Speciality: Mental Health Clinical problem: Eating Disorders in Adults (18 and over*)

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1 Speciality: Mental Health Clinical problem: Eating Disorders in Adults (18 and over*) Scope of Problem St. Richard s Hospital Eating disorders commonly develop during adolescence and are more common in females than males. Physical and social development is disrupted for these young people (sometimes with permanent effects) and the toll on their families can be considerable. Depressed mood often accompanies the eating disorder, partly because of the symptoms, and partly because of the consequences of the disorder on the person s life. Eating disorders are complex conditions involving physical, psychological and social features. Recent research into biological processes suggests that many of the mechanisms that underlie eating disorders are not under conscious or wilful control. Rather, a network of biological systems such as the processing of information, emotions and organisation of behaviour contribute to the illness. Some of these are fixed and are part of the genetic makeup, whereas others emerge from environment. Families are definitely not responsible for eating disorders and people with eating disorders do not choose to have their illness. With appropriate treatment approximately 50% of sufferers will recover, approximately 30% will improve but continue to experience symptoms, and approximately 20% will continue to suffer from a chronic eating disorder. The adverse physical consequences of restricted eating, weight loss and purging are marked. The physical consequences provoke great concern in family members and health service staff and they sometimes prove fatal. Anorexia Nervosa has the highest mortality rate of any psychiatric disorder of adolescence and longer term follow up studies indicate that people with this condition have a 10-fold risk of dying compared to healthy people of the same age and sex. While approximately half of the deaths are due to physical complications of the eating disorder, just over a quarter of the deaths are due to suicide. In a health district like West Sussex, with a population of approximately 750,000, about 300 people will be diagnosed with an eating disorder every year. Of these, 60 will have Anorexia Nervosa, 85 will have Bulimia Nervosa and the rest will have an eating disorder not otherwise specified (EDNOS). It is important to distinguish between Anorexia Nervosa and Bulimia Nervosa (and EDNOS). The treatment of choice for Bulimia Nervosa is Cognitive Behaviour Therapy (CBT). The treatment of choice for Anorexia Nervosa is less clear cut, but most people can be treated with one of the Psychological Therapies and physical monitoring. Patients and their families should also be offered brief Family Based Treatment. Treatment in the community is the gold standard. Admission is occasionally necessary but, particularly in younger patients, there are concerns about the harmful side of this intervention. * This document relates to adults but many of the principles of assessment & diagnosis apply to adolescents Footnote This paper is intended to apply to Sussex Partnership and Primary Care services as they are currently (January 2009) configured and hence it must be seen as interim guidance. It will be revised in the context of imminent service redesign, which will involve Primary Care Mental Health Teams and Access, Recovery and Specialist Services.

2 2 Screening Does the patient have an eating disorder? Most effective screening tool is GP thinking about the possibility of an eating disorder. Prevalence is low so cannot screen all patients. High risk groups include: Young women Patients with low (below 17.5) or high BMI Adolescents consulting with weight concerns, menstrual disturbance or amenorrhea, gastrointestinal disorders and psychological problems. In these cases GP could consider using screening questions: Do you think you have an eating problem? Do you worry excessively about your weight? In addition, GP could consider using SCOFF questionnaire screening tool: Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone in weight in a 3/12 period? Do you believe yourself to be Fat when others say you are thin? Would you say Food dominates your life? Score 1 point for every yes. Score of 2 or more indicates possible eating disorder and need for further assessment. Some patients will be reluctant to talk about their eating disorder yet physical signs of emaciation may be obvious.

3 Assessment and Diagnosis 3 What kind of eating disorder does the patient have? Please note: a diagnosis of Anorexia Nervosa overrides other eating disorder diagnoses. If the patient meets the body weight criterion (BMI less than 17.5) for Anorexia Nervosa then this is the diagnosis no matter how much the patient binges or vomits. Does the eating disorder meet diagnostic criteria for Anorexia Nervosa? (First contact will often be made by a worried family member, friend or teacher, rather than by patient - see resources for book list) Diagnostic Criteria A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g. weight loss leading to maintenance of BMI below 17.5 or in young patients weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one s body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea, i.e. the absence of at least 3 consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g. oestrogen, administration.) Specify type: Restricting Type: during the current episode of Anorexia Nervosa the person has not regularly engaged in bingeeating or purging behaviour (i.e. selfinduced vomiting or the misuse of laxatives, diuretics or enemas). Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa the person has regularly engaged in bingeeating or purging behaviour (i.e. selfinduced vomiting or the misuse of laxatives, diuretics or enemas). Does the eating disorder meet diagnostic criteria for Bulimia Nervosa? (Patient is more likely to be older and consult alone than patient with anorexia.) Diagnostic Criteria A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (i). eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under (ii). similar circumstances. a sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives; diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviours both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Specify type: Purging Type: during the current episode of Bulimia Nervosa the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Nonpurging Type: during the current episode of Bulimia Nervosa the person has used other inappropriate compensatory behaviours, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics or enemas. Does the eating disorder meet diagnostic criteria for Eating Disorder Not Otherwise Specified (EDNOS)? The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include: 1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses. 2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual s current weight is in the normal range. 3. All of the criteria for Bulimia Nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months. 4. The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food (e.g. self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder; recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of Bulimia Nervosa. NB Obesity by itself is not an eating disorder in this context Go to Page 4 Stepped Care for Anorexia Nervosa Go to Page 5 Stepped Care for Bulimia Nervosa Go to Page 6 Stepped Care for EDNOS

