GP Trainee Teaching Day 8th December 2010

Eating Disorders and Psychiatric Emergencies in

Primary Care

• Aims To prepare trainees for managing cases of high risk eating disorders and anxiety provoking psychiatric presentations.

• ObjectivesFor trainees to have a framework for understanding the broad concepts of eating disorders, and know where to seek readily accessible advice about the specifics of medical risk management.For trainees to have a structure in place for conducting a risk assessment and a better understanding of referral processes for mental health services and the conduct of Mental Health Act Assessments.

09.00-10.30

Theoretical Models and general approach to Eating Disorders

• What is an eating disorder?• How do you think about it?• Is it a mental illness?

F50.0 Anorexia Nervosa

AN is a disorder characterised by deliberate weight loss, induced and/or sustained by the patient…

Diagnostic GuidelinesFor a definite diagnosis, all the following are required:• Body weight is maintained at least 15% below that expected or BMI

is 17.5 kg/m2 or less. • The weight loss is self induced by avoidance of “fattening foods”.

One or more of the following may also be present: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics.

• There is body image distortion in the form of a dread of fatness persisting as an intrusive, overvalued idea and the patient imposing a low weight threshold on themselves.

• A widespread endocrine disorder… amenorrhoea.• (Delayed puberty)

ICD F50-F59 • Behavioural Syndromes associated with

physiological disturbances and physical factors

• Transdiagnostic Model

Black Box – “Emotional Problems”

Sm

oking A

lcoholH

eroinC

uttingO

verdosingG

ambling

Abusive relationships

Dietary R

estrictionP

urgingA

ppetite suppressantsLaxativesD

iureticsE

xcessive exercise

Self Defeating Behaviours

Trainspotting – Renton’s commentary on heroin

“People think it’s all about misery and desperation and death and all that shite,

Which is not to be ignored,But what they forget is the pleasure of it.

Otherwise we wouldn’t do it.After all, we’re not fucking stupid.

Or at least we’re not that fucking stupid.”

Change?

Therapist factors-

WarmthHonesty

listening skillsTrust

therapeutic optimism

How many psychiatrists does it take

to change a lightbulb?

Hunt for Red OctoberJack Ryan reasoning with himself whilst shaving,

“Wait a minute. We don't have to figure out how to get the crew off the sub, he's already done that. He would have had to. All we have to do is figure out what he is going to do. So how is he going to get the crew off the sub?They'd have to want to get off. So how do you get a crew to want to get off a submarine? How do you get a crew to want to get off a nuclear submar...”

Transtheoretical Model of Change• (Prochaska and DiClemente 1986-92)

Precontemplation

Contemplation

Determination

ChangeMaintenance

Relapse

Recovery

Motivational Interviewing

• Matching patient’s readiness• Non-critical alliance• Non-authoritarian• Boundaries, responsibility, ownership of problem• “Rolling with resistance”• Balance of pros and cons of change• (Biological, psychological, social)• Decision to change or not

Role play in pairs (discuss)

• 19 yo female dance student admits that her nausea and loss of appetite are as a result of abusing ephedrine that she has bought over the internet as an appetite suppressant. She also takes frusemide that was prescribed for her friends dog, as well as vomiting after every meal. She has a complex history of childhood abuse and insists that she has to keep her weight below BMI 19 to be successful as a dancer.

Treatment?

• Inside the black box?

Treatment

• Very little evidence. “Best practice”

Summary of NICE Guidance for Anorexia Nervosa• “Psychological interventions are treatments of

choice and should be accompanied by monitoring of the patient’s physical state”

ie Balance between “Therapy” and Medical Risk Management

Eisler ’97. RCT n=80 5yr f/u. Family Therapy vs Individual Supportive Therapy. “Outcomes favourable for FT if onset <19yrs and duration <3yrs.

Outcomes favourable for IST for late onset/chronic.”

Chris Fairburn’s Transdiagnostic Model – CBT-E

• Clinical perfectionism• Low self-esteem• Mood intolerance• Problems with relationships• Overvaluation of size and weight

“Coercive procedures should be reserved for the very small group of non-compliant patients whose situation is truly life-threatening; if possible they should be avoided altogether.”

