A
Assessment
t and
dM
Motivation
ti ti iin
Young People with Eating
Disorders
Rachel Lawson
Senior Clinical Psychologist
South Island Eating Disorders Service
A quick introduction
introduction…
South Island Eating Disorders Service
„
„
„
„
Accept
p referrals from 13 yyears of age
g
Twenty five percent of clients aged 1313-17
Treatment offered is mostly outpatient
Six inpatient beds
Medical admissions
Weight Recovery Programme
Overview
Assessment
„
„
„
What are the eating
g disorders in yyouth?
ED specific questions
Physical Risk
Motivation
„
An ego syntonic problem
Rates of Eating Disorders
P
Prevalence
l
((over a lif
lifetime)
ti )
„
„
Anorexia Nervosa:
Bulimia Nervosa:
0.3%
1-2%
Incidence (new cases)
„
A
i N
000
Anorexia
Nervosa: 8 per 100
100,000
Highest for females 1515-19
„
Bulimia Nervosa: 11 per 100,000
The Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
EDNOS
Anorexia Nervosa Diagnostic Criteria
Refusal to maintain body weight at or above a minimally
normal weight for age and height
I t
Intense
fear
f
off gaining
i i weight
i ht or becoming
b
i ffat,
t even
though underweight
Disturbance in the way in which ones body weight or
shape is experienced. Undue influence of body weight
on se
self e
evaluation
or de
denial
of the
seriousness
of the
o
a ua o o
a o
e se
ous ess o
e
current low body weight.
Amenorrhea ((absence of at least 3 consecutive
menstrual cycles)
Anorexia nervosa is divided into two subtypes: restricting type and bingeeating/purging type
type.
Anorexia Nervosa Diagnostic Criteria
Child
Children
and
d Ad
Adolescents
l
t
„
„
Failure to make expected weight gains (i.e.
while growing in height) instead of weight loss
No menstruation by age 15 despite other
pubertal changes (primary amenorrhea)
Bulimia Nervosa Diagnostic Criteria
R
Recurrent
t episodes
i d off bi
binge eating
ti
„
„
Eating, in a discrete period of time an amount of food
that is definitely larger than most people would eat
during a similar period of time and under similar
episodes
A sense of lack of control over eating during the
episode
Recurrent inappropriate compensatory behaviour in
order
d tto preventt weight
i ht gain
i
Bulimia Nervosa Diagnostic Criteria
Both
B th behaviours
b h i
mustt occur att lleastt ttwice
i a
week for three months
Self-evaluation is unduly influenced by body
Selfshape and weight
The disturbance does not occur exclusively
during episodes of anorexia nervosa
Bulimia nervosa is divided into two subtypes:
„
non--purging and purging subtype
non
Eating Disorder Not Otherwise
Specified (EDNOS)
Failure to meet the full criteria for either anorexia
nervosa or bulimia nervosa
„
Individuals receive the diagnosis of the disorder their
symptoms appear to match to the closest
Binge eating disorder (BED)
„
Recurrent episodes of binge eating in the absence of
the regular use of inappropriate compensatory
behaviors characteristic of bulimia nervosa
Others types of clinical eating
disturbance
Pervasive refusal syndrome
Food avoidance emotional disorder
Functional dysphagia /food phobia
Selective eating/extreme faddiness
Restrictive eating/poor appetite
„
Lask,B & Bryant
Bryant--Waugh, R (2007) Eating Disorders in
childhood and adolescence
adolescence, Hove
Hove, East
Sussex:Routledge.
Assessment
Eating Behaviors
Understand eating patterns
„
What she would eat on a typical
yp
dayy and at
different times of the day?
E.g., are they restrictive, chaotic, governed by
rules about time
„
Fluid intake
Physical health problems secondary to dehydration
((especially
p
y in the case of frequent
q
vomiting
g and
laxative use) or excessive fluid intake
Eating Behaviors
Foods that are specifically avoided, and
the reasons for this avoidance
Rituals
„
E
E.g.,
eating
ti ffood
d iin a particular
ti l order
d
Bingeing
Frequency of bingeing over a week
The types of food she binges on
The amount of food eaten in these
episodes
i d
Does
she
of co
control”
oes s
e feel
ee “out
out o
t o while
e
bingeing?
Bingeing
What about
Wh
b
other
h times
i
when
h you eat what
h seems lik
like a llot?
?
How much is that?
Can you give me an example of a typical binge?
How often does it happen?
How long has it been happening?
When does it happen?
Where does it happen?
Wh t’ usually
ll going
i on?
?
What’s
How fast do you eat?
How in control of your eating do you feel? Could you stop once you
started?
How do you feel before/during/after?
What do you think afterwards?
Then what happens?…
Purging
V iti
Vomiting
„
„
„
„
„
For how long?
