Eating Disorders MRCPsych Course Central Lancashire Eating Disorders Service Dr Karen Seal

Aim and Objectives 0 Eating disorders in ICD-10 0 Explore the continuum of eating disorders (EDs) highlighting recent changes in DSM 5 0 Consider potential factors related to identifying and treating people with EDs in the community and managing risk, eating disorder in pregnancy. 0 Highlight evidence based treatments & guidelines 0 Role of GPs 0 Discussion

ICD10 Eating Disorders CodeDisorder F50.0Anorexia Nervosa F50.1Atypical anorexia nervosa F50.2Bulimia nervosa F50.3Atypical bulimia nervosa F50.4Overeating associated with other psychological disturbances F50.5Vomiting associated with other psychological disturbances F50.8Other eating disorders F50.9Eating disorder, unspecified

Anorexia nervosa, F50.0 Criteria AWeight loss, or in children a lack of weight gain, leading to a body weight of at least 15% below the normal or expected weight for age and height BThe weight loss is self-induced by avoidance of "fattening foods". CA self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold. DA widespread endocrine disorder involving the hypothalamic-pituitary- gonadal axis, manifest in the female as amenorrhoea, and in the male as a loss of sexual interest and potency (an apparent exception is the persistence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill). EDoes not meet criteria A and B of Bulimia nervosa (F50.2).

Bulimia nervosa, F50.2 Criteria ARecurrent episodes of overeating (at least two times per week over a period of three months) in which large amounts of food are consumed in short periods of time. BPersistent preoccupation with eating and a strong desire or a sense of compulsion to eat (craving). CThe patient attempts to counteract the fattening effects of food by one or more of the following: (1)self-induced vomiting (2)self-induced purging (3) alternating periods of starvation (4)use of drugs such as appetite suppressants, thyroid preparations or diuretics. When bulimia occurs in diabetic patients they may choose to neglect their insulin treatment. DA self-perception of being too fat, with an intrusive dread of fatness (usually leading to underweight)

DSM 5 changes (2013) 0 Previously DSM-IV defined three categories of ED: anorexia nervosa (AN), bulimia nervosa (BN) and eating disorder not otherwise specified (EDNOS) 0 An aim of revisions was to reduce the number of cases of EDNOS and get more specific diagnosis 0 In DSM-IV, Binge-eating disorder was not recognized as a disorder, but rather described in Appendix B: Criteria Sets and Axes Provided for Further Study and was diagnosable using only the catch-all category of “eating disorder not otherwise specified” 0 On-going debate about the adequacy of DSM-5 criteria for AN for diagnosis in children and adolescents 0 DSM 5 (2013) substantial changes include: recognition of binge eating disorder (BED), revisions to the diagnostic criteria for anorexia nervosa (AN) and bulimia nervosa (BN), the inclusion of pica, rumination and avoidant/restrictive food intake disorder

DSM 5 changes Anorexia Nervosa (AN) 0 AN is characterized by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat 0 Children and adolescents(C&As) may not present with distorted body image 0 Criterion A (AN) focuses on behaviours, like restricting calorie intake, and no longer includes the word “refusal” in terms of weight maintenance since that implies intention on the part of the patient and can be difficult to assess 0 The DSM-IV Criterion D requiring amenorrhea, or the absence of at least three menstrual cycles is removed from DSM 5 as this cannot be applied to males, pre-menarchal females, females taking oral contraceptives and post-menopausal females

DSM 5 changes Bulimia Nervosa (BN) 0 BN is characterized by frequent episodes of binge eating followed by inappropriate behaviours such as self-induced vomiting to avoid weight gain 0 Binge eating may be absent in some young people living with parents/carers due to lack of access to binge foods 0 DSM-5 criteria reduces the frequency of binge eating and compensatory behaviours that people with bulimia nervosa must exhibit, to once a week from twice weekly as specified in DSM-IV 0 Young people may not engage in typical purging and other compensatory behaviours due to lack of access to laxatives, diuretics and diet pills (e.g. T5s)

DSM 5 Binge Eating Disorder (BED) 0 Binge eating disorder is defined in DSM 5 as recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control 0 Someone with binge eating disorder may eat very quickly, even when he or she is not hungry. 0 The person may have feelings of guilt, embarrassment, or disgust and may binge eat alone to hide the behaviour. 0 This disorder is associated with marked distress and occurs, on average, at least once a week over three months.

DSM changes: Avoidant/Restrictive Food Intake Disorder 0 Significant loss of weight (or failure to achieve expected weight gain or faltering growth in children). 0 Significant nutritional deficiency 0 Dependence on enteral feeding or oral nutritional supplements 0 Marked interference with psychosocial functioning 0 The behaviour is not better explained by lack of available food or by an associated culturally sanctioned practice 0 The behaviour does not occur exclusively during the course of AN, BN and there is no evidence of a disturbance in the way one’s body weight or shape is experienced 0 The eating disturbance is not attributed to a medical condition, or better explained by another mental health disorder 0 When is does occur in the presence of another condition/disorder, the behaviour exceeds what is usually associated, and warrants additional clinical attention.

