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OVERVIEW OF EATING DISORDERS

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Title: OVERVIEW OF EATING DISORDERS


1
OVERVIEW OF EATING DISORDERS
  • Dr. Gillian Baksh
  • Monday Meeting
  • February 2011

2
USE OF TERMS
EATING DIFFICULTY
FEEDING DISORDER
EATING DISTURBANCE
EATING DISTRESS
EATING DISTURBANCE
FEEDING PROBLEM
EATING PROBLEM
FEEDING DIFFICULTY
FEEDING DISTURBANCE
EATING DISORDER
3
DIAGNOSIS AND CLASSIFICATION
  • True Eating Disorder grossly disordered or
    chaotic eating behaviour associated with morbid
    preoccupation with body weight and shape
    (irrespective of weight)
  • Eating difficulty / problem not associated with
    clinically significant functional or
    developmental impairment

4
TRUE EATING DISORDERS
  • AN
  • ? Restricting or binge-purge subtypes (DSM 1V)
  • BN
  • ? Purging and non-purging subtypes (DSM 1V)
  • Related atypical or not otherwise specified forms
  • ? EDNOS (DSM 1V)
  • ? Atypical AN and atypical BN (ICD 10)

5
OTHER EATING DISORDERS
  • Selective eating
  • Restricted / minimal eating
  • Phobia associated with limited intake
  • Functional dysphagia
  • Food avoidance emotional disorder (FAED)
  • Food refusal
  • ?Pervasive food refusal syndrome
  • Overeating associated with obesity

6
EATING DISORDERS IN CHILDREN
  • Not developmentally sensitive
  • Do not consider parental observed behaviours
  • FAED Non-fat phobic ED not classifiable in
    DSM as an ED
  • Mismatch between diagnostic categories and
    clinical presentations
  • DSM V and ICD 11

EDNOS or ATYPICAL
FAED
AN
BN
7
DSM ?V vs ICD10 CLINICAL EATING DISORDERS
  • DSM ?V (Amer Psych Assoc1994)
  • AN restricting and binge-purge subtypes
  • BN purging and non-purging subtypes
  • EDNOS (clinically severe but does not meet
    criteria for AN, BN)
  • Feeding disorder of infancy or early childhood
    (onset before 6 years)
  • Pica
  • Rumination disorder
  • ICD 10 (WHO 1992)
  • AN
  • BN
  • Atypical AN and atypical BN
  • Other
  • - Overeating associated with other psychological
    disturbances
  • - Vomiting associated with other psychological
    disturbances
  • - Other eating disorders
  • - Eating disorder, unspecified
  • Feeding disorder of infancy and childhood
  • Pica of infancy and childhood

8
ANOREXIA NERVOSA IN CHILDREN
  • First described in late 19th century
  • Defined from (6 ) 8 years
  • Weight loss at least 15 below normal weight for
    age and height
  • Weight control behaviours mainly dietary
    restriction and exercise, laxatives, vomiting
  • Older patients binge-purge (20-30 BN past
    history of AN)
  • Abnormal cognitions regarding weight and / or
    shape
  • Sometimes difficult to elicit explicit weight /
    shape psychopathology
  • Food preoccupations, guilt around eating, concern
    about eating with others, low self esteem common
  • In boys (10-25) often concern around fitness and
    health shape more than weight excessive
    exercise more common - OCD commonly associated

9
BULIMIA NERVOSA
  • Requires degree of psychological maturation
    including capacity for self evaluation often
    manifest as shame or guilt
  • Rare under 13 years
  • Abnormal cognitions regarding weight and / or
    shape
  • Can arise out of anorexia or secondary to
    repeated dieting behaviour
  • Recurrent binging and inappropriate compensatory
    behaviours occur at least x2 per week for 3
    months
  • Compensatory behaviours- purges, food
    restriction, excessive exercise
    laxative/enema/appetite suppressant misuse more
    common in older adolescents
  • Sense of lack of control chaos
  • May be associated with other teenage problem
    behaviours drinking, self harm, casual sex,
    drugs

