Eating Disorders: GP Tips

Eating Disorders: GP Tips

With thanks to Prof Chris Fairburn (Professor of Psychiatry at the University of Oxford, and author of CBT and Eating Disorders and Overcoming Binge Eating) and Dr Debbie Waller (GP, co-editor Oxford Book of Women’s Health and part of the NICE Eating Disorders Guidelines Development Group).

How common are eating disorders, and how are they defined?

Anorexia Nervosa (1 or 2 patients per 2,000 people)

• Extreme concern about shape and weight (with denial of thinness)
• Marked under eating and maintenance of an unduly low body weight (BMI<17.5)

Bulimia nervosa (18 per 2,000)

• Extreme concern about shape and weight (marked fear of fatness)
• Strict dieting punctuated by frequent episodes of loss of control (binges)
• Extreme behaviour to try to avoid weight gain e.g. self-induced vomiting, strict dieting, mis-use of laxatives etc

 ENDOS ‘eating disorder not otherwise specified’ (>20 per 2,000)

• Resembles AN or BN but do not meet their diagnostic criteria

How should I pick them up?

By thinking and asking! Often hidden due to denial (AN) or shame about binge eating (BN), and often somatic or psychiatric presentations before diagnosis. Keep antennae alert, and consider if

• Low weight in a young woman
• Inappropriate requests for help with dieting
• Fatigue, dizziness, syncope, GI symptoms
• Oligomenorrhea
• Depression (or Anxiety)

And ask the questions:

• Do you think you have an eating problem? 
• Do you have a problem controlling your eating?
• Do you worry unduly about your weight?  Do other people think you do?

Safety first: how should I assess patients’ level of risk?

Measure and record:

• BMI, BP and pulse
• Muscle strength (’the squat test’)
• Co-existent psychopathology
• Depression, anxiety, self-harm and suicide risk
• Lab tests
• Routine blood tests sufficient (FBC, electrolytes, glucose)
• Monitor electrolytes if repeated vomiting/laxative abuse
• Check ECG if BMI<15.5
• Check bone density scanning if amenorrhoeic

What are the broad principles of management?

• Recognition by the patient that they have a problem is the critical first step
• This process may take many weeks and requires a good therapeutic relationship, sensitive handling and family involvement
• Reliable education from reliable sources are key
• Teenagers: either family therapy or CBT.
• Adults: outpatient CBT is key, especially for BN and associated eating disorders. CBT is now also the leading treatment for AN, if the patient can be managed on an outpatient basis. Treatment of severe AN may require a more intensive, approach
• Regular monitoring of physical health by GP if needed.
• Weight only needs regular monitoring if BMI is very low, or dropping
• Osteoporosis may develop quickly in AN, and is partially reversible. Restoration of weight and normal menstruation is key. There is no evidence to support drug treatment (e.g. COCP or HRT) although supplementation with calcium and vitamin D is generally recommended.
• Encourage dental review in patients with frequent vomiting
• Comorbid depression responds to antidepressant medication (fluoxetine well tolerated) but higher than usual doses are often required.

When should I refer to specialist services?

• Refer early to specialist services all cases of AN
• Urgent referral if BMI <13.5, accelerated/rapid weight loss (>1kg per week) and/or significant medical/psychiatric complications
• BN
• GP-guided self-help is first step.  
• Recommend ‘Overcoming Binge Eating’, and offer to see every 2-4 weeks for support/encouragement
• Fluoxetine 60mg mane is not routinely recommended, as the therapeutic effect is so transitory in reducing binges. However, have low threshold for treating co-morbid depression.
• If fail to respond, refer for individualized CBT

What about University students and fitness to study?

Oxford University Guidelines for intermission from college:

• Significantly compromised physical (e.g. BMI<15  women <16 for men, electrolyte disturbance) or mental state
• Rapid weight loss e.g. >0.5 kg per week
• Fit to return when stable physical and mental state and BMI >16

Useful reading

·        Fairburn, CG.  Overcoming Binge Eating. Guilford Press, New York.

·        Treasure, J.  Anorexia nervosa: a survival guide for families, friends and sufferers. Psychology Press, Hove.

·        Abraham, S and LLewellyn-Jones, D. Eating Disorders: the Facts. OUP.

Recommended website: Eating Disorders Association: http://www.edauk.com/

Simon

With many thanks to Prof Chris Fairburn for his expert advice

http://www.psychiatry.ox.ac.uk/research/researchunits/credo/professor-christopher-fairburn

Phenomenology as resource for patients

Discussion of a paper by Dr Havi Carel – Phenomenology as a Resource for Patients, published in the Journal of Medicine and Philosophy (37;96-113, 2012).

