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Anorexia Nervosa

Family Therapy
Campbell Thorpe
Enhanced headspace
South Eastern Melbourne
Starvation
DSM-5 Diagnostic Criteria
1. Restriction of energy intake relative to requirements
leading to a significantly low body weight in the
context of age, sex, developmental trajectory, and
physical health.

2. Intense fear of gaining weight or becoming fat, even
though underweight.

3. Disturbance in the way in which one's body weight
or shape is experienced, undue influence of body
weight or shape on self-evaluation, or denial of the
seriousness of the current low body weight.

Fear of gaining weight
Refusal to maintain body weight above 85% of
the expected weight for a given age and height
Amenorrhea
Refusal to admit the seriousness of the weight
loss
Undue influence of shape or weight on one's self
image
Disturbed experience in one's shape or weight
Restricting Type
Binge-Eating/Purging Type

Prevalence
0.5 3.7% of adolescent and young adult women
meet the criteria for Anorexia Nervosa
1.1 4.2% meet the criteria for bulimia nervosa
Male: female ratio ranges between 1:6 to 1:10
Sub-clinical eating disorders even more pervasive
64% of normal weight women and 23% of normal
weight men with no history of weight problems
are dieting
Prevalence
In developed societies, anorexia nervosa is the
third most common chronic illness for young
females. (obesity & asthma are 1 & 2)
Ten times more common than insulin
dependent diabetes.
Average Duration of Disorder 5 years
First degree female relatives are 10 times
more likely to develop anorexia than other
relative

Mortality
Mortality Rate 20% after 20 years
5 times greater than same aged population
Deaths from natural causes 4 times greater (eg.
cardiac arrhythmia, infection)
Deaths from unnatural causes 11 greater
Suicide is 32 times that expected for same aged
population.
To compare with major depression: Overall mortality
rate is 1.4 times that expected, unnatural deaths 7
times and suicide 20 times greater than expected.
Complications
Brain atrophy - effects on cognition
Cardiac arrhythmias
Growth retardation
Infertility
Osteopaenia leading to osteoposoris
Renal and hepatic function impairment
Neurogenic bowel dysfunction
Dental damage

Cardiac complications
80% patients with ED affected
Reported complications
Bradycardia <50 bpm
Hypotension <90 systolic
QT interval prolongation
Myocardial mass reduced
Cardiomyopathy
Sudden cardiac death
Pericardial effusion

Biopsychosocial Illness

Biological
Social Psychological
Social Influences
Ethnicity
Social class
Career
Culture
Family culture
Family changes and adaptations
Social influences
Ache - body dissatisfaction parallels introduction of
mass visual media
New Zealand a study was done which found that 80%
of the females were within normal weight limits, but
only 18% of them thought their weight was normal.
Thirty years ago the average model was 8% thinner
than the average woman. Now the average model is
23% thinner than the average woman.
Dieting is a $33 billion industry in the states
The failure rate for diets is 95-98%.

Biological
Search for neurotransmitter dysfunction
Abnormal response to anorectic effects of
estrogen
Cognitive dysfunction
Executive
Affective
Self perpetuating nature
Complications

Psychological
Personality Traits
Perfectionism
Fear of offending others
Self Esteem
Control
Fear of psychosexual development
Exposure to abuse

Examination
Postural blood pressure and pulse
Beware bradycardia :ECG

Concern if > 20 mm drop or pulse differential 30

Temperature <36

COLD FRAIL MALNOURISHED
Bloods
EUC/Ca /Mg/PO4/glucose/FBC/LFT
Bloods for differential diagnosis TFT, coeliac
screen, ESR
Micronutritional deficiencies B12, folate Vitamin
D, Zn, Iron studies
Beware hypokalaemia (<3mmol),
hypophosphataemia, hypoglycaemia(<3mmol),
hypontraemia ( <125mmol)
Bone, endocrine, and dental, health

Treatment


BED CHART COPY Date: ____________ UR:

LEVEL FIVE
Breakfast:
1 serve cereal with 1 serve milk
2 slices toast with margarine or butter and choice of spread (spread optional)
Tub yoghurt*
2 x juice (apple or orange) or 1 piece fresh fruit (banana or apple or orange or pear) or preserved fruit
Glass of water
Morning Tea: Purple snack (see below for choices) and glass of water
Lunch:
6 point sandwich. Filling to include:
At least one from: tuna or salmon or chicken or ham or cheese* or egg or beef
At least one from: lettuce, tomato, carrot, beetroot, cucumber, onion
Margarine
Dessert: yoghurt* or 2 ice creams* or main dessert or jelly and ice cream
2 x juice (apple or orange) or 1 piece fresh fruit (banana or apple or orange or pear) or preserved fruit
Glass of water
Afternoon Tea: Purple snack (see below for choices) and glass of water
Dinner:
Medium serve of a hot meal from menu. Meal to include:
Hot main (from the 3 listed in the left column of menu)
Choice of 2 from the following: Rice (if available) or potato (chips or mashed) or slice of bread with
margarine (may have 2 serves of the same item)
At least one hot vegetable or side salad
Dessert: yoghurt* or 2 ice creams* or main dessert or jelly and ice cream
2 x juice (apple or orange) or 1 piece fresh fruit (banana or apple or orange or pear) or preserved fruit
Glass of water
Supper: Purple snack (see below for choices) and glass of water

