Eating Disorders Dr Jackie Hoare Liaison Psychiatry GSH

Eating Disorders Dr Jackie Hoare Liaison Psychiatry GSH

Anorexia nervosa (AN) �is an illness characterised by extreme concern about body weight �with serious disturbances in eating behavior �leading to a self-imposed starvation state �Severe weight loss. �Body image becomes the predominant measure of self -worth �denial of the seriousness of the illness.

International Classification of Diseases, revision 10 (ICD-10) (WHO 1992), �(a) refusal to maintain weight within the normal range for height and age � (b) fear of weight gain; �(c) body image disturbance �(d) absence of menstrual cycles or �amenorrhea in women (and loss of sexual interest in men).

Important Changes in Eating Disorder Diagnoses in DSM-V �Criterion A focuses on behaviors, like restricting calorie intake �But no longer includes the word ‘refusal’ �in terms of weight maintenance since that implies intention on the part of the patient �The DSM-IV Criterion requiring amenorrhea, is deleted. �This criterion cannot be applied to males, children, OC, and post-menopausal females. �exhibit all other symptoms and signs of anorexia nervosa but still report some menstrual activity

DSM V �All 3 of the following: �Energy restriction leading to significantly low body weight �Fear of weight gain or behavior interfering with weight gain �Disturbance in self perceived weight or shape

Subtypes and severity �Restricting type �Binge eating /purging type; recurrent episodes of bingeing or purging in the last 3 months �Mild BMI>17 kg/m 2 �Moderate 16 -16. 9 �Severe 15 -15. 9 �Extreme <15

General guidance �Few controlled trials to guide treatment �Weight restoration, family therapy and structured psychotherapy �Improve nutritional health – refeeding �Drugs can be used to treat co-morbid conditions �Limited role in weight restoration �Phosphate, K+, thiamine, Mg, Ca 2+ supplementation in oral form

Refeeding syndrome �Can occur in any individual who has had negligible nutrient intake for >5 consecutive days �occurs within four days of starting to feed �develop fluid and electrolyte disturbances �results in a decrease in the serum levels of phosphate, potassium, and magnesium, all of which are already depleted. �Causing cardiac arrhythmia, respiratory failure, neuromuscular junction conduction failure

Starvation � hormonal and metabolic changes are aimed at preventing protein and muscle breakdown. � use fatty acids as the main energy source. � increase in blood levels of ketone bodies � brain to switch from glucose to ketone bodies as its main energy source. � The liver decreases its rate of gluconeogenesis, thus preserving muscle protein. � several intracellular minerals become severely depleted � serum concentrations of these minerals (including phosphate) may remain normal. � reduction in renal excretion.

Refeeding � During refeeding, glycaemia leads to increased insulin and decreased secretion of glucagon. � Insulin stimulates glycogen, fat, and protein synthesis. � Insulin stimulates the absorption of potassium into the cells through the sodium-potassium ATPase symporter, which also transports glucose into the cells. � Magnesium and phosphate are also taken up into the cells. � Water follows by osmosis. � These processes result in a decrease in the serum levels of phosphate, potassium, and magnesium � The clinical features of the refeeding syndrome occur as a result of the functional deficits of these electrolytes and the rapid change in basal metabolic rate.

Treatment � Refeeding syndrome can be fatal if not recognized and treated properly. � An awareness of the condition and a high index of suspicion are required in order to make the diagnosis. � The electrolyte disturbances can occur within the first few days � Close monitoring of blood biochemistry is therefore necessary in the early refeeding period. � rate of feeding should be slowed down and essential electrolytes should be replenished. � Fluid repletion should be carefully controlled to avoid fluid overload

Osteoporosis �Bone loss complication serious consequences �Hormonal treatment with oestrogen or dehydroepiandrosterone (DHEA) no positive effect on bone density �Oestrogen not recommended in children and adolescents – risk premature fusion of bones

Acute illness: antidepressants � 2009 Cochrane review: no evidence from 4 placebo controlled trials �On weight gain, eating disorder or associated psychopathology �Suggested neurochemical abnormalities in starvation may explain non-response �Co-prescribing supplementation incl. tryptophan with fluoxetine does not increase efficacy

