Anorexia nervosa Presentation

Mental Health Nursing Professor Vicki Dury

NURS 8818

Group Presentation Regan Preston, Sophie Henry, Sasha Webb Ware, Neville McCloy, Bin Zhou

What is anorexia nervosa1-3 •  DSM-IV-TR Eating disorder(307.1, Axis 1), ICD-10

F50.004 •  a severe, distressing and in many cases chronic

mental illness. •  distorted view of body shape and weight. •  disturbances in their eating behaviour. •  Compulsive exercising for the weight loose purpose.

Diagnostic criteria of DSM-IV-TR3 •  A: Refusal to maintain body weight at or above a

minimal normal weight (less than 85% of ideal body weight)3; BMI<=17.54

•  B: An intense fear of weight gain even though underweight3.

•  C: Distorted or disturbed body image including perception of being fat, denies of underweight3.

•  D: Postmenarcheal females amenorrhea or the absence of at least three consecutive menstrual cycles3.

•  E: Pubertal development delayed or arrested if prepubertal onset4 .

Sub-types •  There are two recognised sub-types: •  ‘restricting’ : severe limitation of food intake3.

(ICD-10-CM F50.01)5 •  ‘binge-eating/purging’3: (ICD-10-CM F50.02)5 •  involving episodes of food intake followed by self-

induced vomiting and/or laxative or diuretic abuse and/or intense exercise.

Common used assessment for Anorexia Nervosa •  Full medical examination6 •  Psychiatric status6 •  Body image6 •  Nutritional conditions6 •  Eating behaviours6 •  Family history6

Epidemiology •  Typically affects adolescent girls and young women. •  Occurs in approximately 0.5% of girls and young

women in developed societies. •  5-15% of all people with AN are males. •  Evidence suggests that more than 50% of adolescents

presenting with eating disorders do not meet the full diagnostic criteria but still require treatment.4  

Aetiology •  The exact cause is unknown 4, 5 •  Multi-factors:4, 5 •  Genetic •  Psychodevelopmental •  Sociocultural factors •  Low self-esteem •  Traits

Genetic factors •  A genetic predisposition to AN but insufficient for

the development of the disorder3 •  The concordance rate is higher in monozygotic

twins 44% than dizygotic 12.5%3 •  A Swedish Twin Registry study of 31,406 twins

yielded a 56% heritability estimate of AN4 •  Study purports to show the development of AN is

mediated by the disruption of serotonergic pathways. Contributing to comorbidities – depression and anxiety.3

Sociocultural factors

•  Exposure to the thin/beauty ideal. Is this a factor?5

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Low self-esteem •  Body Image Dissatisfaction5

•  AN sufferers have lower self-esteem and inefficient coping mechanisms5

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Traits •  Perfectionism5 •  Obsessive – Compulsive5

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Common Signs and Symptoms •  Physical Signs and Symptoms •  Rapid Weight Loss6 •  Amenorrhea6, 7 •  Hypotension, bradycardia and arrhythmias7 •  Thinning hair, dry skin and brittle nails8 •  Peripheral coolness especially in hands and feet8 •  Abdominal bloating, discomfort & diarrhoea8 •  fatigue8 •  electrolyte imbalance especially in patients who are

bulimic6, 8

Psychological and behavioral signs and symptoms •  abnormal fear of becoming obese with distorted self

-image 6, 7 •  disturbance in mood – irritable, withdrawn and easily

upset7, 8 •  Disruption in normal sleep patterns6 •  Attention and concentration levels decrease6 •  Bulky clothes to mask her bodily appearance9 •  Obsession with food and thoughts of food and

development of food rituals6, 8

Psychological and behavioural signs and symptoms •  Some patients show signs of affective mood

disorders, anxiety disorders and personality disorders6

•  Excessive exercise6 •  Binge and Purge behaviours6 •  Laxative abuse8 •  Refusing to acknowledge the illness8 •  Pretending to or lying about eating

Acute presentation •  Excessive weight loss8 •  Emaciation with a marked absence of subcutaneous

fat6 •  Cardiovascular complications – typically hypotension

and bradycardia9 •  Impaired gastric emptying & fatigue9 •  Nutritional hepatitis9 •  Bone marrow hypoplasia9 •  Severe weakness and fatigue9