10
DIFFERENTIAL DIAGNOSIS
Endocrine Diabetes Mellitus, Hyperthyroidism, Glucocorticoid Insufficiency
Gastrointestinal Coeliac Disease, IBD, Peptic Ulcer Disease
Oncological Lymphoma, Leukaemia,Intracranial Tumours
Infections TB
Psychiatric Depression, Conversion Disorder
11
EPIDEMIOLOGY
  • AN
  • Incidence
  • - 4.2 8.3 / 100 000 (Currin et al,Hoek et al)
  • - 40 between 14 19 years
  • - 1.2/ 100 000 hospitalised
  • Stable over time ? except young
  • Prevalence
  • - average 0.3 ( 0-0.9)
  • - 0.4 adolescent girls
  • - lifetime 1.4 2.2
  • BN
  • Incidence
  • - 6.6 13.5 / 100 000
  • More sensitive to global environmental changes -
    possibly decreasing from peak in 1990s (Currin
    et al, BJ Psych 2005)
  • Prevalence
  • - average 1 (similar to schizophrenia)
  • - lifetime 4 -7
  • 3-12 of adolescents experience some form of
    eating disorder most EDNOS (Machado 2007 Slice
    et al 2009)
  • -

12
PROGNOSIS AND OUTCOME
  • Predictors of outcome of EDs mixed results
  • Fair degree of association of morbid family
    functioning and poor prognosis in AN regardless
    of age
  • At 2 years 33 fully recovered, 27 still full
    AN (Toucan study)
  • Adolescents do slightly better than adults 75
    or more fully recover
  • Children lt 11years may do worse only 2 studies

13
RECOVERY AN
? 30
11 27
ADOLESCENT ONSET ED
ADULT ONSET ED
CHILDHOOD ONSET ED
Depression / OCD/ Other axis 1 diagnosis
Halvorsen et al 2003 Raastam et al 2003 Patton et
al 2003
14
MORTALITY
  • Mortality AN 0 22 depending on follow up
    period
  • Crude mortality 4 AN, 3.9 BN, 5.2 EDNOS
  • 3x more likely to die of a childhood or
    adolescent ED than any other causes
  • AN 12x annual death rate from all causes in 15
    24 year females (physical complications
    suicide)
  • Highest mortality (2) in the first year after
    presentation in females and in the first 2 years
    (5) after presentation in males

15
  • EATING DISORDERS ARE SERIOUS
  • AND NEED TO BE TAKEN SERIOUSLY

16
HELPFUL SITES
  • B-EAT
  • http//www.youtube.com/watch?vK5WZv8PrTRo
  • http//sites.google.com/site/marsipannini
  • www.rcpsych.ac.uk/files/pdfversion/CR162.pdf

17
GENES
  • Family studies- female relatives of someone with
    an ED are gtx4 risk of BN and gtx11 risk AN than
    someone with no family history (probably higher
    for subclinical and partial syndromes)
  • Twin studies (MZDZ concordance) AN has
    estimated heritability of 58 -76 , BN from 31
    83
  • Puberty may activate some aspect of genetic
    heritability (Klump et al)
  • A 7 increased incidence in first degree
    relatives may be related to area on chromosome 1p
    at the DF1153721 locus (Grice et al 2002)

18
BIOPSYCHOSOCIAL MODELS OF RISK AND MAINTENANCE
  • Physical and nutritional status
  • Temperament
  • Self esteem,values,personal identity
  • Emotional processing and literacy

SOCIAL
INDIVIDUAL
  • Life events
  • Peer relationships
  • Media influence

SYSTEMIC
Predisposing Precipitating Perpetuating
  • Genetic
  • Family beliefs re weight,shape,
  • eating

19
  • MALNUTRITION IS A MEDICAL EMERGENCY

20
MEDICAL COMPLICATIONS
  • Underweight
  • CVS ECG (low voltagesinus bradycardiaT wave
    inversionsST depression-electrolyte
    imbalanceprolonged QTc), dysrhythmias(SV
    ectopics, VT), pericardial effusions all
    reversible except following ipecac use
  • Growth and development pubertal and growth
    delay, 1 amenorrhoea, delayed bone mineral
    accretion
  • Dietary deficiencies calcium, vit D , folate,
    B12
  • GIT delayed gastric emptying, ?gastric motility,
    constipation, bloating, fullness, abnormal LFTs,
    hypercholesterolaemia, pancreatitis,abnormal
    LFTs(fatty infiltration)superior mesenteric
    artery syndrome all reversible
  • Renal dehydration, ?GFR, stones, polyuria, total
    body Na and K depletion peripheral edema with
    refeeding
  • Haematologic leukopoenia, anaemia,
    thrombocytopoenia, iron deficiency
  • Endocrine sick euthyroid syndrome, amenorrhoea,
    osteopoenia
  • Neurologic cortical atrophy, seizures