Companion to Psychiatric Studies 6th Edition 1998

10.30-10.45 Coffee

10.45-12.30

Physical Risks and Medical Management in Eating Disorders

Minnesota Starvation Experiment

Ancel Keys et al 1950 Ancel Keys et al 1950 • demonstrated profound physical and demonstrated profound physical and

psychological changes in 36 healthy psychological changes in 36 healthy volunteers placed on a very low calorie volunteers placed on a very low calorie diet.diet.

Consequences of Starvation Exercise

• Body is machine made of fat/protein• Emaciation – global/sytemic dysfunction

Fill in the blank spaces for systemic symptoms, signs or abnormalities

Cardiovascular• Poor peripheral circulation (Cold fingers and

toes)• Hypotension (Fainting, collapse)• Oedema• Bradycardia• Arrhythmia• Sudden death• Cardiomyopathy• Cardiac valve disease

Endocrine

• Amenorrhoea• Infertility (acute and chronic)• Low libido• Low LH, LHRH, FSH• Low Thyroid Hormone (T3)• High Cortisol• High Fasting Growth Hormone• Erratic Vasopressin release

Renal

• Electrolyte abnormalities (low Sodium, Phosphate, Magnesium, Calcium, Potassium)

• Renal calculi• Hypokalaemic nephropathy• Proteinuria• Reduced Glomerula Filtration Rate

Haematological and Dermatological

• Anaemia• Leukopenia (recurrent/dangerous infections)• Thrombocytopenia (bruising)• Bone marrow hypoplasia• Reduced Serum Complement levels• Low ESR

• Dry, thin, brittle hair and nails• Lanugo• Loss of collagen, easy bruising, poor healing

Gastrointestinal

• Slowed gut transit time• (Abdominal pain, bloating, delayed gastric

emptying• Constipation)• Parotid swelling• Nutritional hepatitis• Refeeding pancreatitis

Metabolic• Loss of energy• Cold intolerance• Impaired temperature regulation• Hypoglucosaemia• Hypercholesterolaemia• Hypercarotenaemia• Hypoproteinaemia• Impaired Glucose Tolerance• High Beta-hydroxybutyrate• High Free Fatty Acids• Impaired Calcium metabolism• Vitamin deficiencies

Musculoskeletal

• Weakness• Aches, pains, minor soft tissue injuries• Loss of muscle mass• Proximal myopathy (squat test)• Osteoporosis• Osteopenia• Pathological fractures

Neurological and Psychiatric• Generalised Seizures• EEG abnormalities• Peripheral neuropathies (electrolyte abnormality,

mechanical)• Ventricular enlargement (brain shrinkage)

• Depression (all biological symptoms)• Cognitive impairment• Worsening anxiety• (Fear of fatness, bodyimage disturbance, OCD, rituals,

control of food)• Acute confusion, halucinations, coma

Maudsley Guide to Medical Risk Assessment

for Eating Disorders

Janet Treasure (2009) - online

Signs and symptoms of medical instability • Rapid weight loss >7kg in 4/52• Seizures• Fainting• Confusion• Bradycardia <40• Frequent exercise induced chest pain• Renal impairment/ urine <400ml/day• Dehydration• Tetany• Rapidly diminishing exercise tolerance

“The Handbook of Treatment for Eating Disorders” 2nd Edition 1997 (Garner and Garfinkel)

“Although a medical professional can fairly easily identify an emergency situation in progress, ther are few definitive indicators of impending crisis. Death from anorexia nervosa is often the result of a sudden, unheralded cardiac event.”

Role play in pairs (discuss)

• 23 yo man presents with depression. All biological symptoms of depression including loss of apetite and weight which he says is due to stress and depression – not deliberate. He does admit that he has been exercising as a way of managing his mood, and he is a vegan. Weight loss has been gradual over 8 months. His BMI is now 14.3. He wants an antidepressant.

12.30-13.30

Lunch

13.30-14.30

Psychiatric Emergencies in Primary Care and Mental Health Act Assessments

Primary Care Psychiatric Emergencies?

Stress for GP due to risk?