Acute presentation •  hypometabolic state with low levels of potassium,

sodium, phosphorous, magnesium, calcium, hypoglycaemia and metabolic acidosis9

•  depression •  irritability and social withdrawal •  decreased sexual libido •  dysphoria9 •  premorbid perfectionism, introversion, poor peer

relations and low-self esteem9

Chronic presentation •  absorption in their illness9 •  developmental delay socially and emotionally9 •  depression, anxiety and affective mood disorders •  Amenorrhea 7 •  Reduced fertility and increased spontaneous abortion

rate 7 •  Increased basal growth hormone 7

Chronic presentation •  Low T3 syndrome 7 •  Elevated levels of cortisol7 •  Osteopenia & osteoporosis of the trabecular and

cortical bone compartments7 •  Dental defects 7 •  Reduction in kidney function7 •  Ankle oedema 6 •  Lanugo hair – especially over the back and face6

Presentations

The Bottom Line “Treatment is not all about food and eating – it is about

you as a person and what is important to you.”

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Treatment goals •  Treatment of symptoms of eating disorder 11 •  Treating other existing psychological complaints11

(self worth, shame) •  Treating co-morbid psychological disorders

(depression, phobias) •  Preventing relapse 11

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Aims of treatment •  Restore weight and reverse malnutrition13 •  Achieve wellbeing 13 •  Give you freedom from mental anguish 13 •  Give you back your life 13 •  Identify your true values – to help you discover your passions

and our own identity, set u free.13

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Major treatment approaches •  Inpatient treatment – Hospitalization 10 •  Day patient treatment 10, 11 •  Outpatient treatments

•  Family therapy 10, 12-14 •  Cognitive-Behavioral Therapy (CBT)13, 15 •  Interpersonal therapy 15 •  Education and nutritional counseling 11

•  Feminist approaches •  Pharmacotherapy 10

•  Cisapride, Clomipramine, zinc supplements, sulpride, Fluoxetine 13, 15

Cognitive Behavioral Therapy(CBT)

“Therapy that aims to help people develop more efficient coping mechanisms by equipping them with

strategies that promote logical ways of thinking about and responding to everyday situations.”

Elder R, Evans K, Nizette D. Psychiatric and Mental Health Nursing. 2nd ed. Sydney, NSW: Elsevier Australia; 2009.

CBT in the treatment of anorexia nervosa Goal: to restructure dysfunctional and irrational thoughts and behavior patterns that contribute to the eating disorder. This includes the central idea that self-worth is linked to weight, shape and physical appearance

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Appearance + control = self-worth?

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CBT phases – 6 sessions over 3 weeks Elder R, Evans K, Nizette D. Psychiatric and Mental Health Nursing. 2nd ed. Sydney, NSW: Elsevier Australia; 2009

Phase 1 •  Self-monitoring •  Weighing •  Regular eating

patterns •  Self-control strategies

Phase 2 • No more dieting • Problem solving • Modifying thoughts linking self-esteem with weight and shape

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Phase 3 •  Relapse prevention •  Stress management skill development

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Does it work? •Almost 50% of patients who gain weight as inpatients relapse within 1 year of discharge.1 •Evidence is strongest to support efficacy of CBT with adult AN patients.1-3 •Patients are more likely to stay in therapy programs and complete treatment if receiving CBT.3

Some evidence to suggest that CBT is more effective than nutritional therapy.2, 4

Does it work? •2009 RCT - Time to relapse significantly longer for patients who receive CBT compared with Treatment As Usual (TAU). 65% participants in trial who received CBT still not relapsed 1 year after discharge.5 •2011 open trial – full or partial remission achieved by 2/3 patients who completed CBT program – 40% of total sample.6

Best available evidence on management of anorexia nervosa

Best available evidence on management of anorexia nervosa

•  Location of treatment: •  Systematic reviews (SR) on two Randomized control trial (RCT),

concluded inpatient treatment (not extreme), outpatient treatment was as effective as inpatient treatment.15

•  Behavioral Treatment: •  One RCT behavioral family therapy was more effective than individual

therapy in weight gain in adolescents, but not eating habits.13, 15

•  In adults family, psychoanalytic and CBT were all superior to routine

treatment (low contact outpatient therapy).6, 14, 15

•  Greater compliance found towards CBT, however SR showed insufficient evidence over any one therapy been superior than another approach.14, 15

Best available evidence on management of anorexia nervosa

•  Pharmacotherapy: •  In RCT reviewed, Cisapride did not effect weight gain,

however patient appetites improved.16 •  Zinc supplements enhanced weight gains in RCT of adult

patients.15, 16 •  Double blinded RCT on Fluoxetine, there was superior

weight gain and improvement in anxiety and depression.6, 15, 16

•  A Cochrane review found no evidence that antidepressants improved weight gain or the eating disoprder.15

•  Literature reviewed however showed that as a whole pharmacotherapy had little benefit in treatment on AN.6, 15

Best practice recommendations •  Were applicable, patients with AN that do not require

inpatient treatment, outpatient or day patient treatment may be better suited.15

•  Family and CBT are recommended in patients were depression, eating habits are not key therapeutic goals.15

•  Antidepressant medications may be recommended for patients with depressive symptoms.

