice individual therapy family therapy

TREATMENT SETTING IP treatment if:physically unwell rapid weight loss depressed and suicidal failure of outpatient treatment

Name: ____________________________________________ Date: _____________________________________________ Professor Janet Treasure – Consultant Eating Disorders Unit Bethlem Royal Hospital © KEY: – NORMAL WEIGHT RANGE – UNDERWEIGHT: Irregular or absent menstruation. Ovulation failure – ANOREXIA NERVOSA: Amenorrhoea. Loss of substance from all body organs and structure – 15 SEVERE ANOREXIA NERVOSA: All organ systems compromised; bone; heart; muscle; brain. Metabolism reduced by 50% – CRITICAL ANOREXIA NERVOSA. Inpatient treatment recommended. Organs begin to fail: muscle; bone marrow; heart. <12 – LIFE THREATENING ANOREXIA NERVOSA

Motivational Enhancement Therapy Supportive Therapy CBT and others Family Therapy Pharmacotherapy Self Help

MANAGEMENT BN PsychotherapiesCBT, IPT Pharmacotherapy Self-helpBased on CBT Group