We acknowledge the traditional custodians of the land on which we meet today and pay respect to Elders past, present and emerging. We also extend that respect to other Aboriginal and/or Torres Strait Islanders who are joining us here today.

David R Horton, creator, © Aboriginal Studies Press, AIATSIS and Auslig/Sinclair, Knight, Merz, 1996. View an interactive version of the AIATSIS map www.abc.net.au/indigenous/map/ Header Artwork produced for Queensland Health by Gilimbaa

Treating Eating Disorders Made Easy

A Simple 3-Step Guide

Warren Ward

Director, QuEDS

Metro North Mental Health

High mortality rates

10-20% for Anorexia Nervosa The highest mortality rate of any psychiatric illness

Anorexia Nervosa: Mortality Rates

AN SCZ BPAD Depression

Mortality rate per 1000 person years

5 2.8 2 1.6

12 times higher in AN than patients without AN

A fifth of deaths in AN due to suicide

Higher mortality associated with low BMI at presentation

Ref: Arcelus et al, Mortality Rates in Patients With Anorexia Nervosa and Other Eating Disorders A Meta-analysis of 36 Studies, Arch Gen Psychiatry. 2011;68(7):724-731

Eating Disorders are common, and increasing in prevalence

1 in 20 Australians has an eating disorder*

Approximately 15% of Australian women experience an eating disorder during their lifetime*

The number of people in Australia with ED behaviours doubled in 10 years from 1995-2005^

*www.nedc.com.au

^Hay PJ, Mond J, Buttner P, Darby A (2008) Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys in South Australia. PLoS ONE 3(2)

The cost of eating disorders

First report into socioeconomic impact of EDs

Deloitte Access Economics - in 2012: 913, 986 Australians

$69.7 billion

1,828 deaths

515 males

1313 females

Early intervention… …significantly reduces the duration and impact of illness, and

increases the rate of sustainable recovery

Eating Disorders are treatable

Recovery is possible (approx 70% after 5 years)

Evidence-based treatments are available

To get better, the patient needs (a lot of) help from you, often for several years

What causes eating disorders?

The causes of eating disorders are complex and include… Genetic Personality Early attachment problems (trauma/abuse/neglect) Obesity Bullying and teasing The culture and media/certain subcultures Stressors Dieting Starvation syndrome

Dieting & Eating Disorders are more prevalent in Western cultures

Idealisation of thinness

Abhorrence of fat

We are told that to be happy, successful and desirable we need to be thin

Many women therefore base self-esteem on their physical appearance

The impact of TV on teenage girls

Within 3 years of introduction of TV to area in Fiji:

Eating Disorder symptoms increased 5-fold

Vomiting to control weight increased from 3% to 15%

74% felt “too big or fat”

62% dieting in past month

Favourite programs included Melrose Place, ER, Xena: Warrior

Princess.

Becker et al (2002) British Journal of Psychiatry, 180, 509-514

The previous study (2002) was done before:

FACEBOOK (2004)

THE IPHONE (2008)

INSTAGRAM (2010)

FRONT-FACING CAMERAS AND SELFIES (2010)

SNAPCHAT (2011)

Is body image concern an epidemic?

2015 Mission Australia National Survey of Young Australians

19,000 15-19 year olds

26.5% highly concerned about body image

Treatment made easy: 3 Steps

1. Medical stabilisation

2. Weight restoration

3. Psychotherapy

Reasons for each step

1. Medical stabilisation: to keep patient alive

2. Weight restoration: to reverse cognitive effects of starvation (impaired capacity)

3. Psychotherapy: to help patient resist future urges to lose weight

Keeping patients alive

10% of patients diagnosed with Anorexia dead in 10 years

Patient can feel great and have normal bloods just before sudden death due to arrhythmia

Best indicators of cardiac risk are easily assessed: BMI < 14 No oral intake several days Purging several times daily BP < 90mm systolic; postural drop>20mm HR < 50 bpm or > 120 bpm; postural tachy>20bpm Serum K, P04, Mg, Glucose below normal range Prolonged QT interval on ECG Fainting; Cardiovascular symptoms