21
MEDICAL COMPLICATIONS
  • Purging / Binging
  • Fluid and electrolyte imbalance ?K and Na,
    hypochloremic alkalosis
  • Use of ipecac irreversible myocardial damage and
    diffuse myositis
  • Chronic vomiting esophagitis, dental erosions,
    parotitis, Mallory-Weiss tears, oesophageal or
    gastric rupture, aspiration pneumonia
  • Use of laxatives dehydration, renal stones,
    metabolic acidosis, ?Ca and Mg, ?uric acid
    withdrawal may get fluid retention (up to 4 kg in
    24 hours)
  • Amenorrhoea (may see in normal or overweight with
    BN) menstrual irregularities, osteopoenia

22
CARDIOVASCULAR
  • Cardiac death 1/3 all deaths in adults
  • Cardiac deaths unknown in paediatrics
  • ? PR- ? vagal tone, ? BMR- aim to ?cardiac
    output and preserve energy and reduce demand on
    malnourished heart
  • ? BP myocardial atrophy
  • Orthostatic changes leg and heart muscles
  • ECG electrolytes
  • Changes reversible with weight restoration
  • Caution with fluids boluses often unnecessary
    and can be dangerous

23
HISTORY
  • Detailed feeding history
  • Duration eating concerns
  • Rapidity weight loss - gt 1 kg/week serious risk
  • Current intake pattern including fluids
  • Use laxatives, diuretics etc
  • Weight / shape cognitions
  • Sleep pattern
  • Menstrual history / pubertal progression
  • Co-morbid mental illness (anxiety, phobia, OCD,
    depression)
  • Personality description from relatives
  • Suicidal ideation, DSH, overdose
  • Symptoms of hyperthyroidism, diabetes,
    malignancy, IBD, tumour etc
  • Symptoms related to complications acute and
    chronic

24
HISTORY
  • Family and social history ED , mental illness
  • Female relative of someone with an ED is gt x4
    likely to have BN and gt x11 likely to have AN
    than someone with no family history
  • Activities / exercise
  • School attendance
  • Relationships

25
MEDICAL ASSESSMENT
  • History
  • WFH / BMI
  • Temp
  • Urine
  • Examination
  • -haemodynamic stability lying / standing BP
    PR
  • -pubertal status
  • -signs of malnutrition
  • -signs of possible underlying medical condition
  • SUSS Test stand up sit up test
  • Investigations

26
EXAMINATION
  • Oversized clothes
  • Muscle wasting / lack subcutaneous fat
  • Cold extremities, cyanosis
  • Anaemia
  • Dehydration
  • Murmurs, arrythmias, weak pulse
  • Lanugo, dull thin scalp hair
  • Signs binging / purging Russells sign, palatal
    scratches / petechiae, dental erosions, parotitis
  • Signs of vitamin and mineral deficiency anaemia,
    dry/sallow skin, carotenaemia , glossitis, lip
    fissures, bleeding gums, brittle nails,
    Chvosteks sign, Trousseaus sign
  • Look for signs to help rule out possible
    underlying medical condition

27
BMI AND WEIGHT FOR HEIGHT
  • Weight loss loss fat and muscle
  • A low BMI more strongly correlated with lean
    muscle mass than fat mass (Cole et al BMJ 2007)
  • BMI
  • - Adults concern if BMI lt 17.5
  • - Adults severe malnutrition cut off BMI
    13
  • WFH Median BMI Actual BMI / Median BMI (50th
    percentile for age sex) x 100
  • WFH 100 BMI 50th centile

28
WFH
  • Be concerned if WFH lt 90 BMI lt 9th
    centile stop exercise
  • Be very concerned WFH 80 BMI lt 2nd centile
    (definition of underweight) stop school
  • Consider hospitalisation if WFH lt 75