4 Stepped Care for Anorexia Nervosa 4 Patient has eating disorder which meets criteria for Anorexia Nervosa What is the level of physical risk? Physical Risk Assessment System Examination Moderate risk High risk Nutrition BMI < 15 < 13 BMI centiles < 3 < 2 Weight loss/wk > 0.5 kg > 1.0 kg Purpuric rash - any Circulation Systolic BP < 90 mm Hg < 80 mm Hg Diastolic BP < 60 mm Hg < 50 mm Hg Postural drop > 10 mm Hg > 20 mm Hg Pulse rate < 50 BPM < 40 BPM Extremities Dark blue/cold Musculoskeletal Unable to get up without using - Squat Test arms for balance Unable to get up without using arms as leverage - Sit up test (from Unable to sit up without using lying) arms as leverage Unable to sit up at all Temperature < 35 o C < 34.5 o C Investigations FBC, urea, electrolytes (including PO4), LFT, Albumin, Creatinine kinase, Glucose Concern if outside normal limits K < 2.5 Na < 130 PO4 < 0.5 ECG Rate < 50 Rate < 40 Prolonged QT interval Physical risk is moderate - low Physical risk is high Referral to local CMHT Eating Disorder Consultation Service Tertiary Services Dietitian Consultation Service Consider urgent medical admission to General Hospital On medical admission make urgent referral to local CMHT Voluntary admission refused Urgent referral to local CMHT for support in assessing capacity

5 5 Stepped Care for Bulimia Nervosa Patient has eating disorder which meets criteria for Bulimia Nervosa What is the level of physical risk? The physical risk assessment screen for Anorexia Nervosa (page 4) may also be considered for Bulimia Nervosa - but remember patients with a diagnoses of Bulimia Nervosa cannot, by definition, have a BMI of less than The main risk in this group is vomiting or laxative misuse leading to low potassium levels Physical risk is moderate - low Physical risk is high (rare) Possible first step offer evidence based CBT self help via books on prescription and consider referral to Primary Care Counselling And/or offer trial of SSRI antidepressant drug fluoxetine 20mg increasing to 60 mg Consider urgent medical admission to General Hospital On medical admission make urgent referral to local CMHT Most will require referral to local CMHT for CBT- Bulimia nervosa

6 6 Stepped Care for EDNOS Patient has clinically significant eating disorder which does not meet criteria for anorexia nervosa or bulimia nervosa Does eating problem most closely resemble Anorexia Nervosa? No Does eating problem most closely resemble Bulimia Nervosa? No Does eating problem consist of binge eating without compensatory behaviours and physical risk is low? Follow Stepped Care for Anorexia Nervosa P. 4 Follow Stepped Care for Bulimia Nervosa P. 5 Possible first step offer evidence based CBT self help via books on prescription and consider referral to Primary Care Counselling And/or trial of FLUOXETINE 20mg possibly increasing to 60mg Some may require CBT for binge eating

7 7 Patients under 18 Patients aged Patients aged 65 and over. Referrals should be addressed Referrals should be addressed to the relevant team in: to the relevant team in: Child and Adolescent Services Orchard House 9 College Lane Chichester PO9 6PQ /4514 Bognor sector The Bedale Centre 1 Glencathra Road Bognor Regis (tel) (fax) Bognor BWMH (tel) (fax) Chichester sector Chapel Street Clinic Chapel Street Chichester (tel) (fax) Midhurst sector The Old Court House Grange Road Midhurst (tel) (fax) Chichester Harold Kidd Unit Graylingwell Chichester (tel) (fax) Midhurst Midhurst Community Hospital Dodsley Lane Midhurst GU29 9AW (tel) (fax) Resources Skills-based Learning for Caring for a Loved One with an Eating Disorder by Janet Treasure, Grainne Smith & Anna Crane published by Routledge (2007 ISBN ) as the title suggests a very practical book about how to support someone with an eating disorder. Should be recommended to all patients and their families (RRP 12.99) Breaking Free from Anorexia Nervosa; A Survival Guide for Families, Friends and Sufferers by Janet Treasure published by Psychology Press ( ISBN ) - a good self-help book for people with anorexia nervosa (RRP 12.99) Getting Better Bit(e) by Bit(e) by Ulrike Schmidt & Janet Treasure published by Psychology Press ( ISBN ) - a good self-help guide for people with bulimia or other bingeing problems not for people who have anorexia nervosa even if they binge (RRP 12.95) Overcoming Binge Eating by Christopher Fairburn (2005 ISBN ) - another very good self-help guide for people with bulimia or other bingeing problems (RRP 13.50) Eating Disorders: A Parents Guide by Rachel Bryant-Waugh & Bryan Lask published by Brunner-Routledge ( ISBN ) - a good guide to what parents can do (RRP 9.99) Royal College of Psychiatrists Website a source of basic information about eating disorders

8 8 beat - the leading UK charity for people with eating disorders and their families a very good source of information & useful contact numbers Institute of Psychiatry Eating Disorders Research Site as described it contains a lot of useful materials for professionals, families and patients CBT & Eating Disorders a link to a site about the best manual for professionals wanting to offer a CBT approach to Eating Disorders. It offers downloadable useful handouts References Bell, L., Clare, L., & Thom, E. (2001) Service Guidelines for People with Eating Disorders. BPS: London. NICE (2004) Eating Disorders. Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. BPS and Gaskell: London. Authors : Others involved: Lin Creasey and Dr Neil Joughin, Sussex Partnership NHS Trust. Marie Smith, Mental Health Dietitian, St Richard s Hospital, The Royal West Sussex NHS Trust. Sussex Partnership NHS Trust Guidelines Group. Local Referral and Management Guidelines Committee Royal West Sussex NHS Trust, Chichester. Published: December 2008 Review Due: December 2010* *This document will be reviewed in the context of service redesign as per the footnote on page 1

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