Other psychotropic drugs �Olanzapine, benzodiazepines or promethazine to reduce anxiety with refeeding � 1 RCT showed 88% of patients given olanzapine achieved weight restoration (55% placebo) �Quetiapine may improve psychological symptoms but few data

Relapse prevention and co-morbid disorders �Small trial suggested that fluoxetine useful in improving outcome and preventing relapse after weight restoration �Other studies found no benefit �Antidepressants often used to treat co-morbid depression and OCD �However these conditions may resolve with weight gain alone

Avoidant/restrictive food intake disorder �Significant disturbance in eating manifested by persistent failure to meet nutritional/energy requirement associated with 1 of: �Significant weight loss �Significant nutritional deficiency �Dependence on enteral feeding or supplements �Interference with psychosocial functioning �NOT due to lack of food or body image disturbance

Clinically Significant Restrictive Eating Problems Are Key � Avoidant/Restrictive Food Intake Disorder (ARFID) has replaced Feeding Disorder of Infancy and Early Childhood and EDNOS which was described in the DSM-IV. � While few data on ARFID have been published, it appears that it usually presents in infancy or childhood, but it can also present or persist into adulthood. � The course of illness for individuals relatively unknown. � Avoidance due to sensory characteristics of food, emotional difficulties, food beliefs etc. � ARFID may be associated with impaired social functioning and affect family functioning, especially if there is great stress surrounding mealtimes.

Distinguishing ARFID from Other Disorders � The presence of other psychological disorders may be risk factors for ARFID, such as anxiety disorders, obsessivecompulsive disorders, attention deficit disorders, and autism spectrum disorders � If an individual presents with one of these illnesses and an eating problem, a diagnosis of ARFID should be given only when the feeding disturbance itself is causing significant clinical impairment � individuals with a history of gastrointestinal conditions such as gastroesophageal reflux may develop feeding disturbances, but a diagnosis of ARFID should be assigned only when the feeding disturbances require significant treatment beyond that needed for the gastrointestinal problems.

Treating ARFID �Little is currently known about effective treatment interventions for individuals presenting with ARFID � given the prominent avoidance behaviors, it seems likely that behavioral interventions, such as forms of exposure therapy � depression or anxiety that affects feeding, cognitive behavioral therapy and other treatments for the underlying condition

Bulimia nervosa �Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food � feeling a lack of control over the eating. �purging (e. g. , vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise � DSM-5 criteria reduce the frequency of binge eating and compensatory behaviors to once a week from twice weekly as specified in DSM-IV.

BN treatment � Psychological treatments first choice � Adults mat be offered antidepressants � SSRI’s esp fluoxetine � 60 mg effective dose � Can reduce frequency of binge eating and purging � Long term effects unknown � Early response at 3 weeks strong indicator of response overall � Used off licensed in adolescents � Some evidence for topiramate, duloxetine, lamotrigine and sertraline reduce binges

Binge eating disorder � Binge eating disorder will now have its own category as an eating disorder. � In the DSM-IV, under the category Eating Disorder Not Otherwise Specified � “recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes accompanied by feelings of lack of control. ” � eat quickly and uncontrollably, despite hunger signals or feelings of fullness. � feelings of guilt, shame, or disgust � behavior will have typically taken place at least once a week over a period of three months.

BED treatment �NICE recommends �Evidenced based self help programme of CBT as first line �Trial of SSRI as an alternative or additional first step

�Although AN is not a common condition �its morbidity and mortality are amongst the highest psychiatric disorders �due to malnutrition, purging �behavior and suicide. � 18 -fold increase in mortality in patients with AN

Diagnostic Crossover in Anorexia Nervosa and Bulimia Nervosa: Implications for DSM-V Kamryn T. Eddy, �Over 7 years, the majority of women with anorexia nervosa experienced diagnostic crossover: more than half crossed between the restricting and binge eating/purging anorexia nervosa subtypes over time; one-third crossed over to bulimia nervosa but were likely to relapse into anorexia nervosa. Women with bulimia nervosa were unlikely to cross over to anorexia nervosa

Conclusion �Key is MDT �Dietician, psychology, medicine, psychiatry, OT and social worker �Clearly defined case manager , roles of team members in case defined