ISSUE 13
EATING DISORDERS SECTION
ROYAL COLLEGE OF PSYCHIATRISTS
June 2014
Inside this issue
1) Foreword from the editors
2) Foreword from the chair
3) New to Eating Disorders Specialist Training Programme
4) Risk Management
5) The 2014 BEAT Eating Disorders International Conference
6) Guidance about Photos and Consent
7) EDSECT Annual Conference – 7 November 2014
8) Executive Members of the Eating Disorders Faculty
1- Foreword from the Editors:
Dear readers
Apologies from Rebecca and Irene for a long silence as we plod on with the decision of getting out our newsletter less frequently now in the spring and autumn only.
Developing a “New to Eating Disorder Training Programme” on the EDSECT work plan is moving forwards and we have included Jane Morris’ introductory piece on this. Following this is Joan McCann’s contribution to risk assessment and management for those new to Eating Disorders. MARSIPAN implementation and training also continues as a focus on the EDSECT work plan with an aim to include it in the Core training. Dr Paul Robinson has kindly shared his teaching slides in MARSIPAN and he has invited us to use them in our training as well. They can be accessed through the College website under the Eating Disorders Section under resources for professionals. The Section annual conference unfortunately skipped this spring as we all ran out of time and we will be concentrating on the autumn conference on the 7th of November. The theme is going to be “Transitions”.
We are still trying to promote a letters section within the newsletter, opinion and debate would be welcome and we invite you to submit letters for the next edition (if provocative and opinionated all the better!) and do please encourage your trainees to approach us if they have experiences or perspectives on their training which they would like to share.
With best wishes
Dr Irene Yi Rebecca Cashmore
Co-Editor Editor
2- Foreword from the Chair:
We continue to experience tremendous flux in our health service, representing both threats and opportunities to eating disorders. This is challenging to the Section, particularly its Executive, and I am grateful for the proactive responses of our membership.
Our voice is strongest when shared across the College, and I continue to attend meetings of both the Policy Committee and College Council. It is reassuring to learn that issues of outcome framework, research and training are shared across the board.
The activities of our Section need to be clearly understood in order to be adequately commissioned. As we have moved firmly into the new commissioning era, our Executive Committee remain concerned about the impact of funding arrangements on seamless care pathways. It is interesting to reflect on the differences between Scotland, England, Wales and Northern Ireland.
The speed and gravity of change requires all members of the Executive, and beyond, to work against considerable deadlines and demands on time. We welcome new blood in facilitation of our goals, and offers of help will be warmly received.
Professor John F Morgan MA MD FRCPsych FHEA
Director of the Yorkshire Centre for Eating Disorders, Leeds / St Georges University of London
Chair EDSECT
3- New to Eating Disorders Specialist Training Project
The ‘NEW 2 EATING DISORDERS’ basic specialist training project
Background
An important item on the Workplan of EDSECT (the Eating Disorders Section of the Royal College of Psychiatrists) is the provision of high quality training in the speciality. At the 2013 strategy day there was particular discussion around the need for a structured basic training for specialist trainees. We sought resources that would be specially designed for experienced mental health clinicians, particularly junior psychiatrists and those more senior colleagues working in general (rather than ED) specialisms.
A small, enthusiastic subcommittee volunteered itself to investigate current resources, analogous precedents and possible funding opportunities, with the expectation that the pack would be used across the UK. So far, any promising funding streams have dried up, but the enthusiasm of the editorial committee has not done so, and we are continuing with the project, powered (like Brio trainsets) by imagination and by non-monetary resources such as time, expertise and generosity.
Who we are
The sub-committee, now functioning as the Editorial Group for the project, includes Susan Ringwood of BEAT and Award-winning carer Veronica Kamerling, to ensure that the voices of people with eating disorders are heard, together with those of their families and other carers. Successive Trainee reps on EDSECT have taken great interest and provided the trainee’s view, whilst myself, Irene Yi and Christine Vize are Psychiatric members of the group, working in close consultation with the broader membership of the EDSECT Committee.
