EATING DISORDERS IN PRIMARY CARE

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EATING DISORDERS IN PRIMARY CARE

• Dr Nicki Mazey

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Overview

• Statistics
• Diagnostic criteria
• ED presentation
• Complications
• Primary Care Management
• Questions/Case studies

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Lies damn lies and statistics(Oscar Wilde) AN

• 20 to 50 recover
• 30 to 60 improve but retain partial symptoms
• 20 remain severely disturbed
• 220 die in the UK each year.
• ¼ to ½ deaths from suicide.
• 200 x general population suicide risk
• Increasing in men
• present at 14-18 years
• 5 years average before presenting
• Approx 2 per GP list
• Admission worsens prognosis

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Statistics Bulimia

• Incidence 11.5/100,000 but likely higher.
• Cities 5 rural 1
• High relapse rate
• Treatment impact may disappear after 5 years
• 20 per average GP list
• 70 women SIV

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Types of Eating Disorder

• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Atypical Eating Disorder / Eating disorder not
  otherwise specified (EDNOS)
• Obesity

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Think in terms of behaviours rather than ICD 10
classifications

• Restricting
• Bingeing
• Vomiting
• Over exercising
• Laxative abuse
• Diuretic abuse

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ED Presentation

• Friends
• Tutors
• Family
• Physical symptoms
• Psychological symptoms (depression/OCD)
• Infertility/period problems

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Complications of low weight/restrictive eating

• CVS
• GIT
• Endocrine
• Skin/hair
• Renal
• haematological
• Musculoskeletal
• METABOLIC
• Immunological
• Neurological

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Complications of SIV

• Mechanical
• Chemical
• Metabolic K, Na, dehydration
• Other

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Complications of Bingeing/Diuretics/Laxatives

• Binges
• Diuretics
• Hypokalaemia (same as for SIV)
• Hyponatraemia (same as for SIV)
• Hypomagnesaemia
• Laxatives
• Physical effects (SIV)
• Metabolic effects (SIV plus metabolic
  acidosis)
• Other effects

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Management Rules/Roles in Primary Care (hands in
the air)

• Rules
• Roles

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Nickis Rules (but you can borrow them)

• Engage the patient
• Continuity of care
• Think in terms of behaviours
• Honest reporting encouraged
• Avoid
• a. crises
• b. therapising
• c. splitting
• d. labels until appropriate
• e. displaying anxiety

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more Rules

• Put things into perspective (70 SI vomiting)
• Accept failures inevitable
• Define your role with the patient
• Take the goggles off (other illnessess/problems
  aside from the all consuming ED)
• Dont refer to their appearance looking well
  gained weight healthy looking etc.. at
  reviews.
• Cover your backside
• Regular reviews/ pragmatic clear path
• Co-ordinate care/links with other services

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just a couple of teensy weensy rules

• Medical complications should be directly
  proportional to severity of behaviours
• Beware Munchausens as an ED presentation
• Child protection
• Any suggestions?????

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Primary Care Roles
Co-ordination of care
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History

• Assessment need to invest time
• Reviews make regular at appropriate intervals and
  purposeful, short consulting time.
• Ask about onset/frequency/triggers etc..
• Restricting
• Vomiting
• Laxatives
• Diuretics
• Binges
• Exercising for weight loss
• Self harming
• Suicidal thinking
• Course/work issues
• Support at University.
• Medical problems.

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Examination

• As appropriate. Take the goggles off
• CVS focus in AN
• Often negative
• Russells sign

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Investigations

• As per behaviours. FBC UE TFT Glucose
• ECG if bradycardia, prolonged QT interval.
• BMD scan

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Restrictive eating/drinking

• Hx fluids
• Exam CVS focus
• Ix bloods/BMD/ECG
• Mx define role agree initial path/review
  frequency/referral/monitor with changes/minimise
  risk P.I.L (hair loss).
• Multidisciplinary

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Vomiting/laxatives/diuretics/exercise

• Vomiting frequency/notify when changes/baseline
  Ix/PIL/dental advice/common.
• Laxatives. Waste of time, wean gradually weeks.
  Rectal prolapse!
• Diuretics. Waste of time, wean and monitor.
• Exercise. Medical dilemma good or bad.

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Binge eating

• Hx. Meals regular??Frequency, triggers, duration,
  compensatory purging or not. Indirect
  Questioning.
• Exam. Nil
• Ix Nil
• Mx meals/distract/company/fluoxetine.PIL.

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Referrals

• Specialist Eating Disorders Psychotherapist
• Psychiatry
• Dentist
• University support systems (welfare/sick
  notes/deferring courses)
• Secondary care for medical complications
• Inpatient psychotherapy

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Education

• No shock tactics
• P.I.L.
• Crisis team access explanation
• Contracts with friends/family
• Laxatives (waste of time wean off)
• Binges (avoid with regular meals and company)
• Vomiting (no brushing and 1hr company)

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Summary

• GP role Monitoring, Education and Referral.
• Guide through clear agreed path
• Continuity of care
• Sick notes/deferring courses
• Liaising with services
• Engage in regular purposeful review

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Keeping up with Uni Course Support needed? Notes
needed? Supervision Deferring

• Take the goggles off
• Dont insist on label until
• appropriate
• Avoid duplicating
• Verbalising anxiety to pt may
• Facilitate escalation
• Inhibit them

Self harming
Abuse
Suicide risk
Depression
Emotional
Personality Disorder
Do ask how they feel Dont say Youve gained
weight or you look well
Ix
Physical exam
hx
BP /Pulse /ECG /Bloods Bone density

• Uni/support systems
• Welfare
• Mental health
• Counselling
• Specialist
• psychotherapy

No shock tactics!
Professional meetings
Co-ordination of care
Crisis team access
Complications
P.I.Ls
Dentist
Laxatives

• Honest reporting
• Co-ordinate care
• Avoid therapising
• Avoid crises
• Avoid splitting
• Define your role to patient
• Continuity of care VIP
• Big up local services!
• Support them
• Cover your backside

Psychiatrist

• Aims
• Use behaviour descriptions
• Review regularly rather than responding to crisis
• Sick notes / fitness to practice
• Good communication with team
• Perspective lots of eating behaviours
• Accept that you cant fix all behaviour

Waste of time Wean off slowly
2o care medical admission
Avoid binges
3o Care
Regular meals Company
In-patient EDS
Avoid vomiting
Psychotherapy
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Questions / Case Studies / More rules.?