Eating Disorders A Resource for General Practitioners (PDF)

EatingDisorders AResourcefor GeneralPractitioners  Eating Disorders A Resource for General Practitioners Written by Dr. Sinead O’Dea, MB DCH MICGP CFP, ICGP Clinical Lead for Eating Disorders & Harriet Parsons, MA., MSc., Reg. Prac. APPI, Services Co-ordinator, Bodywhys In partnership with Pearse Finnegan, Director, Mental Health Project, ICGPs With sincere thanks to Marie Devine This project was funded by National Office for Suicide Prevention (NOSP) © Think Bodywhys Ltd. (2013)  Whileeveryeffort has been made to ensure that the information contained in EatingDisordersAResource for General Practitioners is accurate, no legal responsibility isaccepted by the authors or Bodywhys for any errors or omissions.  Contents Introduction 3 1. Basic Understanding of Eating Disorders 5 Who should be screened? 6 Presenting Signs and Symptoms 8 Assessment TOOL: SCOFF Questionnaire 10 Anorexia Nervosa 12 Bulimia Nervosa 13 Binge Eating Disorder 14 2. Assessment 15 Checklist for Assessment 16 Reviewing the information 21 3. What Next? 23 What are the goals of treatment? 24 Helpful hints for parents/family 25 Treating and supporting within your practice 25 Treatment options 25 Types of ‘talking’ therapies 25 4. Bodywhys Services 29 5. Appendix 1 - Understanding the spectrum of disordered eating 31 6. Appendix 2 - DSM-5TM Diagnostic Criteria for Eating Disorders 33 Anorexia Nervosa 33 Bulimia Nervosa 34 Binge Eating Disorder 35 Other Specified Eating Disorder 36 7. References 37  LIFE SOMETIMES GETS COMPLICATED  www.bodywhys.ie 3 Introduction This guide has been developed to assist general practitioners (GPs) in the identification, assessment and management of patients with eating disorders. The typical image that comes to mind when we think of a person with an eating disorder, is the severely emaciated frame of a young woman, and while this is one way a person with an eating disorder may present, there are also many other ways in which eating disorders can present that are not so obvious. Eating disorders are extremely complex and when a patient is entrenched in the disorder, the complexity can increase and make the diagnosis and management more difficult. GPs are uniquely placed to the early detection and management of eating disorders, offer intervention and help co-ordinate and monitor treatment. Early detection and management may contribute to better outcomes.(1) However, existing medical literature suggests that eating disorders may in fact go undetected in general practice, despite the high rate of associated medical problems.(2) Research also suggests that people with eating disorders consult their GP more frequently than other people in the five years prior to being diagnosed.(3) However, it is common for a patient to present to the GP and not identify eating disorders as a problem. GPs are therefore uniquely placed to identify and assess those patients with disordered eating prior to these behaviours and psychological distortions becoming entrenched. In their guidelines for the management of eating disorders, the National Institute for Health & Clinical Excellence (NICE, 2004) states that the majority of eating disorder patients can be managed in primary care or by local services with access to specialist multi-disciplinary advice and support. This resource will give GPs a practical tool to use to identify those who need treatment and support for an eating disorder. Each section begins and ends with ‘key points’ which are elaborated on within each section to ensure GPs are fully informed and feel adequately equipped when presented with a patient with an eating disorder. 1 Morgan, JF, Reid, F and Lacey JH. The SCOFF Questionnaire; assessment of a new screening tool for eating disorders. BMJ 1999; 319 (7223): 1467-8. 2 Treasure J, Schmidt U, Hugo P; Mind the gap: service transition and interface problems for patients with eating disorders. Br J Psych 2005; 187: 398-400. 3 Ogg, E., Miller, H., Pusztai, E., Thom, A. (1997), 'General practice consultation patterns preceding diagnosis of eating disorders', International Journal of Eating Disorders, 22, 89-93.  