•  Nasogastric feeding if required must be a collaborative decision.13, 15

•  Recommend discharge from hospital at normal weight minimizes risk of re-admission. 15

Best practice recommendations •  Treatment of patients in all location setting should be

undertaken by therapists with expertise in eating discorders.11

•  In treatment of children and adolescents, parents and family should be involved in treatment.11

•  Inpatient setting: weight gain between 500g – 1000g per week, Outpatient: goal 200-500g per week. Weigh same time every morning.11

Best Practice? Q: “Is evidence-based treatment of anorexia nervosa

possible?” •  2005 – “Barely.”10 •  2003 – “…dogmatism is best avoided.”17 •  2009 – “More evidence-based research is needed…

to facilitate better outcomes.”20 •  2009 – “There remains much work to be done.”21

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Consensus supported by research

•  Multi-disciplinary, multi-dimensional treatment plans are most effective.17, 20

•  Start treatment the earlier the better.21 •  Family therapy can be effective in the treatment of younger

people with AN, e.g. Maudesley family therapy.17 •  Treatment can be effectively delivered in outpatient and day

patient settings, particularly long-term therapy.17, 21 •  Evidence is scant to support the efficacy of pharmacotherapy

but some evidence to suggest the efficacy of anti-depressants. 10, 20, 21

 

Psychoeducation

•  Contributes, as one aspect of multi-disciplinary psychotherapeutic approach, to attitudinal change.

•  Often involves carers as well as patient. •  Assists patient to gain insight and understanding,

enhances cooperation and motivation and provides affirmation of support.

References: Elder R, Evans K, Nizette D. Psychiatric and Mental Health Nursing. 2nd ed. Sydney, NSW: Elsevier Australia; 2009. Treatment Protocol Project. Management of Mental Disorders. 3rd ed. Sydney, NSW: World Health Organization Collaborating

Centre for Mental Health and Substance Abuse; 2000

Delivery methods •  Will vary according to care delivery setting, severity

of illness, stage of recovery and patient needs and wishes.

•  One-to-one individual therapy •  Group therapy •  Self-help, e.g. self-help manuals and on-line therapy

packages

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Elements of education •  Information about the disease – what is it? •  Biological theories of weight regulation •  What happens when you starve? Physically?

Psychologically? •  What happens when you vomit a lot? When you use

laxatives a lot? When you use diuretics a lot? •  What happens when you binge? What is the binge/

purge cycle?

Elements of education •  What is a healthy weight range? •  When is exercise good for you? When is it not so

good? •  What are the short and long term effects of anorexia

nervosa? •  What is a healthy eating pattern?

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Elements of education •  How can goal setting help and how do we do it? •  What techniques and alternative coping strategies

can be developed for managing stress? •  How can relapse be prevented? •  What are self-monitoring skills? •  Challenge unrealistic beliefs (sensitively but firmly) •  Reward and affirm positive adaptive behaviours •  Provide feedback

Elements of education •  Challenge unrealistic beliefs (sensitively but firmly) •  Reward and affirm positive adaptive behaviours •  Provide feedback

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Families, Carers and Friends •  Accept that there are no quick or easy solutions. •  Practice self-care. •  Try not to allow the disorder to influence family or

group activities. •  Provide unconditional love – not tied to expectations

regarding weight gain etc. •  Talk about something other than food

Families, Carers and Friends •  Listen. •  Avoid power struggles. •  Avoid manipulative interactions – eg “You are

destroying this family”, etc…. •  Be alert to cooking and feeding others as a potential

substitution behaviour for eating. •  Work with multi-disciplinary professional care team. •  Avoid self-blame and chronic guilt

Useful sources of information •  www.ranzcp.org •  www.womenshealthworks.org.au •  www.eda.org.au •  www.eatingdisorders.org.au

Questions & Answers

Resources •  1. Reach Out Australia. Anorexia nervosa 2011 [updated 14 Nov 2011; cited 2012 16 Mar ].