29
DIAGNOSTIC DECISION TREE
YES
NO
YES
YES
NO
NO
NO
YES
NO
YES
YES
30
INVESTIGATIONS
  • Baseline bloods including clotting, Ca, PO4, Mg,
    HCO3, iron studies, folate, B12, Vit D, amylase,
    ESR, CRP,TFTs, lipids, glucose
  • ECG
  • Urinalysis
  • Wrist Xray - Bone age and density
  • Pelvic USS
  • Consider
  • DEXA scan
  • CXR
  • Abdominal Xray
  • MRI / CT scan
  • Autoimmune, coeliac screen
  • Cardiac ECHO
  • DONT BE FALSELY REASSURED BY NORMAL BLOOD RESULTS

31
MEDICAL TREATMENT
  • When to hospitalise / inpatient treatment?
  • Weight recovery usually 2 3 kg per month
  • Target weight WFH 95 110
  • Resumption of growth and / or menses are better
    indicators of recovery than targets

32
EDs and GUIDELINES/ EVIDENCE BASE
  • Clinical guidelines (e.g. NICE 2004) mostly based
    on consensus views
  • NICE guidelines developed to advise on the
    identification, treatment and management of AN,
    BN, and related conditions in those 8 years and
    over
  • EDNOS may not be same as in adults
  • Guidelines do not cover other eating disturbances
  • Evidence for effectiveness of treatments weak
    across age range (5RCT 3 AN, 2 BN)
  • No large scale randomised controlled drug trials
    for AN
  • MARSIPAN (2010) and Junior MARSIPAN(2011)
  • http//www.rcpsych.ac.uk/files/pdfversion/CR162.p
    df
  • Nicholls D, Hudson L, Mohamed f. Arch Dis Child.
    2010 Oct 7. (Epub) Managing anorexia nervosa

33
INPATIENT TREATMANT
  • 1 in 4 AN will be hospitalised
  • The need for inpatient treatment for AN and the
    need for urgent weight restoration should be
    balanced alongside the educational and social
    needs of the young person (NICE)
  • Admit locally and in age appropriate setting
    (NICE)
  • Do not isolate
  • Attend school

34
INDICATIONS FOR HOSPITALISATION IN AN ADOLESCENT
WITH AN EATING DISORDER (Society for Adolescent
Medicine position paper Dec 2003)
  • One or more of the following
  • Wt for ht 75
  • Dehydration
  • Electrolyte disturbance (hypokalaemia,
    hyponatremia, hypophosphataemia, hypomagnesemia)
  • Cardiac dysrhythmia
  • Physiological instability
  • Severe bradycardia (lt 50 b/min day lt 45 b/min
    night)
  • Hypotension (lt 80/50 mm Hg)
  • Hypothermia (lt 35 C)

35
INDICATIONS FOR HOSPITALISATION IN AN ADOLESCENT
WITH AN EATING DISORDER (Society for Adolescent
Medicine position paper Dec 2003)
  • Orthostatic changes in pulse (?gt 20 b/min) or ?
    BP (gt 10 mm Hg systolic) from lying to standing
  • Arrested growth and development
  • Failure of outpatient treatment
  • Acute food refusal
  • Uncontrollable binging and purging
  • Acute medical complications of malnutrition (
    e.g. syncope, seizures, cardiac failure,
    pancreatitis etc.)
  • Acute psychiatric emergencies (e.g. suicidal
    ideation, acute psychosis)
  • Co-morbid diagnosis that interferes with the
    treatment of the eating disorder (e.g. severe
    depression, OCD, severe family dysfunction)

36
MEDICAL INPATIENT TREATMENT
  • Difference between stabilisation and refeeding
  • Food medicine therefore need to be helped to eat
  • Support for nurses
  • Admission may give the wrong message to patient
    and family
  • Autistic spectrum disorder patients fare badly
    when admitted
  • Studies on outcome following admission patients
    admitted are very ill or dont do very well

37
REFEEDING
  • Parents helped to take responsibility
  • Establish parental control of food and fluid
    intake
  • Patient encouraged to negotiate the how of food
    intake and not the whether
  • Consistency of approach