We have inevitably been the authors of the first drafts of sample chapters but would encourage YOU to take on the writing of whichever part of the work most excites and inspires you. We are happy to supply model chapters, structures and editorial input. Do remember that you do not have to provide ‘chapter and verse’ on your chosen topic. The material is intended as a stimulus and guide for learning, not as a set of gospel truths. We would also welcome offers of editing and provision of additional references – for instance if you have a favourite text, paper or online resource, please let us know, and please do help us to identify particular extracts which can be cited to illustrate particular modules.
Learning from other models:
Discussions at 2013 Committee Meetings identified several comparable resources for our further investigation. These included:
• EEATS (Eating Disorders Education Accreditation and Training Scotland), a multi-disciplinary 2 year curriculum leading to an Accreditation in Eating Disorders
• The ‘Flying Start’ Programme for newly qualified nurses
• ‘New to….’ programmes, including ‘New to CAMHS’ (now rebranded as ‘Essential CAMHS) and ‘New to Forensic’
All of these met our criteria for delineating core training, in a style somewhere between a textbook ‘primer’ and a course syllabus; encouraging learning that is interactive, with the potential for multi-media delivery, and also fits well with existing portfolio learning.
• We also liked the College's CPD online modules, which are electronic, half or one hour modules on different topics. They are interactive and use MCQs for people to test themselves, but they cannot capture the benefits of having an experienced mentor at one's side – we felt we should adapt our package to incorporate the expectation that people will be working through it with a mentor rather than alone. We will cross reference CPD online as well as Advances, in our pack.
Trainee recommendations led us to learn more from discussions with Prof Lindsay Thompson and Nurse Consultant Helen Walker who have produced, delivered, audited and published their experiences of the ‘New to Forensic’(N2F) Learning resource. These colleagues emphasised the importance of offering enough structure and authority in the pack itself whilst also allowing an ‘implied space’ for the expert supervisor and mentor to interact with the trainee and the material in a flexible way so that the experience comes to life in the clinical context. N2F share the pack only in hard copy to preserve the essence of the work as a mentored and monitored programme and to keep track of its use.
Our model
Our aim is to provide an illustrated syllabus to structure didactic supervision sessions. This resource is no means a textbook, but rather a series of stimuli to bring alive the basic principles of the speciality for the learner, in the presence of an experienced supervisor or mentor. We seek not to replace the live teaching experience, but to provide materials to structure and inform fruitful discussion.
At the current stage of conception we would like to make our own resource potentially multidisciplinary too, but with the expectation that the ‘central’ audience would be junior psychiatrists. Our resource will be designed to shape specialist supervision on 6 – 12 month ED placements – providing 1 or 2 modules each month of placement to be worked through the assumption is that new professionals in the field will be provided with a close attachment to a mentor/supervisor who will be supported by the resource and accompanying materials to prioritise key topics and offer additional depth proportionate to the trainee’s stage and needs. Some, at least, of the material will be available online.
We have drafted a 12 chapter programme; each chapter will provide a short overview of the topic, followed by illustrative vignettes, a couple of test questions and a series of references for further reading (e.g. book chapters, original papers, websites) and finally some suggestions for 'homework', such as construction of a formulation, writing up a particular type of case history, conducting a mini-audit. This could provide the 'bones' for guided learning and supervision at different levels and intensities.
Content
We are providing a list of chapters in the hope that readers of this article may feel inspired to contribute. Please contact the editorial committee if you are interested.
1.What ARE eating disorders? Diagnosis, what is it like to suffer from an ED – the sufferer’s perspective, what is the prevalence, incidence, prognosis?
2.Causes of and formulation of eating disorders
3.The Carer’s perspective (already drafted)
4.Risk assessment and management, ethical and medico-legal issues (in preparation)
5.Evidence-based treatments for BN & BED
6.Evidence based treatments for anorexia nervosa
7.Nutritional care – both dietetic and behavioural
8.Exercise and activity
9.Body image
10.SEED- chronic eating disorders, maintaining hope, compassionate management of death
11. Joined-up care – teamwork, collaborative care, managing transitions
12. Current research in the field
Supervision and mentoring
Alongside the provision of the learning materials themselves, we intend to provide support and guidance for supervisors – explaining what is their role in this learning resource and how we can best support this. The pack contains a model Supervision contract and timetable, review template and feedback forms. We suggest that trainer/trainee dyads complete the supervision contract before embarking upon the material. The 12 Chapters provided may be used in the order provided or any other order which suits, and can be timed for one chapter each weekly session or to be spread out over longer intervals. Allowing for an introductory session, a review meeting half way through the course, and a final feedback session, the syllabus could fit intensively into the space available to junior doctors on 6 moth rotations, or might be spread out over a year, allowing for more background reading, research and clinical experience.