www.bodywhys.ie 5 1. Basic understanding of EatingDisorders KEY POINTS � Eating disorders are complex mental health conditions and should always be taken seriously � Understanding an eating disorder as a coping mechanism should inform your initial approach � The SCOFF Questionnaire(4) can be used as a screening tool Eating disorders are complex serious expressions of emotional distress with physical, mental and family consequences. With early intervention, eating disorder patients respond well to treatment. The main eating disorders are: (detailed in a later section) • Anorexia Nervosa (AN) • Bulimia Nervosa (BN) • Binge Eating Disorder (BED) and • Other Specified Eating Disorders that do not fully meet the criteria for either AN, BN or BED. Creating trust and a sense of safety Keep in mind - We all cope with life in different ways. If you were asked to suddenly stop coping in the way you do, how would you feel? Anxious, panicky, frightened? As a first communication the most important step you can take as a GP is to make the person feel safe and that they can trust you. 4 Morgan et al. (1999) Eating disorders are not primarily about food or weight, they develop as the coping mechanism that the person uses to manage how they are feeling – resistance to talking about what they are doing is NORMAL.  www.bodywhys.ie 6 How to create trust: • Communicate concern: Be clear as to why you are concerned and are making an assessment of an eating disorder • Empathise: Ask them how they feel about what they are doing, rather than telling them to stop • Collaborate: Make a plan with the person by combining what they think would help them, and what you can advise Most common presentation for GPs Eating disorders may be difficult to detect in primary care settings. Patients may be reluctant to disclose to their GP, and also GPs may not consider an eating disorder. Adults with eating disorders appear to consult their general practitioner more frequently than controls, presenting particularly with psychological, gastrointestinal and gynaecological problems (Ogg et al., 1997). Consultations of this nature present an opportunity to screen for eating disorders. Top Tips for Screening • Consider the possibility of an eating disorder • Gently inquire in a non-judgmental way • Establish trust by communicating concern, empathising, and collaborating The patient’s history is paramount and special investigations are not normally required to make a diagnosis. Who should be screened?(5) Target groups for screening should include: • Young women with low body mass index (BMI) compared with age norms • Patients consulting with weight concerns who are not overweight • Adolescents consulting with weight concerns • Women with menstrual disturbances or amenorrhoea • People with gastrointestinal symptoms • Patients with physical signs of starvation or repeated vomiting • Children with poor growth 5 Eating Disorders Resource for Health Professionals, The Victorian Centre of Excellence in Eating Disorders  www.bodywhys.ie 7 When to consider if there is an underlying eating disorder(6): • Amenorrhoea, infertility, pre-menstrual syndrome, irregular periods • Constipation, abdominal bloating and pain, indigestion, diarrhoea, nausea, vomiting • Psycho-sexual or mental health problems • Sore throat • Difficulties sleeping, or concentrating • Weight loss • Generally feeling unwell • Weak, dizziness or tired • Wanting to lose weight when normal or underweight • Headaches Common mis-diagnoses(6): • Lactose intolerance or IBS • Abdominal pain • Hypoglycaemia • Premenstrual syndrome • Systemic candidiasis • Food allergies • Chronic Fatigue Syndrome Be aware - A patient with an underlying eating disorder can also present with depression, anxiety and suicidal ideation. Ask the appropriate questions, in an appropriate way, to get a better and more complete picture. Be concerned - If time is an issue on an initial consultation, make another appointment and leave more time to explore the many options for what might be going on. Remember - An eating disorder is the person’s coping mechanism – they will resist talking about it because they will feel frightened and ashamed. You can help them to talk to you if you ask around the issue, and communicate an understanding that letting it go, and change, is difficult. 6 Eating Disorders Resource for Health Professionals, The Victorian Centre of Excellence in Eating Disorders  www.bodywhys.ie 8 General • Marked weight loss, gain or fluctuations • Weight loss, weight maintenance or failure to gain expected weight in a child and adolescent who is still growing and developing • Intolerance to cold • Weakness • Fatigue or lethargy • Dizziness • Syncope • Hot flashes, sweating episodes Oral and Dental • Oral trauma or lacerations • Dental erosion • Perimolysis • Parotoid enlargement Cardiorespiratory • Chest pain • Heart palpitations • Arrhythmias • Shortness of breath • Oedema Gastrointestinal • Epigastric discomfort • Early satiety, delayed gastric emptying • Gastroesophageal reflux • Hematemesis • Hemorrhoids and rectal prolapsed • Constipation Endocrine • Amenorrhea or irregular menses • Loss of libido • Low bone mineral density and increased risk for bone fractures and osteoporosis • Infertility Neuropsychiatric • Seizures • Memory loss / poor concentration • Insomnia • Depression / anxiety / obsessive behaviour • Self-harm • Suicidal ideation / suicide attempt Dermatologic • Lanugo hair • Hair loss • Yellowish discolouration of skin • Callus or scars on the dorsum of the hand (Russell’s sign) • Poor healing PRESENTING SIGNS AND SYMPTOMS Source: AED Academy for Eating Disorders (2012)  www.bodywhys.ie 9 Summary of important SIGNS and SYMPTOMS for early recognition of an eating disorder: 1. Substantial weight fluctuations 2. Failure to gain expected weight in a child or adolescent who is still growing and developing 3. Electrolyte abnormalities especially hypokalemia, hypochloremia, or elevated CO2. High normal CO2 in the presence of low chloride and/ or urine pH of 8.0 – 8.5 can indicate recurrent vomiting. Hypoglycemia may accompany such electrolyte changes. 4. Bradycardia 5. Amenorrhea or menstrual irregularities 6. Unexplained infertility 7. Excessive exercise or extreme physical training 8. Constipation in the setting of other inappropriate dieting and/or weight loss promoting behaviours 9. Type 1 diabetes mellitus and unexplained weight loss and/or poor metabolic control or diabetic ketoacidosis (DKA). These patients are at increased risk of developing sub-threshold and full syndrome eating disorders. Intentionally changing insulin doses will lead to weight loss, poor glycemic control, hypoglycemia/hyperglycemia, DKA, and acceleration of diabetic complications. 10. A history of using one or more compensatory behaviours to influence weight after eating, or perceived overeating or binge eating e.g. self induced vomiting, excessive exercise, fasting. 11. A history of using/abusing appetite suppressants, excessive caffeine, diuretics, laxatives, enemas.  www.bodywhys.ie 10 Assessment Tool: SCOFF Questionnaire(7) Can you ask? What should you ask? If you are presented with an individual with some of the signs or symptoms as listed, and you wish to get a clearer understanding of how the person is behaving around food, eating, and their attitude towards their weight, it can be helpful to get into the habit of routinely enquiring into this by using the SCOFF Questionnaire. S Do you make yourself Sick because you feel uncomfortably full? C Do you worry you have lost Control over how much you eat? O Have you recently lost more than One stone (6.35kg) in a three-month period? F Do you believe yourself to be Fat when others say you are too thin? F Would you say Food dominates your life? One point is assigned for every ‘yes’. A score greater than two should raise the index of suspicion. You may also ask the following two questions for indications of bulimia nervosa: 1. Are you satisfied with your eating patterns? 2. Do you ever eat in secret? When screening for eating disorders a range of other questions can be asked: • Do you think you have an eating problem? • Do you worry excessively about your weight? • What do you eat in an average day? • Which foods feel ‘safe’ and what do you avoid? • Do you ever vomit, exercise, abuse laxatives and/or diuretics? If so how much and when? • How often do you weigh yourself? Remember - Resistance to answering or giving a full picture is NORMAL. General practitioners must be prepared to align themselves with the patient against the eating disorder, using a collaborative approach. Think of the eating disorder as an entity in and of itself. ‘It’ does not want the person to talk openly about it. ‘It’ wants to be kept secret, and the person will struggle to tell this secret. 7 Morgan et al. (1999)  www.bodywhys.ie 11 Barriers to GPs considering the possibility of an eating disorder - MYTHS Myth No. 1 - Eating disorders are a female issue. FALSE. Eating disorders can occur in men and women, boys and girls. It is estimated that one in every 10 cases of an eating disorder is male, while for Binge Eating Disorder it is 1 in every 2 cases. Myth No. 2 - Eating disorders are a teenage issue. FALSE. An eating disorder can occur at any age from under 10 to over 70. The average age of onset is 15-24, and when you think about the life changes that happen during these years you can understand why this might be the average age of onset. But, at any age, for some reason, some people turn to controlling their body and food intake as a way of coping. Myth No. 3 - An eating disorder is a faddy diet. FALSE. An eating disorder is not a type of diet that somebody uses to lose weight. An eating disorder is a serious mental illness that has the highest mortality rates of all psychiatric disorders. It is a mistake to think that eating disorders are only about food and weight. They are about the person’s sense of themselves, their self-esteem and self-worth. Myth No. 4 - An eating disorder is a lifestyle choice. FALSE. A person does not ‘choose’ to have an eating disorder, and certainly living with an eating disorder is not about emanating a certain type of lifestyle. A person becomes trapped in an eating disorder, and in a similar way to an addiction, feels compelled to continue engaging in the disordered eating behaviour in order to feel safe and secure. This compulsion replaces the conscious choice a person has, and they need help and support to be able to choose a different way of coping and living. Myth No. 5 - An eating disorder is a phase. FALSE. An eating disorder is not just a phase, it is not something that a person ‘will grow out of’. It is much more serious than that and should be taken as such by all medical and treatment practitioners involved.  