5 minute medical check

History ‘Have you had any medical or physical problems in the last

few weeks?’ Ask about cardinal cardiovascular symptoms and fainting

Examination BP and heart rate lying/standing Wt/Ht2

Investigations FBC, Serum Biochem, ECG

Brain-flexible thinking

Heart -BP >90 systolic. -HR>60 -no postural changes

Bone Marrow-Neutrophils 2-8

Liver-BSL>4 LFTs Normal

Ovaries-menstruating

Bones-normal density

Weight- BMI 20-25

Intake vs output-adequate

Electrolytes (K,Na,Hco3,P04,Mg) normal

Brain-rigid terrified thinking Na < 125*=seizures

Heart- -BP <90 systolic* -HR<50* or > 120 bpm -postural changes>20* -Potassium <3* -Phosphate below normal*

Bone Marrow-Neutrophils <1.0*

Liver-BSL<3* LFTs>500*

Ovaries- no periods

Bones-osteoporosis

Weight-BMI <14*

Intake vs output-grossly inadequate intake, out of control purging or exercise

*admit

Not killing patients

Refeeding Syndrome Feeding a malnourished person can also cause sudden death

due to arrhythmia Caused by rapid drops in serum phosphate, potassium,

magnesium, glucose, thiamine

Prevented by: Clinician awareness of refeeding syndrome first 2 weeks Carefully controlled intake first 1-2 weeks Daily thiamine Daily checks of serum phosphate, potassium, mg and replace

if below normal range BSLs QID Daily ECGs/Obs lying/standing QID

Step 2: Weight Restoration

Starvation impairs brain functioning, affecting the patient’s reasoning, judgement and decision-making capacity

We know this thanks to the Minnesota Semi-Starvation Study, as well as observations in eating disorders units

Restoration of normal weight sometimes ‘cures’ the anorexia, and nearly always significantly improves patient’s ability to benefit from psychotherapy

Patients must ‘bring their brains to therapy’

How to assess weight

Use same scales each time

Empty pockets, no shoes, check no weights attached

Ignore weight if Na, Cl, Osm below normal range

Plot weight on a graph

Only report meaningful changes in weight (BMI band)

Are weight changes consistent with: Dietary intake? Other nutritional indicators (HR, BP, T, Neutrophils)

Plotting weight in kg (ht 1.7m)

Plotting weight in BMI

BMI Band (Band = 2 consecutive weighs in that BMI band)

Achieving weight restoration

Prescribe adequate diet for weight restoration 0.5-1.0 kg/wk weight restoration

Link contingencies to weight gain, e.g. For outpatient at BMI 15: 2kg weight gain in 4 weeks or

admission For inpatients, increased leave if increase BMI band Minimum BMI band 16 for psychotherapy Minimum BMI band 17 for discharge Readmit BMI band 15

Step 3: Psychotherapy

After weight restoration

Minimum BMI 16, preferably 20

Effective

Aims to help patients deal with thoughts that tempt them to lose weight, retriggering starvation syndrome

6-12 months minimum

CBT or SSCM (or MANTRA)

Best with eating disorders specialist

In conjunction with weekly medical monitoring

CBT-e

Metacognitive stance (eg pie chart – see next slide)

Formulation developed with patient

Psychoeducation

Regular meals and snacks

Monitoring behaviours and thoughts

Addresses ‘feeling fat’; body checking

Binge

Purge

Restrict

Treating BN and BED

CBT-e or GSH for BN and BED

SSCM

Developed by Virginia McIntosh, Christchurch

Proven effectiveness for AN

Flexible

Focus on wt gain, normal eating, psycho-education, focus on key symptoms, supportive and validating, pt-generated issues

Psychotherapies for people not ready for psychotherapy

Motivational

Psychoeducational

Narrative

Enlisting family

Behavioural (safety contingencies)

Team containment

Shift concrete thinking to metaphorical

Other things to consider

Get primary diagnosis right

Don’t negotiate with the terrorist

Team decisions

Countertransference

Use the mental health act

Listen to the advice of people who have recovered

Maudsley family therapy if live with parents

QuEDS Services Consultation 3114 0809 Phone consultation OPD consultation (RBWH) Inpatient consultation Service development consultation

Training 3100 7500 Inpatient Treatment inservice (full day) Customised to your needs

Treatment 3114 0809 5 inpatient beds Day program (8 patients, 8 weeks, 4 days/week) Evidence-based OPD: CBT-e/SSCM (20/40 weeks)

Useful Resources

Google ‘QuEDS’

RANZCP guidelines

eda.org.au

eatingissuescentre.org.au

anzaed.org.au

thebutterflyfoundation.org.au

nedc.com.au

cci.health.wa.gov.au

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