Jane Morris, on behalf of the ‘New to Eating Disorders’ Editorial Committee
REFERENCES
EEATS www.eeats.co.uk
Essential CAMHS http://www.nes.scot.nhs.uk/education-and-training/by-discipline/psychology/multiprofessional-psychology/essential-camhs.aspx
Flying Start http://www.flyingstart.scot.nhs.uk
New to Forensic http://www.forensicnetwork.scot.nhs.uk/sofmh/new-to-forensic
Walker, H. (2012). Introductory level forensic education programmes, The British Psychological Society, 6, 33-37.
Walker, H., Turner, J., Langton, D., Thomson, L.D.G. (2013). Organisational impact of a forensic education programme. Journal of Forensic Practice, 15, 3, 218-230.
4 – Risk Management
Risk Management in Eating Disorders – in New To Eating Disorders
Managing risk in eating disorders can be particularly anxiety provoking as there is risk of death due to malnutrition, the treatment of which is largely physical which can feel difficult for professionals used to dealing only with psychiatric problems. Clinicians with little experience in managing eating disorders should seek support from specialist centres when treating medically ill patients particularly with Anorexia Nervosa.
In addition to physical risk secondary to malnutrition, patients with eating disorders are also at risk of harming themselves in other ways and ultimately suicide. Assessment of these risks are similar in eating disorders to other psychiatric disorders but it must be remembered that risks due to self harm can become greater as the person gains weight and lose their main coping mechanism.
This chapter should be read in conjunction with;
• King’s Risk Assessment in Eating Disorders
• MARSIPAN
This chapter will mainly look at the physical risks linked to severe anorexia nervosa as this has the greatest mortality but will also discuss issues in relation to electrolyte imbalances secondary to purging which is also pertinent to Bulimia Nervosa.
When should I worry?
All major organs come under strain when someone loses a significant amount of weight. The King’s risk assessment tool provides a helpful list of physical parameters and which results give rise for concern and therefore need regular monitoring and which results should alert clinicians to indicators of imminent collapse and therefore require urgent treatment. The treatment for all of the abnormalities is food and therefore treatment should primarily be aimed at supporting patients to feed themselves adequately whilst monitoring their physical state.
Main Indicators of Risk:
• Sudden changes are more dangerous than chronic low weight
o For example a patient who has lost 20kg in 6 months falling to a BMI = 13.5 is probably at greater risk than someone who has a maintained a BMI = 12.8 for many years.
• Cardiac factors
o Sudden death in underweight patients increases significantly once the BMI drops below 13.5 and the main predictor of death in this group is a prolonged QTc interval on the ECG of greater than 450.
o Bradycardia of less than 50, and low blood pressure with a postural drop are also indicative of risk.
• Absolute BMI
o Once the BMI drops below 11, the risk of death increases exponentially regardless of other parameters are normal or abnormal.
o Measurement of weight can in itself become problematic as it may be falsified in many ways including weights in clothes and excessive water drinking. If the weight does not appear congruent, it may be worth re-checking at a time when your patient doesn’t expect it to minimize the chance of falsification.
o It is also important to look at all of the results together rather than relying on one particular reading.
• Abnormal electrolytes
o Repeated vomiting and laxative abuse can cause low potassium levels which can lead to cardiac arrest. Levels of less than 3 require an ECG and oral supplementation. Levels less than 2.5 will require IV supplementation and assessment in an acute hospital.
• Proximal muscle weakness
o Development of leg weakness e.g. inability to complete SUSS test or difficulty climbing the stairs can be indicative of imminent collapse as it represents the body utilising muscle stores for nutrition including the heart thus the risk of cardiac arrest increases.
• Abnormal Liver Function Tests
o It is fairly common to have abnormal ALT or AST levels once the BMI drops below 13.5 but if the levels begin to double exponentially, e.g. daily, this again indicates that the body is not coping and is close to going into organ failure.