www.bodywhys.ie 12 What are common presentations to look out for? Anorexia Nervosa The first contact with a GP is often made by a concerned family member, rather than the patient. Concerns expressed may be related to weight loss, food-related behaviours such as skipping meals, hiding food or adopting a restrictive diet. There may be a change in mood, sleep patterns and increased activity. Typical psychopathological features: • Fear of gaining weight or becoming fat despite being underweight; • Disturbance in evaluating or experiencing body weight or shape; • Undue influence of eating or changes in body weight on self-evaluation; and • Preoccupation with shape or weight-related matters. These features may not all be present, easy to elicit or they may be denied. Denial of the seriousness of the weight loss or consequences, both physical and psychological is not unusual. Established anorexia nervosa with signs of emaciation is usually obvious. However, patients may present initially in primary care with non-specific physical symptoms such as abdominal pain, bloating, constipation, cold intolerance, light headedness, hair, nail or skin changes. Amenorrhoea, combined with unexplained weight loss, in the population at risk should always prompt further enquiry. Apparent food allergy/intolerance and chronic fatigue syndrome sometimes precede the development of an eating disorder and may cause diagnostic confusion. In children, growth failure may be a presenting feature. In practice, typical cases should cause little difficulty when the time is taken to explore the history including corroborative information and the patient’s attitude to the weight loss. Indeed, diagnosis is often delayed when doctors inadvertently collude by over investigating and referring to other specialties rather than confronting the possibility of an eating disorder. In anorexia nervosa, although weight and body mass index (BMI) are important indicators of physical risk they should not be considered the sole indicators (as on their own they are unreliable in adults and especially in children)(8). 8 Eating Disorders Resource for Health Professionals, The Victorian Centre of Excellence in Eating Disorders  www.bodywhys.ie “In assessing whether a person has anorexia nervosa, attention should be paid to the overall clinical assessment (repeated over time), including rate of weight loss, growth rates in children, objective physical signs and appropriate laboratory tests.” (9) The effective management of anorexia nervosa depends on a full assessment of physical status, psychological features, risk and capacity to consent to treatment. Young people are typically brought to the attention of the GP by concerned parents because of the extent of their weight loss. Other presenting features may include: • Altered eating or dietary behaviour • Excessive exercise • Amenorrhoea • Depressed mood and/or social withdrawal • Self-harm • Suicidal ideation The young person may also present with physical complaints related to undernutrition including dizziness, fatigue and headache, or abdominal symptoms such as nausea or bloating, unexplained vomiting, lack of appetite and constipation. The young person may deny any problem and offer assurances for concerns. Bulimia Nervosa The patient with bulimia nervosa is more likely to be older and to consult alone than a patient with anorexia nervosa. There may be a history of previous anorexia nervosa or of unhappiness with previous weight and attempts to diet. Appropriate questioning (see screening section) may reveal patterns of restriction, binge eating and purging and psychopathology that make the diagnosis clear. Not infrequently, physical symptoms are presented which may be related to or consequences of purging or laxative use. These are parotid enlargement, Russell’s sign (callus formation on the dorsum of the hand) and dental enamel erosion. Also common are electrolyte abnormalities, so urea and electrolytes should be routinely obtained. These symptoms, particularly in a young woman should be a ‘red flag’ in prompting the GP to consider further enquiry. 9 National Collaborating Centre for Mental Health, (2004), p.64 13