CLINICAL OPINION continued from Page 21 Treating Anorexia Nervosa The biggest risk of refeeding is a condition known as ‘Refeeding Syndrome’ which comprises several potentially life threatening medical complications including low serum phosphate and magnesium levels, severe hypoglycemia or congestive heart failure. This risk can be reduced by monitoring serum phosphate and magnesium and prescribing prophylactic phosphate in the refeeding period. Counter-transference and therapeutic nihilism Patients with anorexia nervosa are often viewed by clinicians and by healthcare systems in a negative way. The patient's denial, hostility and ambivalence to treatment, the concerned family and friends, the possibility of medical compromise – all serve to heighten a clinician’s anxiety, resulting in reluctance to treat such patients. Yet this is a serious mental illness with equally serious medical complications that require our continued efforts to keep the patient engaged. So enlist help from those around, re-evaluate progress and seek advice or refer on if necessary. It is important to keep in mind that most patients recover outside of hospital, with minimal support. However, others instil ongoing anxiety, frustration, despair, and ultimately demoralisation in their medical carers. This is particularly likely to be the case if adequate tertiary support and treatment is not available. It’s essential to acknowledge that anorexia nervosa is not a lifestyle choice and recovery can take years though early intervention is predictive of a shorter duration of illness. The first step in treatment is to reverse the physical and cognitive effects of starvation, so that the person can engage in outpatient psychotherapy which is the hallmark of treatment. The long-term aims of psychological treatment are to reduce risk and to encourage weight gain, normal eating and exercise behaviours, with full psychological and physical recovery being the ultimate goal. Patients are best managed by a multidisciplinary team which includes their GP, psychiatrist, psychologist and dietician. ED: Dr Urvashnee Singh is the lead psychiatrist for the eating disorders inpatient services at Hollywood Clinic. Public Resources Last year, the state government moved to shrink the gaping gulf in services for those with eating disorders who are over the age of 16. At that age, young people must leave the embrace of PMH’s eating disorders program and find programs where they can. The WA Eating Disorders Outreach and Consultation Service (WAEDOCS) located at SCGH provides consultation and education services to clinicians caring for patients with eating disorders. And the statistics show a serious need with eating disorders falling within the top 10 contributors of disease in Australia for those aged between 16 to 24 years. Anorexia nervosa has the highest mortality rate (20%) of any psychiatric condition. WAEDOCS offers support for health professionals across all settings, including GPs and community health and mental health care services across public, private and communitymanaged organisations. Ph 1300 620 208 9am-4pm Mon-Fri Table. Indicators for consideration for psychiatric and medical admission for adults (Bold parameters highlight adolescent criteria different to those for adults) Psychiatric admission indicateda Medical admission indicatedb Rapid weight loss 1 kg/week over several weeks or grossly inadequate nutritional intake (<100Cal daily) or continued weight loss despite community treatment Re-feeding risk Low High Systolic BP < 90 mmHg (80 mm Hg) < 80 mmHg (70 mm Hg) Postural BP > 10 mm Hg drop with standing > 15 mm Hg drop with standing ≤ 40 bpm (50 bpm) or > 120 bpm or postural tachycardia > 20 bpm Heart rate Temperature < 35.5°C or cold/blue extremities < 35°C 12-lead ECG Normal sinus rhythm Any arrhythmia including: QTc prolongation, Non-specific ST or T-wave changes including inversion or biphasic waves Blood sugar Below normal range* < 2.5 mmol/L Sodium < 130 mmol/L* < 125 mmol/L Potassium Below normal range* < 3.0 mmol/L Magnesium Below normal range* Phosphate Below normal range* eGFR <60ml/min/1.732 or rapidly dropping (25% drop within a week) Albumin Below normal range < 30 g/L Liver enzymes Mildly elevated Markedly elevated (AST or ALT > 500)* Neutrophils <1.5 x 109 / L < 1.0 x 109 / L Weight Body Mass index (BMI) <14 ** (75-85% IBW) BMI < 12 ** (<75% IBW) Risk Assessment Suicidal ideation, Active self-harm, Moderate to high agitation and distress a b Patients who are not as unwell as indicated above may still require admission to a psych or other inpatient facility Medical admission refers to admission to a medical ward, short stay medical assessment unit or similar *Any biochemical abnormality which has not responded to adequate replacement within the first 24 hours of admission should be reviewed by a medical registrar urgently. Source: RANZCP, 2014 MEDICAL FORUM May 2017 | 23

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