There is a long history of thinking and theorising about what goes on in general practice, and this has contributed I think, to more effective and meaningful communication, to greater empathy, understanding, trust, and ultimately a better outcome for patients, however you choose to define it. Two notable examples are the biopsychosocial model and narrative-based medicine. The narrative-based approach in many ways “turned the conventional biomedical approach and even patient-centred one on its head”, as wrote Dr John Launer in an editorial in the BJGP back in February 2003. He continued:

“…Instead of listening to ‘the patient’s history’ to determine what to do, it judges our actions by whether they contribute to an improvement in the patient’s narrative”.

The huge increase in projects, groups and websites which focus on patient’s stories and on personal experience of illness is increasingly valuable in providing a source of support and information of a sort that is so important but unfortunately just not possible, it seems, to provide in the conventional GP setting..DiPEX website and the Oxford Health Experiences Research Group being an obvious example.  

These developments have arisen from an unmet need or from dissatisfaction with conventional western medicine, and are underpinned by work in anthropology, sociology, philosophy and social sciences.

As a GP and someone with a lay interest in philosophy, I was interested to read a paper in the Journal of Medicine and Philosophy which described some work being carried out in Bristol between philosophers and medics, who are working towards using phenomenology as a resource for patients…. Does this seem ridiculous? Philosophy is after all often considered a very non-practical ‘head in the clouds’ discipline. On the contrary I think this work is thought-provoking and innovative, should complement the way in which we conceptualise illness, and importantly just may provide a new way for us to support patients in developing their own understanding and coping strategies in times of ill-health.

A useful route into describing this work is to mention the author of this paper and one of the leading academics involved in the project. Havi Carel is a philosopher who was diagnosed with a rare lung condition (LAM) in her thirties. She turned to her area of interest -phenomenology- to help her come to terms with this, and subsequently developed a project exploring how phenomenology could be used to enhance the “constricted concepts and dry medical language” which are generally used to describe illness. Phenomenology is a broad philosophical movement developed from work by Edmund Husserl at the start of the last century, but can be simply defined as the study of the structure of experience. Carel’s work involves discussions with health professionals and is now included in the medical curriculum at Bristol Medical School. You can read more about Havi Carel and her work here:  http://medicalhumanities.wordpress.com/2011/03/09/standing-on-the-shoulders-of-giants/

Literature and the arts have long been used to express the experience of illness, and Carel’s work is taking this concept forward in developing potential benefits from philosophy for patients and health provision more broadly, in a structured way. Developing a workshop for patients using this approach is especially interesting for doctors because the concepts used are in contrast to those we are familiar with from the bulk of our medical training. But the concepts do perhaps tap into our personal experiences of illness, or of those of our loved ones.

The toolkit proposed takes the form of a process that brings about redefinition of illness, with 3 phenomenological steps:

1.      Phenomenological reduction

This could be seen as something already engrained in us as GPs, namely seeing the person behind the diagnosis, but is expressed in the paper more as a shift away from the disease and towards the experience. It is suggested that illness forces a kind of phenomenal reduction on us when we are ill because it causes us to suspend our normal approach to the world. “Once the belief in the objective disease entity is bracketed and we are distanced from our usual way of experiencing, we can begin to explore how illness appears to the ill person, its structure and its essential features”.

2.      Thematizing illness

This part is about focusing on different aspects of the person’s experience of illness and also allows the many perspectives eg. of family members, friends, doctors etc. to be brought out and explored. This can help patients move to a more descriptive way of understanding their experience, bringing out a more adaptable and multidimensional view of illness, and away from seeing it as something objective and strictly defined. Different aspects can be explored depending on the individual.

3.      Review of one’s being in the world

This heading in laden with weighty philosophical discourse, and Heidegger’s broad understanding of ‘one’s being in the world’ is brought out in the article. But in summary this part of the workshop follows on from thematizing illness and involves exploring the overall effects of illness on one’s sense of place, interactions with surroundings and other people, on meanings and norms and on each aspect of that person’s individual world.  “By moving away from the narrow understanding of illness as a biological process a thick account of illness as a new way of being in the world can be developed by patients”.

This may all seem far removed from the consulting room, but I encourage you to consider the ideas brought out in this paper with an open mind. Carel and many philosophers not to mention practitioners before her have agreed that illness is ‘phenomenology in action’, but the work described in this paper is exciting in that it transforms the theory into a structured one-day workshop that is being planned by Carel and her collegues in Bristol. This has the potential to bring real benefits for patients although some details on how this will be run remain unclear. Another question is whether type of project can ever be made accessible to a broad variety of patients or will benefit a self-selecting minority.

Unfortunately the full text of the above article requires a subscription, but the abstract can be accessed for free: http://jmp.oxfordjournals.org/content/37/2/96.abstract

Zoe

What makes us doctors? Lasagna and warmth

What makes us doctors?

Hippocratic Oath – Modern Version

Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University

I swear to fulfil, to the best of my ability and judgment, this covenant:

• I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.
• I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.
• I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
• I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.
• I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.
• Most especially must I tread with care in matters of life and death. If it is given me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.
• I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.
• I will prevent disease whenever I can, for prevention is preferable to cure.
• I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
• If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter.
• May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.