1. Risk Management in Eating Disorders Dr Phil Crockett

2. Risk Management Risk in Eating Disorders-Why Worry? Risk Assessment vs Risk Management The Physical, Psychological, Social Context Transitions Communication Networks and Frameworks Taking advice Summary

3. Risk in Eating Disorders-Why Worry? For A.N.: 5-30% long term mortality(Theander, Halmi(1992)) Difficulties in psychological adjustment up to 50% (Pike, 1998) Wide variation outcome-depends on study centre e.g. Korndorfer (2003), Johnson et al (2003) more benign Keski-Rahkonen, (2008): Finnish nationwide N=2880: 5yr recovery 67%

4. Risk in Eating Disorders-Why Worry? B.N. sig psychological impairment and physical morbidity AN can: –Sudden death –Cardiac failure –GI bleeds –Sepsis –Suicide »(Millar,2005)

5. Risk Assessment vs Risk Management Risk Assessment: an estimation of the likelihood of particular adverse events occurring under particular circumstances. Within a specified period of time Risk Management: organised attempts to minimise the likelihood of adverse events

6. Risk Assessment vs Risk Management Approaches to risk assessment broadly grouped into ‘clinical’ versus ‘actuarial’. The actuarial approach: clues to broad populations at risk, but informs us inadequately on the individual The clinical perspective: “individualised and contextualised assessment”, vulnerable to poor inter-rater reliability and influence of other considerations Remember the protective… Only tells you about the current situation From Feenay, A

7. Five-step structured professional judgement approach to risk management (Doyle and Duffy (2006)) Step 1: Step 2 : Step 3 : Step 4 : Step 5: Case information History, mental state, substance use, physical parameters Presence of risk factors Historical, current, contextual, physical Presence of protective factors Historical, current, contextual, physical Risk formulation Nature, severity, imminence, likelihood, risk reducing/enhancing Management plan Treatment, management, monitoring, supervision,

8. The Physical Starvation and Malnutrition Other Behaviours Co-morbidities and complications Self Harm and Suicide Re-feeding Syndrome Past history and factors

9. Re-Feeding Syndrome The major physical risk of treatment Cascade of metabolic and electrolyte changes Hypophosphataemia, hypomagnesaemia, hypokalaemia major risks Raised risk with n.g. re-feeding Very slow initiation feeding Take advice “Have you considered re-feeding syndrome”

10. The Psychological Depression Anxiety Personality Disorder Obsessionality (OCD) Hopelessness and Frustration Past history and individual factors

11. The Social Families and Friends Work and studies Home environment Professionals The In-Patient Environment The Unexpected Past history and factors

12. Context Context always important Major influence on risk for individual Major influence on judgement of risk Part of risk assessment Will alter most appropriate course of action

13. Transitions Geographical and Developmental Life cycle challenges In-patient units Travel and relocation The Scottish Ombudsmen's Report, 2006

15. Communication Ensuring care plans are a team effort Note limitations of them Liaison between areas important Patients and carers involved Recording

16. Networks For patients protective and maladaptive A way for professionals to gain guidance EDSECT MCNs Benchmarking and audit

17. Guidelines and Frameworks NICE and QIS APA Specific for context Crisis planning Consistently reviewed/revised CPA/MHA

18. Taking Advice Role of the Gastroenterologist/Physician Especially when very high risk Co-morbidities Second opinions and consultations

19. Conclusions No simple methods to quantify risk in EDs Physical/Psychological complications common including resulting from intervention Broad assessment important Principles risk assessment/management useful

20. Conclusions Developing appropriate frameworks to the context you are based in Applying the guidelines Making use of containing networks and maintain communication Take advice