38
REFEEDING
  • Aim for 0.5 -1.0 kg weight gain per week
  • At least 500 1000 Kcals above basic requirement
  • Inpatients may need 3000 Kcals /d
  • Start at 15 20 Kcal/kg/d
  • Avoid underfeeding syndrome
  • NICE refeeding is a necessary component but is
    not sufficient
  • - refeeding against the will of a patient is a
    highly specialised procedure requiring expertise
    Mental Health Act 1983, Children Act 1989,
    (Mental Capacity Act 2007)

39
REFEEDING SYNDROME
  • Oral, enteral, parenteral route
  • Refeeding ? insulin surge ? extracellular to
    intracellular phosphate, magnesium, potassium,
    glucose, water
  • Cardiovascular, neurologic, haematologic
    complications
  • Can cause prolonged QTc or variable QTc
  • Can be associated with significant morbidity and
    mortality
  • Usuallly 4-6 days after refeeding started
  • Highest risk WfH lt75, BMI lt 13,laxative use,
    diabetics, too rapid feeding, abnormal
    electrolytes (Glucose, Na, K, PO4, Ca at start)
  • Start Thiamine 50 200mg bd (necessary for
    utilisation glucose in Krebs cycle)
  • Daily bloods and ECG for 1 week then alternate
    days for 1 week
  • Daily physical assessments and weights

40
INPATIENT TREATMENT - AN
  • Short term
  • Physical evaluation and stabilisation
  • Reestablishment of food intake
  • Risk assessment
  • Relief of patient, parent, professional anxiety
  • Assessment of treatment needs
  • Long term
  • Establish healthy body weight
  • Identify and manage emotions
  • Develop new coping skills
  • Develop communication skills
  • Develop peer relationships
  • Learn to use help
  • Reintegrate to home or other environment

41
INPATIENT TREATMENT - BN
  • Not used in adults as a rule
  • Means of breaking cycles of binge / purge and
    establishing regular eating patterns
  • Related to risks of other self-harming behaviours
  • Related to severity of other co-morbid illness

42
PSYCHOLOGY
  • AN
  • Avoidance, anxiety, obsessionality
  • Vicious circle of restraint
  • Need for control is central
  • Egosyntonic rarely seek voluntary treatment
  • BN
  • Impulsivity, emotionality, chaos
  • Vicious circle of failed restraint
  • Need for control is central
  • Depressed by behaviour
  • Egodystonic more motivated but ambivalent about
    weight gain

43
PHYSICAL EFFECTS OF AN ON BRAIN
  • Cortical atrophy and ventricular enlargement
  • Secondary to starvation
  • Reverse with restoration of adequate nutrition

44
FUNCTIONAL EFFECTS OF AN ON BRAIN
  • Significantly reduced activity in antero-medial
    temporal region (insula)
  • Correlates with neuropsychological findings
  • Does not correlate with BMI, mood, length of
    illness nor cerebral dominance
  • No reversal with nutritional restoration
  • Gordon et al 1997, Chowdhury et al 2003, Key et
    al 2004, Lask et al 2005, Agrawal and Lask 2009,
    Brewerton et al 2009, Frampton et al 2010

45
FUNCTIONS OF THE INSULA
  • Regulates the ANS (anxiety)
  • Regulates appetite and eating
  • Monitors the gut (sense of fullness / emptiness)
  • Monitors body image
  • Reception, perception and integration of taste
  • Perception and integration of disgust
  • Perception of pain
  • Integrates thoughts and feelings
  • Awarenass of illness
  • Social awarenaee
  • Global processing
  • Motivation

46
BRAIN FUNCTION IN AN
UNLIKELY THAT EACH OF THESE IS NOT FUNCTIONING
CORRECTLY
47
THERAPY
  • Family therapy
  • - family members including siblings should
    normally be included in the treatment of children
    and adolescents with EDs (NICE)
  • Multi- family therapy
  • Individual therapy
  • - child should be offered individual sessions
    with professional separate from family worker
    (NICE)
  • Adolescent focussed therapy
  • Interpersonal therapy
  • Directed behaviour therapy
  • Group therapy
  • CBT
  • - adolescents with BN may be treated with CBT,
    adapted as needed to suit their age,
    circumstances and level of development (NICE)
  • - some suggest if WFH lt 80 should avoid
  • Motivational enhancement therapy
  • Cognitive remediation therapy focuses on the
    process (how) rather than the content (what) of
    thought and perception

