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EATING DISORDERS IN PRIMARY CARE

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EATING DISORDERS IN PRIMARY CARE Dr Nicki Mazey Overview Statistics Diagnostic criteria ED presentation Complications Primary Care Management Questions/Case studies ... – PowerPoint PPT presentation

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Title: EATING DISORDERS IN PRIMARY CARE


1
EATING DISORDERS IN PRIMARY CARE
  • Dr Nicki Mazey

2
Overview
  • Statistics
  • Diagnostic criteria
  • ED presentation
  • Complications
  • Primary Care Management
  • Questions/Case studies

3
Lies damn lies and statistics(Oscar Wilde) AN
  • 20 to 50 recover
  • 30 to 60 improve but retain partial symptoms
  • 20 remain severely disturbed
  • 220 die in the UK each year.
  • ¼ to ½ deaths from suicide.
  • 200 x general population suicide risk
  • Increasing in men
  • present at 14-18 years
  • 5 years average before presenting
  • Approx 2 per GP list
  • Admission worsens prognosis

4
Statistics Bulimia
  • Incidence 11.5/100,000 but likely higher.
  • Cities 5 rural 1
  • High relapse rate
  • Treatment impact may disappear after 5 years
  • 20 per average GP list
  • 70 women SIV

5
Types of Eating Disorder
  • Anorexia Nervosa
  • Bulimia Nervosa
  • Binge Eating Disorder
  • Atypical Eating Disorder / Eating disorder not
    otherwise specified (EDNOS)
  • Obesity

6
Think in terms of behaviours rather than ICD 10
classifications
  • Restricting
  • Bingeing
  • Vomiting
  • Over exercising
  • Laxative abuse
  • Diuretic abuse

7
ED Presentation
  • Friends
  • Tutors
  • Family
  • Physical symptoms
  • Psychological symptoms (depression/OCD)
  • Infertility/period problems

8
Complications of low weight/restrictive eating
  • CVS
  • GIT
  • Endocrine
  • Skin/hair
  • Renal
  • haematological
  • Musculoskeletal
  • METABOLIC
  • Immunological
  • Neurological

9
Complications of SIV
  • Mechanical
  • Chemical
  • Metabolic K, Na, dehydration
  • Other

10
Complications of Bingeing/Diuretics/Laxatives
  • Binges
  • Diuretics
  • Hypokalaemia (same as for SIV)
  • Hyponatraemia (same as for SIV)
  • Hypomagnesaemia
  • Laxatives
  • Physical effects (SIV)
  • Metabolic effects (SIV plus metabolic
    acidosis)
  • Other effects

11
Management Rules/Roles in Primary Care (hands in
the air)
  • Rules
  • Roles

12
Nickis Rules (but you can borrow them)
  • Engage the patient
  • Continuity of care
  • Think in terms of behaviours
  • Honest reporting encouraged
  • Avoid
  • a. crises
  • b. therapising
  • c. splitting
  • d. labels until appropriate
  • e. displaying anxiety

13
more Rules
  • Put things into perspective (70 SI vomiting)
  • Accept failures inevitable
  • Define your role with the patient
  • Take the goggles off (other illnessess/problems
    aside from the all consuming ED)
  • Dont refer to their appearance looking well
    gained weight healthy looking etc.. at
    reviews.
  • Cover your backside
  • Regular reviews/ pragmatic clear path
  • Co-ordinate care/links with other services

14
just a couple of teensy weensy rules
  • Medical complications should be directly
    proportional to severity of behaviours
  • Beware Munchausens as an ED presentation
  • Child protection
  • Any suggestions?????

15
Primary Care Roles
Co-ordination of care
16
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17
History
  • Assessment need to invest time
  • Reviews make regular at appropriate intervals and
    purposeful, short consulting time.
  • Ask about onset/frequency/triggers etc..
  • Restricting
  • Vomiting
  • Laxatives
  • Diuretics
  • Binges
  • Exercising for weight loss
  • Self harming
  • Suicidal thinking
  • Course/work issues
  • Support at University.
  • Medical problems.

18
Examination
  • As appropriate. Take the goggles off
  • CVS focus in AN
  • Often negative
  • Russells sign

19
Investigations
  • As per behaviours. FBC UE TFT Glucose
  • ECG if bradycardia, prolonged QT interval.
  • BMD scan

20
Restrictive eating/drinking
  • Hx fluids
  • Exam CVS focus
  • Ix bloods/BMD/ECG
  • Mx define role agree initial path/review
    frequency/referral/monitor with changes/minimise
    risk P.I.L (hair loss).
  • Multidisciplinary

21
Vomiting/laxatives/diuretics/exercise
  • Vomiting frequency/notify when changes/baseline
    Ix/PIL/dental advice/common.
  • Laxatives. Waste of time, wean gradually weeks.
    Rectal prolapse!
  • Diuretics. Waste of time, wean and monitor.
  • Exercise. Medical dilemma good or bad.

22
Binge eating
  • Hx. Meals regular??Frequency, triggers, duration,
    compensatory purging or not. Indirect
    Questioning.
  • Exam. Nil
  • Ix Nil
  • Mx meals/distract/company/fluoxetine.PIL.

23
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24
Referrals
  • Specialist Eating Disorders Psychotherapist
  • Psychiatry
  • Dentist
  • University support systems (welfare/sick
    notes/deferring courses)
  • Secondary care for medical complications
  • Inpatient psychotherapy

25
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26
Education
  • No shock tactics
  • P.I.L.
  • Crisis team access explanation
  • Contracts with friends/family
  • Laxatives (waste of time wean off)
  • Binges (avoid with regular meals and company)
  • Vomiting (no brushing and 1hr company)

27
Summary
  • GP role Monitoring, Education and Referral.
  • Guide through clear agreed path
  • Continuity of care
  • Sick notes/deferring courses
  • Liaising with services
  • Engage in regular purposeful review

28
Keeping up with Uni Course Support needed? Notes
needed? Supervision Deferring
  • Take the goggles off
  • Dont insist on label until
  • appropriate
  • Avoid duplicating
  • Verbalising anxiety to pt may
  • Facilitate escalation
  • Inhibit them

Self harming
Abuse
Suicide risk
Depression
Emotional
Personality Disorder
Do ask how they feel Dont say Youve gained
weight or you look well
Ix
Physical exam
hx
BP /Pulse /ECG /Bloods Bone density
  • Uni/support systems
  • Welfare
  • Mental health
  • Counselling
  • Specialist
  • psychotherapy

No shock tactics!
Professional meetings
Co-ordination of care
Crisis team access
Complications
P.I.Ls
Dentist
Laxatives
  • Honest reporting
  • Co-ordinate care
  • Avoid therapising
  • Avoid crises
  • Avoid splitting
  • Define your role to patient
  • Continuity of care VIP
  • Big up local services!
  • Support them
  • Cover your backside

Psychiatrist
  • Aims
  • Use behaviour descriptions
  • Review regularly rather than responding to crisis
  • Sick notes / fitness to practice
  • Good communication with team
  • Perspective lots of eating behaviours
  • Accept that you cant fix all behaviour

Waste of time Wean off slowly
2o care medical admission
Avoid binges
3o Care
Regular meals Company
In-patient EDS
Avoid vomiting
Psychotherapy
29
Questions / Case Studies / More rules.?
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