How often?
Only after binges?
Other times?
Are there any rules around vomiting?
Laxatives, diuretics, diet pills
„
type and dose
Any
y other p
purging
g g behaviours?
Excessive Exercise
Ai T
Aim:
To establish
t bli h th
the diff
difference b
between
t
h
healthy
lth and
d
excessive exercise
„
„
Excessive exercise - four or more hours per week undertaken
solely or primarily to influence weight or shape
Postponement is accompanied by intense guilt
(Mond et al
al, (2006) Int J Eat Disord
Disord, 39:2 147147-153)
„
„
„
„
Does she exercise?
How much exercise does she take?
Wh type off exercise?
i ? Wh
h purpose off the
h exercise?
i ? If
What
What iis the
she could not exercise how would she feel?
Compulsive exercise
Is there a rigid number of sitsit-ups that must be completed?
Triggers To Behaviours
Triggers to the bingeing and purging
behaviours
To get a sense of the function the behaviour is
serving, e.g. affect regulation as well as a
response to starvation
Behaviour Hunger/fullness
(tick
(t
c if reported)
epo ted)
Social
(tick
(t
c if reported)
epo ted)
Emotional states?
((indicate
d cate which
c apply)
app y)
*
*
*
*
*
*
*
*
Bingeing
Anger ; anxiety ; depression ; shame ;
*
*
boredom ; loneliness
Purging
Anger ; anxiety ; depression ; shame ;
*
*
boredom ; loneliness
Psychosexual functioning
Current and past menstrual function
current frequency and nature of her periods
her age at menarche and her reaction to the onset
of her periods
history of absence of periods is linked to her
weight history
Central Cognitive Elements
Di t b
Disturbance
off Body
B d Concept
C
t
How she feels about her body? If she likes/dislikes
it? Do
D her
h feelings
f li
diff for
differ
f different
diff
t parts
t off her
h
body?
Body checking practices,
practices including weighing
Disturbance of Body Percept
(sees self as too
fat/thin)
How she sees herself when she looks in the
mirror? Do other people agree with what she
sees?
Body percept exercise
Central Cognitive Elements
F
Fear
off fatness
f t
„
„
How would you feel if you gained a kilo?
Wh t might
What
i ht you d
do about
b t th
that?
t?
Self--Evaluation
Self
„
I am now going
i to
t askk you a rather
th hard
h d question
ti –
you may not have thought about this before. Over the
past four weeks has your weight/shape been
important in influencing how you feel about think
yourself as a person?
F example,
For
l ffriend
i d who
h plays
l
th
the piano
i
Self--Evaluation
Self
Cli t' Current
Client's
C
t Self-Evaluation
S lf E l ti
Pie Chart
Relationship
Family
Friends
School
Weight and
Shape
Client's Ideal Self-evaluation Pie
Ch t
Chart
Familyy
Friends
Relationship
School
Wgt/Shape
Hobbies
Weight History
History
„
Plunket books
Natural Body Weight
„
„
Set Point theory
Family tree for weight and height
Ri k tto Physical
Ph i l H
lth
Risk
Health
„
What has been happening to your weight over the
past 88-12 weeks?
k ?
Presenting History
When did you first start having concerns
g
p
g
about yyour weight/shape/eating?
Teasing/bullying around weight and shape
Wh t was/is
What
/i your ffamily’s
il ’ attitude
ttit d tto
eating/shape/weight?
Who in your family dieted/struggled with
weight control?
Psychometrics
B d Ch
Body
Checking
ki Q
Questionnaire
ti
i (BCQ)
„
23 items looking at checking related to overall
appearance, specific body parts and
idiosyncratic checking rituals
Eating Disorders Examination
Examination--Q4 (EDE(EDE-Q)
„
„
Focuses on p
past 28 days
y and asks for
frequencies of eating disorder behaviours
Subscales – dietaryy restraint,, eating
g
concerns, concerns about weight and shape,
and a global score
Physical Risk
Physical Risk
All clients with eating disorders are at
medical risk to some degree
g
Weight or BMI is only one aspect of this
„
„
e.g, A patient
ti t with
ith a BMI off 15 but
b t who
h is
i
losing weight at a kilo a week is likely to be
i k than
th someone who
h h
more att risk
has kkeptt a
stable BMI of 14 over many years
Frequent use of purging (vomiting, diuretics,
laxatives) greatly increases physical risk,
especially if patient underweight
Urgent Medical Review
The client should have a review by a
physician
p
y
as a matter of urgency
g
y if any
y of
the following apply:
BMI is 13 or below
There is recent rapid weight loss (more than a kilo
per week)
over
several
pe
ee ) o
e se
e a weeks
ee s
The patient reports fainting, dizziness or blackouts.
