ANOREXIA NERVOSAANOREXIA NERVOSAININ

YOUNG PEOPLEYOUNG PEOPLE

PSYCHOPSYCHO--EDUCATIONEDUCATIONINFOINFO

Importance of Importance of PsychoeducationPsychoeducation

Less threatening engagement.Less threatening engagement.Knowledge Knowledge –– increasing understanding and increasing understanding and potential expertise.potential expertise.Can help reduce guilt and blame.Can help reduce guilt and blame.Beginning of Beginning of ““externalisationexternalisation””..Easy to learn for professionals of any Easy to learn for professionals of any background.background.Needs repetition!Needs repetition!Visual and verbal information increases Visual and verbal information increases attention and retention.attention and retention.

THE EFFECTS ON THE EFFECTS ON BEHAVIOUR OF BEHAVIOUR OF STARVATIONSTARVATION

ANCEL KEYS 1950ANCEL KEYS 1950

36 Healthy, psychologically normal men.36 Healthy, psychologically normal men.Detailed study of behaviour, personality and Detailed study of behaviour, personality and eating patterns.eating patterns.3/12 Normal eating.3/12 Normal eating.3/12 Restriction of calories by 50% (weight 3/12 Restriction of calories by 50% (weight loss @ 25%).loss @ 25%).3/12 Rehabilitation and re3/12 Rehabilitation and re--feeding.feeding.9/12 Follow9/12 Follow--upup

Attitudes & BehaviourAttitudes & Behaviour

↑↑ Food preoccupation, affecting concentration, Food preoccupation, affecting concentration, daydreams, conversations, reading daydreams, conversations, reading –– 3 chefs!3 chefs!““toyedtoyed”” with food, unusual concoctions, smuggled with food, unusual concoctions, smuggled out food, longer to eat.out food, longer to eat.Pleasure from smelling food, watching others eat.Pleasure from smelling food, watching others eat.↑↑ time planning & preparing food, Conflict gulping v time planning & preparing food, Conflict gulping v slowly.slowly.↑↑ coffee, tea and gum so excessive had to be coffee, tea and gum so excessive had to be limited.limited.

Binge EatingBinge Eating

If unable to tolerate If unable to tolerate ↑↑hunger, episodes hunger, episodes bingebinge--eating and selfeating and self--reproach.reproach.Lost control of appetite and Lost control of appetite and determining how full they were. determining how full they were.

BOTH ABOVE PERSISTED INTO REBOTH ABOVE PERSISTED INTO RE--FEEDING STAGEFEEDING STAGE

Emotional & Personality Emotional & Personality ChangesChanges

Most periods of emotional distress, 20% Most periods of emotional distress, 20% extreme/interfered with functioning.extreme/interfered with functioning.↑↑ Anxiety and Depression with starvation, Anxiety and Depression with starvation, occasional occasional elationelation→→lowlowExtreme mood swings, irritability and anger.Extreme mood swings, irritability and anger.Nail biting, smoking Nail biting, smoking –– nervousnervousApathy, selfApathy, self--neglect personal hygiene.neglect personal hygiene.Shoplifting, violence, wanting to selfShoplifting, violence, wanting to self--harm, harm, compulsion to route throcompulsion to route thro’’ rubbish, rubbish, suicidalitysuicidality

Social ChangesSocial Changes

↑↑ Withdrawn, isolated and sense of inadequacyWithdrawn, isolated and sense of inadequacy↓↓ Sense comradeship and libidoSense comradeship and libido

Changes in ThinkingChanges in Thinking

Reported Reported ↓↓ concentration, alertness, concentration, alertness, comprehension, judgementcomprehension, judgementNot the case on formal testingNot the case on formal testing

Physical ChangesPhysical Changes

GI discomfort, bloating, indigestion, GI discomfort, bloating, indigestion, constipationconstipation↓↓ Need to sleep and tolerance of coldNeed to sleep and tolerance of coldHeadaches, dizziness, hypersensitivity to Headaches, dizziness, hypersensitivity to noise and light, difficulties visually noise and light, difficulties visually focussing, tingling hands/feet, ringing earsfocussing, tingling hands/feet, ringing ears↓↓ Strength , poor motor controlStrength , poor motor controlSlowing bodies physiological responses Slowing bodies physiological responses -- ↓↓HR, BP, RR, Metabolic rate, Temp.HR, BP, RR, Metabolic rate, Temp.

StarvationStarvation

Acute effects of starvation are Acute effects of starvation are dependent on fat stores.dependent on fat stores.Proportion of fat varies throughout Proportion of fat varies throughout childhood, peaks during puberty, childhood, peaks during puberty, lowest in early childhood.lowest in early childhood.