48
PARENTS
  • Sense of guilt, self-blame
  • Sense of failure
  • Mistrust for professionals
  • May reject child in response to ED
  • View ED as a personal attack on them as parents
  • No empirical evidence to suggest that families
    cause EDs, but no doubt that families becomes
    dysfunctional in response to ED
  • Engaging parents as important as engaging child

49
THERAPY
DOCTOR
Parent patient relieved of anxiety Patient
relieved of internal conflict Reinforces
parents sense of failure
PARENT
PATIENT
50
LONG TERM PHYSICAL SEQUELAE
  • Growth
  • Bone density
  • Puberty

51
GROWTH
  • Important in boys and prepubertal girls
  • Slows / stops in starvation
  • No weight gain weight loss
  • Catch-up growth- may be first sign of a healthy
    weight
  • The dose of starvation needed to have a
    permanent effect on height is 4 years before
    completion of growth

52
LINEAR GROWTH
  • Retardation may be related to
  • - ? T4, T3
  • - ? cortisol
  • - ? sex hormones
  • - relative resistance to GH
  • Catch up growth with weight restoration
  • Variable reports of effect on final height versus
    height potential

53
BONE MINERAL DENSITY
  • Changes start early in disease
  • Impaired bone formation and increased absorption
  • Factors low oestrogen IGF1
  • high cortisol
  • poor nutrition, low BMI
  • low Ca and Vit D
  • Greatest risk gt 12 months onset AN
  • gt 6months amenorrhoea
  • low BMI
  • low Ca intake
  • low physical activity (Castro et al 2000)

54
BONE DENSITY
  • Mainstay treatment weight gain, nutritional
    rehabilitation, spontaneous resumption menses
  • Oestrogen administration should not be used to
    treat bone density problems in children and
    adolescents as this may lead to premature fusion
    of the epiphyses (NICE)
  • Ca and Vit D supplements may be prescribed
  • Full recovery unlikely osteopoenia in 1/3
    recovered AN
  • Long term fracture risk around x3 x7 of general
    population

55
PUBERTY
  • Menses
  • Clearest marker of adequate endocrine function
  • Pubertal delay / arrest almost inevitable with
    WFH lt 90
  • Pelvic USS more sensitive than other hormone
    markers and not susceptible to diurnal variation
  • - regression in size uterus and ovarian activity
  • - experienced ultrasonographer
  • - can be used to guide weight restoration and
    determine onset of menses
  • No use in boys!
  • May not return until 6 months after achieving
    appropriate weight (about 95 WFH)

56
OUTCOME
  • Response to treatment difficult to distinguish
    from natural course as treatment almost
    invariably ensues and limited on untreated cases
  • Remission
  • Recovery
  • Remission and recovery similar for AN since
    relapse rare

57
PROGNOSIS AND OUTCOME
  • Predictors of outcome of EDs mixed results
  • Fair degree of association of morbid family
    functioning and poor prognosis in AN regardless
    of age
  • At 2 years 33 fully recovered, 27 still full
    AN (Toucan study)
  • Adolescents do slightly better than adults 75
    or more fully recover
  • Children lt 11years may do worse only 2 studies

58
POOR OUTCOME
  • Continuing illness associated with functional
    impairment or death
  • Lower body fat at presentation (Mayer et al. Am J
    Psych 2007)
  • Longer duration illness
  • Hospitalised (Gowers et al. B J Psych 2007)
  • Readmitted (up to 45) (Steinhausen 2007)

59
MORTALITY
  • Mortality AN 0 22 depending on follow up
    period
  • Crude mortality 4 AN, 3.9 BN, 5.2 EDNOS
  • 3x more likely to die of a childhood or
    adolescent ED than any other causes
  • AN 12x annual death rate from all causes in 15
    24 year females (physical complications
    suicide)
  • Highest mortality (2) in the first year after
    presentation in females and in the first 2 years
    (5) after presentation in males

60
HELPFUL SITES
  • B-EAT
  • http//www.youtube.com/watch?vK5WZv8PrTRo
  • http//sites.google.com/site/marsipannini
  • www.rcpsych.ac.uk/files/pdfversion/CR162.pdf
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