Purple snack list
Muesli bar
Fruit & nut bag
Breaka and (chocolate or strawberry) dry biscuits and cheese*
Breaka and (chocolate or strawberry) Fruche*
Custard and sultanas
Custard and muesli bar
Yoghurt and muesli (available at morning tea only)*
2 packets of dry biscuits, 2 portions cheese and 1 serve milk*
2 packets of sweet biscuits, glass of milk and muesli bar
* Denotes 1 serve of calcium. You need to include 4-6 serves of calcium on each menu
Please note that flavour preferences may only be nominated for items with flavour options listed
Dislikes: Boluses:
Ensure Plus
Breakfast 2 cans
1.___________________________ Morning Tea 1 can
Lunch 2 cans
2. ___________________________ Afternoon Tea 1 can
Dinner 1 cans
3. ___________________________ Supper 1 can

Developed by Dietetics Department, Monash Medical Centre Updated June 2010
G:\diet\Dietetics\Eating Disorders\Meal Plan Levels\Bed Chart Meal Plans.doc
Treatment
Resuscitation
Nutritional support
Family Therapy
Maudsley FBT
eCBT
Longer term supportive therapy
Medication
No evidence
Reversibility with weight restoration
Spanish study 40 adolescent girls with AN
f/u 9 -18 months
Echo changes
Myocardial mass returned to normal
ECG changes
QT prolongation improved
Bradycardia resolved

Key points
patients near to death often look well
BMI range: <13 high risk
Weight loss > 1kg per week for a month
physical examination, including muscle power (Sit
upSquatStand test)
blood tests: especially electrolytes, glucose,
phosphate, Mg, liver function tests, full blood
count;
ECG, especially QT interval: when to monitor?
Family Therapy
What is it?

Family Therapy
Using relationship(s) with a family or subsystem
To change
Relationships
Understandings
Beliefs
Expectations
Behaviour
Communication
Why Use Family Therapy?
Family role:
Aetiology of a disorder
Maintenance of a disorder
Management of a disorder
Recovery from a disorder
Achieving a developmental process
Ideal Family Characteristics
Boundary - defined, semi-permeable
Clear internal boundaries age appropriate
Clear hierarchy of authority
Clear communication between members
Effective conflict resolution and problem
solving



Ideal Family Characteristics
Flexibility and definition of members roles
Tolerance of difference and encouragement of
individual identity
Positive emotional climate respectful,
committed, trusting, caring, forgiving, playful,
humorous
Consideration of individual and group needs

Spectrum of Family Input
Collateral history
Psychoeducation
Illness effect upon family
Co-opted therapists/treating team
Maintaining factors
Causative factors
High Care
Low Control
High Control
Low Care
High Care
Low Control
High Control
Low Care
Chaotic
Conduct disordered
Depressed
Rebellious
Anxious
Anorexic
Psychosomatic
Enmeshed
Family as a System
Components interact
Established patterns of interaction
Homeostatic mechanisms
Keep things the same
Information and behaviour change the system
System in regular developmental flux
Symptoms
Symptoms may have a role within the family
What role could the symptom serve within
this family?
What role does the family have in maintaining
the symptom?
Cyclical Interactions
Child anxious
about
relationship
Child seeks out
parent and
becomes clingy
Parent feels
intruded upon
and sick of
clinginess
Parent
reluctantly
comforts child
and disengages
as fast as
possible
Parent does not
give spontaneous
comfort to child
Simple Family Therapy Techniques
Changing perspectives
New information
Getting in the others shoes
Noticing exceptions
A different understanding
Doing something different
Changing roles
Prescribed behaviour

Simple Family Therapy Techniques
Different forms of communication
Reinforcing hierarchy and subsystems
Defining the real problem
Who?
Externalising
Avoiding the detail
Redefining development
Umpiring/Brokering

Family Therapy and Anorexia
Family to help feeding
Family roles and conflict resolution
Adequate attention and valuation
Encouraging independence
Solving other problems within the family

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