Starvation cont:Starvation cont:Food Deprivation (no Fat stores)Food Deprivation (no Fat stores)

↓↓Conservation of EnergyConservation of Energy

Most essential functions preserved most (brain/heart)Most essential functions preserved most (brain/heart)Energy from tissue breakdown, glycogen stores in liver,Energy from tissue breakdown, glycogen stores in liver,

then protein in musclethen protein in muscle↓↓

Least essential organs reduce energy and blood supply Least essential organs reduce energy and blood supply Limb peripheries, stomach, gut, skin, bladder, liver Limb peripheries, stomach, gut, skin, bladder, liver

↓↓Body can function well with limited energy but if extraBody can function well with limited energy but if extrais needed, chronic starvation or purging behaviours?is needed, chronic starvation or purging behaviours?

↓↓Heart insufficient reserve, Heart failure/arrhythmiasHeart insufficient reserve, Heart failure/arrhythmias

Brain last to be affected (except hypothalamicBrain last to be affected (except hypothalamic--pituitary pituitary axis axis –– hormones)hormones)

↓↓DEATHDEATH

Physical contPhysical cont::

ReRe--feeding feeding --Metabolic Rate Metabolic Rate ↑↑ greater greater the larger amount of calories eatenthe larger amount of calories eatenNB ReNB Re--Feeding initially most weight Feeding initially most weight gained is gained is FATFAT→→ Concern about Concern about sluggishness, feeling flabby and sluggishness, feeling flabby and expressed fear of weight gain. expressed fear of weight gain.

By 9 months normal By 9 months normal redistribution of body fatredistribution of body fat

Physical ActivityPhysical Activity

↓↓ Activity generally Activity generally –– tired, weak, tired, weak, listless, apathetic.listless, apathetic.Some Some ↑↑ exercise deliberately to try and exercise deliberately to try and lose weight to avoid a lose weight to avoid a ↓↓ rations.rations.

StarvationStarvation

SIMILAR SYMPTOMS TO YOUNG SIMILAR SYMPTOMS TO YOUNG PEOPLE WITH ANOREXIAPEOPLE WITH ANOREXIAMANY CHANGES THAT OCCUR MANY CHANGES THAT OCCUR PERSIST DURING REPERSIST DURING RE--FEEDING FEEDING and RECOVERY and RECOVERY –– SAME WITH SAME WITH ANOREXIA!!ANOREXIA!!

ANOREXIA NERVOSAANOREXIA NERVOSA

SOME FACTSSOME FACTS

Average time for recovery in adolescents is Average time for recovery in adolescents is SIX YEARSSIX YEARS..If becomes chronic (>20 years), conveys If becomes chronic (>20 years), conveys the the HIGHEST MORTALITY RATEHIGHEST MORTALITY RATE of all of all psychiatric diagnoses. Deaths due to psychiatric diagnoses. Deaths due to SUICIDE SUICIDE or or MEDICAL MEDICAL COMPLICATIONSCOMPLICATIONS..

Anyone who has suffered/is suffering Anyone who has suffered/is suffering from Anorexia Nervosa has an from Anorexia Nervosa has an increased risk of increased risk of FERTILITYFERTILITY problems problems & & OSTEOPOROSISOSTEOPOROSIS (peak bone (peak bone density 15density 15--30 years).30 years).Important to treat adolescents Important to treat adolescents ASAPASAPas can cause as can cause STUNTED GROWTHSTUNTED GROWTHthat can never be made up even if that can never be made up even if healthy weight reached.healthy weight reached.

PROGNOSISPROGNOSIS

Seems to be worse if:Seems to be worse if:Very young age of development (<11)Very young age of development (<11)Very severe weight lossVery severe weight lossRequiring an inpatient admission (50% Requiring an inpatient admission (50% risk of readmission)risk of readmission)

PROGNOSIS ContPROGNOSIS Cont::

Vomiting/purging behavioursVomiting/purging behavioursLack of parental/carer consistency, Lack of parental/carer consistency, support and supervision in managing a support and supervision in managing a young personyoung person’’s eating difficultiess eating difficultiesDisengagement from treatmentDisengagement from treatment

WHY?WHY?

Common QuestionCommon QuestionITIT’’S NOS NO--ONEONE’’S FAULT S FAULT –– Nobody Nobody CAUSES or CHOOSES to have CAUSES or CHOOSES to have Anorexia!!Anorexia!!NO NO clear or clear or SINGLE SINGLE answers answers –– Likely Likely to be different for different individuals.to be different for different individuals.

