anorexia

1. 2007 anorexia

2. Facts • Highest mortality rate of mental illnesses • Prevalence of 0.3% in young women • Average of onset 15 yrs

3. Hallmarks of anorexia • Extreme overvaluation of shape and weight • Physical capacity to tolerate extreme self imposed weight loss • Use of over exercise and over activity to burn calories • Purging practices – self induced vomiting, misuse of laxatives, diuretics, slimming medication. • Body checking – mirror gazing

4. ICD criteria for anorexia • Body weight 15% < expected BMI < 17.5 • Weight loss self induced – avoid fattening foods + self induced vomiting, purging, over activity, use of appetite suppressants, diuretics • Body image distortion • Widespread endocrine disorder involving hypothalamic- pituitary-gonadal axis

5. Endocrine disorder • Women • Amenorrhoea • Men • Loss of sexual interest or potency • Both • Growth hormone and cortisol may be raised • Abnormalities of insulin secretion • Changes in peripheral metabolism of thyroid hormones

6. Causes • Genetic predisposition • Found in families with following traits • Obsessive • Perfectionist • Competitive • ? Autistic spectrum traits

7. Causes • Precipitated as a coping mechanism against • Developmental challenges • Transitions • Family conflict • Academic pressures • Onset of puberty and adolescence • Sexual abuse • Also found in well functioning families

8. Diagnosis • Often suspected by friends, family school • Special investigations not needed • Basic investigations • Blood tests ecg weighing provide opportunity for patient to return to discuss results and probe for psychological problems

9. Physical; risk assessment • There is no safe cut off weight or BMI • Death unusual where low weight maitained purely by starvation • Death more likely if weight fluctuates grreately rather than being stable even if BMI < 12 • Risk increased in patients that misuse substances or purge frequently

10. Management • Takes 5-6 years from diagnosis to recovery • Up to 30% do not recover • Hospital admission correlated with poor outcome • Patients admitted voluntarily do better than those on compulsory admission • Brief hospital admission at times of crises associated with lower mortality

11. ManagementTemporary acceptance of low weigth • Acceptance of low weight as long as it is stable and regularly monitored • Patients/family take responsibility for re feeding • Psychotherapeutic interventions • Separate dietetic advice • Weight gain is slow but avoids iatrogenic risks

12. ManagmentEarly refeeding in hospital • Early refeeding in hospital • Exposes patient to iatrogenic complications such as infections • Exposed to pro anorexia culture form other patients • Weight maintenance not as good as home treatment

13. Psychotherapy • Short term structured treatments such as CBT do not work • Long term wide ranging complex treatments such using psychodynamic understanding, systemic principles, and techniques borrowed from motivational enhancement therapy and dialectical behavioural therapy

14. Management • Therapy involving whole family is superior • Sessions involving family and patient together give better family psychological adjustment • Weight gain greater when family seen separately from patient • Dynamically informed therapies both family and individual produce the best results

15. Summary • Anorexia has highest mortality of all psychiatric disorders • Positive diagnosis of psychologically driven weight loss • Short term treatments (CBT) don’t help • Focussed family work effective in adolescents • No drugs are effective