Available from: http://au.reachout.com/find/articles/anorexia-nervosa •  2. Brownell KD, Hotelling KJ, Lowe MR, Rayfield GE. Eating Disorders. Washington:

American Psychological Association 2011 [updated October 2011; cited 2012 16 Mar]. Available from: http://www.apa.org/helpcenter/eating.aspx

•  3. American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. 4th ed. Washington, DC: American Psychiatric Association 2000 [cited 19/03/2012]. Available

•  4. Chen. Anorexia Nervosa . In: 5-Minute Clinical Suite. 6th ed. St Louis (MO): Wolters Kluwer Health: 2012 [Cited 21/3/2012] Available from: Clin-eguide. 2012.

•  5. Bulik C, Streigel-Moore R. Risk Factors for Eating Disorders. American Psychologist 62:3 181-198 2007.

•  6. Gilbeet. Helping Children and Adolescents with Chronic and Serious Medical Conditions [Internet] In: Other Conditions That May Occur in Childhood or Develop in Adolescence. Issue 14, 2010. Hoboken, NY: AS Wiley. 2010.

•  7. Fairburn. Eating Disorders and Obesity. New York : The Guilford Press, 1995. 1995. •  8. Edwards. Anorexia Nervosa. MedicineNet. [Online] 2012. [Cited: 17 March 2012.]

www.medicinenet.com. 2012.

Resources •  9. Centre. Anorexia Nervosa. University of Maryland Medical Centre. [Online] 2012. [Cited:

20 March 2012.] www.umm.edu/. 2012. •  10. Furth. Handbook of Eating Disorders . England : Treasure, Schmidt & van Furth.John

Wiley & Sons Ltd, 2003. 2003. •  11. Fairburn CG. Evidence-based treatment of anorexia nervosa. International Journal of

Eating Disorders. 2005;37(S1):S26-S30. •  12. Herpertz S, Hagenah U, Vocks S, von Wietersheim J, Cuntz U, Zeeck A. The Diagnosis

and Treatment of Eating Disorders. Deutsches Aerzteblatt International. 2011;108(40):678-685. Available from: jlh

•  13. Fisher Caroline A, Hetrick Sarah E, Rushford N. Family therapy for anorexia nervosa. Cochrane Database of Systematic Reviews [serial on the Internet]. 2010; (4): Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004780/frame.html.

•  14. Psychiatry AaNZJo. Australian and New Zealand clinical practice guidelines for the treatment of anorexia nervosa. Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Anorexia Nervosa. 2004 [cited 15/3/2012];38:659-670.

•  15. Hay Phillipa PJ, Bacaltchuk J, Byrnes Roanna T, Claudino Angélica M, Ekmejian Avedis A, Yong Poh Y. Individual psychotherapy in the outpatient treatment of adults with anorexia nervosa. Cochrane Database of Systematic Reviews [serial on the Internet]. 2003; (4): Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003909/frame.html

Resources •  16. Jayasekara. Anorexia Nervosa: Management. The Joanna Briggs Institute. 2010 [cited

15/3/2011]:3. •  17. Jonine P-W. Anorexia nervosa, Australian treatment guide for consumers and carers.

2009 [cited 15/3/2012]. Available from: Website: www.ranzcp.org •  18. Treating anorexia nervosa. Harvard Mental Health Letter [Internet]. 2009 [cited 11 Mar

2012];26(2):1-3. •  19. Beumont P, Hay P, Beumont R. Summary Australian and New Zealand clinical practice

guideline for the management of anorexia nervosa (2003). Australas Psychiatry [Internet]. 2003 [cited 7/2/2012];11(2):129-133. .

•  20. Jayasekara R. Anorexia Nervosa: Management [Evidence Summary on the Internet]. Adelaide: Johanna Briggs Institute; 2012 [updated 02/12/20109/2/2012]. Available from: JBI Connect+.

•  21. Byrne S, Fursland A, Allen K, Watson H. The effectiveness of enhanced cognitive behavioural therapy for eating disorders: An open trial. Behaviour Research and Therapy. 2011;49(4):219-226.

•  22. Elder. Elder R, Evans K, Nizette D. Psychiatric and Mental Health Nursing. 2nd ed. Sydney, NSW: Elsevier Australia; 2009. 2009.