- Risk Assessment

Risk factors (for suicide)

• Mental illness (if not..?)• Alcohol/drugs• Age• Gender• Occupations• Help seeking

- Limitations

History

Previous behaviour -predicts future behaviour

- Limitations

Current Mental State

• Thoughts• Planning• Intent

Protective Factors

• Family• Dog• Religious beliefs• Hope for future/possible treatment• Engagement with services• Engagement with safety plan

Interface with Mental Health Services

Community Mental Health Teams

• 2/52’s target• Severe and Enduring• Risk• “short term work”• Up to x2 weekly contact• MDT – CPN, MHSW, OT, CSW, Clin Psy,

and Psychiatry

Intensive Home Treatment Team (Crisis)

• 4hr target• Assessment in conjunction with Duty Psychiatrist

(Junior)• Up to x2 daily contact• Telephone through night• Alternative to ward admission• Must be safe enough for home alone at night• Must be insightful and cooperative enough for

visits• Gatekeepers for admission to ward

Admission to Ward?

• Mental illness• Risk• Necessity

Date of referral Time of referral Team Member

Service User Information: Referrer Details:

Name Referrer

P / NHS No. Base

D.O.B Contact Details

Address

Care Coordinator

GP Details:

GP

Practice

Tel. No. Tel. No.

1.What is the referrer requesting (inpatient care, home treatment, early d/c, MHA assessment)?2.Has the referrer (or other MH professional) assessed the service user in person within the past 24 hours?3.Does the patient need to be seen in the next four hours? (If patient does not need assessment within four hours, then other contingency plans should be put in place by the referrer until a re-referral is made in keeping with the four hour target).4.Can the referrer attend a joint visit? 5.Has the crisis and contingency plan been implemented?6.When was the last medical review?7.Is there a significant risk history?8.Has the SAMP been updated recently?9.Can the referrer supply a copy of the SAMP and management plan?10.What medications, if any, are they currently prescribed?11.Are they concordant with medication?12.If the person is in A&E/hospital, are they medically fit?13.Are there any children at home?14.Is there a carer/family member at home?

Clinical Information: (Include info on current presentation / risk factors / personal & social circumstances / past history & drug / alcohol use)

Triage Response:

Consultation Only Assessment Required Admission Signpost Flag For Info

Plan:

Questions on IHTT Triage Form• What is the referrer requesting (inpatient care, home treatment, early d/c, MHA

assessment)?• Has the referrer (or other MH professional) assessed the service user in person

within the past 24 hours?• Does the patient need to be seen in the next four hours? (If patient does not need

assessment within four hours, then other contingency plans should be put in place by the referrer until a re-referral is made in keeping with the four hour target).

• Can the referrer attend a joint visit? • Has the crisis and contingency plan been implemented?• When was the last medical review?• Is there a significant risk history?• Has the SAMP been updated recently?• Can the referrer supply a copy of the SAMP and management plan?• What medications, if any, are they currently prescribed?• Are they concordant with medication?• If the person is in A&E/hospital, are they medically fit?• Are there any children at home?• Is there a carer/family member at home?

Mental Health Act Assessments

14.30-15.00

Tea

15.00-16.15

Case discussion exercises

Part 2. Medical ScrutinyDate Section papers sent for scrutiny:………………………………………………………………………Print name of scrutinising doctor:………………………………….…………………………………………

Yes No

a) Are the reasons for detention sufficient for the patient to be detained under the recommended section?

b) Have the recommending doctors written an adequate clinical description of symptoms?Medical Recommendation 1…………………………………………..…(name)Medical Recommendation 2………………………………………….….(name)

c) Is the appropriate medical treatment described and the availability confirmed? (treatment sections only)

d) Have the doctors stated why informal admission is not appropriate? Medical Recommendation 1…………………………………………..…(name)Medical Recommendation 2………………………………………….….(name)

e) Are you satisfied with the medical examinations?If “Yes”, please sign and date below. If “No”, please state your reasons clearly below.

(NB If you have indicated a medical recommendation requires amending, this form will be returned with the medical recommendation and you may be contacted about any queries.)

……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ………………………………………………………………………………………………………………Signed:………………………………………………Print Name:…………………………………………..

Date:…………………………………………………