WHY? Cont:WHY? Cont:

Multiple factors likely to be involved at Multiple factors likely to be involved at different times in the lifedifferent times in the life--cycle cycle including:including:Predisposing factorsPredisposing factorsPrecipitating factors/TriggersPrecipitating factors/TriggersPerpetuating factorsPerpetuating factors

Some Possible Influences:Some Possible Influences:

Genetic vulnerability (Genetic vulnerability (““Genetic BucketGenetic Bucket””))Personality Traits (e.g. perfectionist/high Personality Traits (e.g. perfectionist/high achievers/low self esteem)achievers/low self esteem)Important transitions Important transitions –– SchoolSchool

Moving homeMoving homeLifeLife--CycleCycle(Puberty)(Puberty)

Influences cont:Influences cont:

Losses/BereavementsLosses/BereavementsPeer relationship difficulties/BullyingPeer relationship difficulties/BullyingSocial Pressures Social Pressures –– ““Looking GoodLooking Good””

Academic Academic AchievementAchievement

Influences cont:Influences cont:

Family Factors Family Factors –– Parental disharmony orParental disharmony orSeparationSeparationHistory of PsychiatricHistory of PsychiatricIllnessIllnessCommunication StyleCommunication Style

Abuse Abuse –– Physical, Emotional, Neglect,Physical, Emotional, Neglect,SexualSexual

BUT NEED TO REMEMBER NONE BUT NEED TO REMEMBER NONE OF THESE IN THEIR OWN OF THESE IN THEIR OWN

RIGHT HAVE BEEN SHOWN TO RIGHT HAVE BEEN SHOWN TO CAUSE ANOREXIA NERVOSA CAUSE ANOREXIA NERVOSA

OR OTHER EATING OR OTHER EATING DISORDERS.DISORDERS.

All similar factors that can increase All similar factors that can increase an individual vulnerability to an individual vulnerability to

develop many different emotional develop many different emotional (and sometimes physical) (and sometimes physical)

problems. problems. But, But, individuals will all individuals will all respond differently, at different respond differently, at different

times, depending on their times, depending on their vulnerability and resilience factors.vulnerability and resilience factors.

Process of RecoveryProcess of Recovery

RECOVERY TAKES A LONG TIME!!RECOVERY TAKES A LONG TIME!!

Three Stage Model Of RecoveryThree Stage Model Of Recovery1) EATING PROBLEM1) EATING PROBLEM2) ASSERTIVENESS2) ASSERTIVENESS3) AGE3) AGE--APPROPRIATE EXPRESSION APPROPRIATE EXPRESSION OF FEELINGSOF FEELINGS

Stages of Anorexia NervosaStages of Anorexia Nervosa

IntensityIntensity

1 2 3 4 5 6 7 8 9 10 11 12Time in months

231

TREATMENTTREATMENT--PSYCHOTHERAPIESPSYCHOTHERAPIES

EVIDENCEEVIDENCE FROM CLINICAL TRIALSFROM CLINICAL TRIALSOnly evidence for an effective Only evidence for an effective treatment for adolescents and young treatment for adolescents and young adults with adults with Anorexia Nervosa Anorexia Nervosa is with is with FAMILY THERAPY/INTERVENTIONSFAMILY THERAPY/INTERVENTIONSbased on the based on the MaudsleyMaudsley Model. Model.

The Family Therapy Model has beenThe Family Therapy Model has beendeveloped into a developed into a MULTIFAMILYMULTIFAMILYGROUP GROUP programme of treatment and isprogramme of treatment and iscurrently undergoing a clinical trial andcurrently undergoing a clinical trial andstarting to be a useful modality ofstarting to be a useful modality oftreatment in increasing numbers oftreatment in increasing numbers ofcentres.centres.

Treatment cont:Treatment cont:

NONO evidence of any specific form of evidence of any specific form of individual therapy being most effective in individual therapy being most effective in treating adolescents with anorexia.treating adolescents with anorexia.CBT CBT has only shown so far to be more has only shown so far to be more effective in adult outpatients with effective in adult outpatients with Bulimia Bulimia NervosaNervosa. Further adaptations of the CBT . Further adaptations of the CBT treatment for other Eating Disorders, treatment for other Eating Disorders, including anorexia nervosa are currently including anorexia nervosa are currently being trialled.being trialled.

Treatment cont:Treatment cont:

Likely individual therapy in conjunction Likely individual therapy in conjunction with family therapy is effective in with family therapy is effective in treatment and is recommended.treatment and is recommended.N.B. Not all young people can use N.B. Not all young people can use individual therapy at low weights.individual therapy at low weights.