DSM 5 changes: Rumination Disorder 0 Repeated regurgitation of food for a period of at least one month 0 Regurgitated food may be re-chewed, re-swallowed, or spit out 0 The repeated regurgitation is not due to a medication condition (e.g. gastrointestinal condition) 0 The behaviour does not occur exclusively in the course of AN, BN, BED, or Avoidant/Restrictive Food Intake disorder 0 If occurring in the presence of another mental disorder (e.g. intellectual developmental disorder), it is severe enough to warrant independent clinical attention.

Other Specified Feeding or Eating Disorder (OSFED) Feeding or eating behaviours that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders 0 Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range. 0 Binge Eating Disorder (of low frequency and/or limited duration): All of the criteria for BED are met, except at a lower frequency and/or for less than three months. 0 Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate compensatory behaviour occurs at a lower frequency and/or for less than three months. 0 Purging Disorder: Recurrent purging behaviour to influence weight or shape in the absence of binge eating 0 Night Eating Syndrome: Recurrent episodes of night eating; eating after awakening from sleep, or by excessive food consumption after the evening meal. The behaviour is not better explained by environmental influences or social norms. The behaviour causes significant distress/impairment. The behaviour is not better explained by another mental health disorder (e.g. BED)

Severe and Ensuring Eating Disorders (SEED) A recovery orientated approach: “ Seeing people beyond their problems…valuing their abilities, possibilities, interests and dreams and recovering the social roles and relationships that give their lives value and meaning,” (Slade, 2010)

Complex causes

Early physical illness as a risk factor for developing an ED 0 Physical illness (Watkins, Sutton, & Lask, 2001) 0 Prior to onset of AN, C&As are more likely to have suffered one or more physical illness 0 Physical illness damages the body and can damage sense of self (Danman & deGroot, 1983) 0 Physical illness may act as a trigger or exacerbate eating pathology 0 No significant differences have been found between alimentary and non -alimentary illnesses (Patton et al., 1986) 0 Trauma e.g. car accident

Considering Risk 0 People with eating disorders, in particular those with AN are at high risk in terms of their own health and safety 0 They have the highest mortality of any psychiatric illness others is less of a concern 0 Both their physical state and suicidal behaviours contribute to this risk. 0 Risk to others is usually less of a concern, although there could be potential safeguarding concerns related to pregnant women 0 The factors involved in the assessment of risk in people with eating disorders include: medical risk psychological risk psychosocial risk insight/capacity and motivation.

Medical Risk 0 The medical risk arises from a combination of the restrictive behaviours (food and in some cases fluid) and the compensatory behaviours 0 Features in history that indicate medical risk are: excess exercise with low weight blood in vomit inadequate fluid intake in combination with poor eating rapid weight loss factors which disrupt ritualised eating habits (journey/ holiday/exam)

Psychopharmacology 0 No medication is used in the first-line treatment of AN or BN 0 Appropriate drugs may be effective in the treatment of co-morbid conditions such as anxiety and depression 0 In AN symptoms of depression and obsessive compulsive disorder often resolve with weight restoration 0 Fluoxetine may be prescribed to weight-restored adolescents with AN and supplementary vitamins, folate, zinc and calcium can be used 0 In adults there have been increasing case reports and retrospective studies on the use of atypical antipsychotics such as olanzapine; however given the risks of metabolic syndrome in young people short trial of risperidone may be more appropriate where there is significant psychological rigidity and anxiety in treatment-resistant young people 0 Risks of cardiac arrhythmias with these drugs necessitates regular ECG monitoring and often these drugs are not given until normal weight is restored

Eating disorders and pregnancy

 ED may first be disclosed/diagnosed during pregnancy or conversely may go unrecognised, potentially presenting significant risk of complication  As the average woman gains between pounds during pregnancy, changes in body shape can amplify anxiety in woman with EDs magnifying eating difficulties  Guilt associated with eating  Disgust at weight gain and associated shame  Amplification of other mental health difficulties e.g. OCD, depression, anxiety  Conversely pregnancy may motivate positive change

Pregnancy: perceived loss of control  Because of the shame and secrecy often associated with EDs they can go unrecognized by health care providers  Less than half of obstetricians ask about body weight control or disordered eating  Only 45% of people with EDs seek treatment themselves  Women EDs are often intensely ashamed of ED behaviours and can feel terrified of losing control without their coping behaviours  Pregnancy for a woman with an ED can be terrifying as they may feel as if they have lost of control over their body, their ability to control their weight, and their perceived ability to control their own life

Kings College Guidance 0 BMI 0 Blood pressure and pulse rate, lying and standing 0 Muscle strength 0 Examination of the skin and temperature for those at high risk for dryness 0 A full physical examination looking for e.g. infection (note can be with normal temperature) and signs of nutritional deficiency

NICE Guidelines: Evidenced based practice 0 GP medical assessment and monitoring (including ECG) 0 Motivational interviewing 0 CBT 0 Cognitive analytic therapy (CAT) 0 Compassion Focused therapy (CFT) 0 Family therapy 0 Group therapy 0 1:1 0 Dietary support: meal planning and preparation 0 Supported eating 0 Consultancy, including training seminars about EDs e.g. for midwives, practice nurses

GP and eating disorders GPs play a pivotal role in both primary and secondary prevention of eating disorders 0 Early detection 0 Initial evaluation 0 Referral 0 Preventing progression 0 Preventing chronicity 0 Identification and treatment of medical complications 0 Provision of nutritional rehabilitation

Questions & Discussion

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