Eating disorders

Pre-referral guidelines for primary care providers

Referrals
Prereferral guidelines A-Z index
Eating disorders

Referrals pathways for Regional Paediatric model

Index:

Diagnosis

Practice Points

Management

Referral Pathways

Eating disorders (ED) are a common and often serious mental and physical health problem encountered in the adolescent population. Life time prevalence for females have been estimated as high as 15%.

Diagnosis

Eating disorders (ED) should be suspected in anyone presenting with suggestive symptoms or signs (see Practice Points below).

The diagnosis of ED have been reclassified in the DSM V, with the following being a summary of the key points:

DSM-V criteria:

  • AN (Anorexia Nervosa).
    • Persistent restriction of energy intake leading to significantly low body weight (<85% expected weight for height)
    • Either an intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain
    • Disturbance of body image, or lack of recognition of seriousness of current low body weight
    • Subtypes – restricting vs. binge-eating/purging
    • Amenorrhoea is not part of the diagnosis of AN (compared with DSM-IV).
  • BN (Bulimia Nervosa)
    • Recurrent episodes of binge eating
    • A fear of not being able to stop whilst bingeing
    • Compensatory behaviours (vomiting, laxatives, exercise or fasting)
    • Overeating & compensatory behaviours once per week for 2 months
    • Self evaluation unduly influenced by body weight or shape
    • The disturbance does not occur exclusively during episodes of AN
    • No distinction between purging & non-purging subtypes (as compared with DSM-IV).
  • BED (Binge Eating Disorder)
    • Recurrent episodes of binge eating, with a fear of not being able to stop whilst bingeing
    • The binge eating episodes are associated with 3+ of:
      • Eating much more rapidly than normal
      • Eating until feeling uncomfortably full
      • Eating large amounts of food when not feeling physically full
      • Eating alone due to feeling embarrassed by how much one eats
      • Feeling disgusted, depressed or very guilty afterwards
    • Marked distress regarding bingeing is present
    • Binge eating occurs at least once per week for 3 months
    • Binge eating is not associated with compensatory behaviours.
  • OSFED (Other Specified Feeding or Eating Disorder)
    • Atypical AN – all other features of AN are met without significant LOW
    • Atypical BED or BN – less than 3 months duration
    • Purging disorder – recurrent purging to influence weight/shape in the absence of binge eating
    • Night eating syndrome – recurrent episodes of eating after awakening from sleep, or excessive food consumption after the evening meal, not explained by another ED.

Practice points

  • Eating disorders (ED) are common and often serious mental and physical health problems that the clinician should be alert to.
  • Early ED management can be undertaken by a General Practitioner, without referral to specialist medical services.
  • A psychologist is essential in the management of eating disorders.
  • Be alert for early warning signs (including offering parents web based resources - see below):
    • Sudden loss of weight
    • Physical symptoms
      • cold sensitivity, postural dizziness, muscle cramps, bloating, abdominal pain
    • Physical signs
      • dehydration, stress fractures, dental problems & knuckle calluses
    • Behavioural symptoms
      • restrictive diet, fear foods, focus on weight, preoccupation with exercise, calorie counting, use of diet pills/laxatives, social isolation
    • Psychological symptoms
      • body image distortion, loss of control, low self esteem, perfectionism, anxiety/depression, guilt.

Management

The management of adolescent eating disorders (ED) must involve a combination of medical (GP or paediatrician), psychological and dietetic input. Early detection and rapid recovery are paramount to minimising long term morbidity and mortality.

Psychology

  • A psychologist is essential in the management of eating disorders.
  • Family Based Therapy (FBT) is the mainstay of therapy for ED and trained clinicians are available through ICHMS (Infant and Child Mental Health Service) and YMHS (Youth Mental Health Service).
  • Other therapies useful in the management of ED include:
    • Individual therapy
    • Cognitive Behavioural Therapy – Extended (BD, BED)
    • Others (Specialist Supportive Clinical Management for AN, Interpersonal therapy for BN, MANTRA, ACT, DBT).

Medical

  • Medical input remains critical in the management of eating disorders to monitor for complications and manage appropriately.
  • Early ED management can be undertaken by a General Practitioner, without referral to specialist services.
  • Ensure comprehensive initial history including:
    • overview of early warning signs (see Practice Points section above)
    • daily food/fluid intake assessment
    • HEADSS assessment (home, education, activities, drugs, sexuality, self harm & suicidality).
  • Monitor with exam for:
    • lying/standing pulse & BP (wait 2 minutes after standing)
    • temperature
    • urine specific gravity
    • weight, BMI (use CDC BMI charts – male and female)
    • calculation of %IBW/EBW (percent of ideal/expected body weight, or 50th centile BMI).
  • Consider investigations for:
    • UEC, CMP, BSL, LFT (can be repeated as required in unstable patients)
    • FBE, Fe studies, B12/folate, celiac screen, ESR +/- FSH/LH
    • bone age, DEXA scan (must have paediatric setting with z-scores)
    • ECG (if HR <50 bpm).
  • Refer if approaching or meeting medical admission criteria:
    • Bradycardia (<45 bpm)
    • Postural hypotension (> 20 mmHg drop)
    • Postural tachycardia (>30 bpm rise)
    • Hypothermia (<35.5 degrees celcius)
    • Loss of weight >30% body weight or >1kg/week for several weeks
    • BMI <13 (post-pubertal)
    • Clinical dehydration
    • Electrolyte instability
    • Persistent failure of outpatient therapy
    • Suicidality (screen with HEADSS assessment - above).

Other resources

  • Multiple community support services exist to assist the ED sufferer and their family, as well as treating clinicians - see Referral Pathways section below.

Medication

  • Medication is not first line management of eating disorders, although can be considered in the some circumstances, e.g.:
    • SSRIs – BD, BED (rarely AN given evidence demonstrates no improvement in symptoms)
    • olanzapine – AN (used in severe cases to reduce persistent intrusive and compulsive thoughts).

Referral pathways

  • Paediatrician
    • consider a semi-urgent referral (if approaching medical admission criteria) to paediatric outpatient services or urgent referral (if meeting medical admission criteria) to an Emergency Department attached to paediatric services.
    • Information to bring to any appointments:
      • previous weights and charts (if available)
      • previous investigations performed
      • contact details of any other health practitioners involved in care.
    • Note that the Royal Children's Hospital eating disorder service is generally not required for families in the Grampians region given the multidisciplinary services offered in Ballarat.
  • Psychologists
    • Psychology services are an essential part of management for adolescent ED.
    • ICMHS (Infant and Child Mental Health, 0-14yo) or YMHS (Youth Mental Health Services) have clinicians throughout the Grampians region trained in FBT (Family Behavioural Therapy).
    • Private psychologists will often be able to provide either FBT or other ED-specific therapies.