Evidence of ketoacidosis (e.g., breath has a
distinctive sweet smell, similar to nail varnish
remover or pear drops)
Urgent Medical Review
Children and Adolescents
„
„
„
Rapid
p weight
g loss
Rapid dehydration
Less reserves including body fat
South Island Eating Disorders
Service Physical Assessment
Weight
W i ht and
dH
Height
i ht
„
“% weight for height scales”
Bloods
„
„
„
„
Urea and Electrolytes: To assess for electrolyte imbalance,
dehydration, kidney function
Li
Liver
F
Function
ti ttests:
t To
T assess for
f damage
d
to
t liver
li
secondary
d
to
t
low weight/ and or alcohol misuse
Full Blood Count: To assess for bone marrow suppression
secondary to low weight
Thyroid stimulating hormone (TSH): To exclude thyroid
g loss ((NB thyroid
y
levels may
y be reduced
abnormalities for weight
in low weight individuals or in people on very restrictive diets)
South Island Eating Disorders
Service Physical Assessment
ECG
„
To assess effect of extreme state of starvation on the
heart
Squat Test
„
To assess proximal muscle weakness and whether
extensive muscle failure has occurred
Pulse and blood pressure (lying and standing)
„
To assess stress on cardiac systems and the effects
of dehydration
Bone Scan
May be arranged following assessment
Risk factors: Low weight and amenorrhea
for more than six months
Appendix
ppe d
Physical Assessment
General Health
Diabetes and an ED can coco-occur as a
devastating combination
„
„
„
„
P
Poor
di
diabetes
b t control
t l
Withhold insulin to provoke hyperglycaemia
and weight loss
Repeated
p
ketoacidosis and coma
Rapid onset of severe diabetic complications
Motivation
Developmental Tasks
Adjust to new physical sense of self
Establish intimacy
Develop autonomy
Develop new intellectual abilities
self-esteem
Develop competencies and selfEstablish a unique identity
Functions of an Eating Disorder
Task:
T k New
N
Ph i l self
Physical
lf
„
„
Rapid gains in weight and height
Development of secondary sexual characteristics
Starvation helps avoid adjusting to a new physical sense
of self
Task: Establish Intimacy
„
P
Peer
groups
Social withdrawal associated with eating disorders can
provide protection from the lack of peer group/ issues
within a peer group
Anorexia becomes a friend
Functions of an Eating Disorder
T k Development
Task:
D
l
t off Autonomy
A t
„
To think, feel, make decisions and act on his or her own
Anorexia can reduce the complexities of life
„
„
to a list of rules about food
Filters decisions to the level of “will this make me fat?”
Task: Development of competencies and selfself-esteem
„
„
Achievement preferences and areas where adolescents are
willing to strive for success
A time to try a variety of activities
Anorexia can provide a sense of success
„
“I am good at losing weight”
Functions of an Eating Disorder
Task: Development of Identity
„
Knowing
g where yyou fit,, or your
y
place
p
in the
world
Anorexia can provide an identity
Maintaining Factors
Key’s Study
„
„
Preoccupation
p
with food
Social withdrawal
Biological
Effects
g
„
„
Gastric emptying slows
Metabolic rate slows
Psychometrics
Pros and Cons of Anorexia Scale (P(P-Can)
„
50 items
“I see my anorexia as being dependable and
consistent’
“Anorexia is something I am good at”
Serpell et al. (2004) The development of the PP-CAN, a measure to
operationalize the pros and cons of anorexia nervosa, International Journal
of Eating Disorders, 36, 416416-433
Motivation
Clinician Stance
(Geller et al)
St t i
Strategies
for
f assessing
i
and
d
enhancing motivation:
P
Pros
and
d cons
Friend or foe letters
Pie charts
Life Plans
Miracle question
Problems and goals
Model
Stages of change
(Procheska & DiClemente)
Appendix
Medical indicators for hospital
admission – Dr Geoff Buckett
Rapid wt loss (>4kg in a month) BMI<13
Inability to eat/retain food
Confusion, organic brain syndrome,
ophthalmoplegia,
hth l
l i ataxia,
t i syncope, LOC
LOC,
seizures, tetany
Dysrhythmia, angina, chest pain, SOB,
y
p , variable HR ((<60 and
bradycardia<40bpm,
>150, HR >25 lying vs standing
Raised creatinine, oliguria (<400ml/day)
Rapidly diminishing exercise tolerance
Marked lab abnormalities: K<2.5,
PO4<0.3, glucose<2.5
Severe neutropenia <0
<0.6
6
ECG abnormalities – QTc >500,
ventricular arrhythmia
Medical Risk Information
“A guide to medical risk assessment for
eating
g disorders”
„
Maudsley Hospital, London
www.eatingresearch.com