Risk Management in Eating Disorders
Dr Phil Crockett
Risk Management
•
•
•
•
•
•
•
•
•
Risk in Eating Disorders-Why Worry?
Risk Assessment vs Risk Management
The Physical, Psychological, Social
Context
Transitions
Communication
Networks and Frameworks
Taking advice
Summary
Risk in Eating Disorders-Why
Worry?
• For A.N.: 5-30% long term
mortality(Theander, Halmi(1992))
• Difficulties in psychological adjustment up
to 50% (Pike, 1998)
• Wide variation outcome-depends on study
centre e.g. Korndorfer (2003), Johnson et
al (2003) more benign
• Keski-Rahkonen, (2008): Finnish
nationwide
• N=2880: 5yr recovery 67%
Risk in Eating Disorders-Why
Worry?
• B.N. sig psychological impairment and physical
morbidity
• AN can:
–
–
–
–
–
Sudden death
Cardiac failure
GI bleeds
Sepsis
Suicide
» (Millar,2005)
Risk Assessment vs Risk
Management
• Risk Assessment: an estimation of the
likelihood of particular adverse events
occurring under particular circumstances.
Within a specified period of time
• Risk Management: organised attempts to
minimise the likelihood of adverse events
Risk Assessment vs Risk
Management
• Approaches to risk assessment broadly
grouped into ‘clinical’ versus ‘actuarial’ .
• The actuarial approach: clues to broad
populations at risk, but informs us inadequately
on the individual
• The clinical perspective: “individualised and
contextualised assessment” , vulnerable to poor
inter-rater reliability and influence of other
considerations
• Remember the protective…
• Only tells you about the current situation
From Feenay, A
Five-step structured professional judgement approach to
risk management (Doyle and Duffy (2006))
Step 1:
Step 2 :
Step 3 :
Step 4 :
Step 5:
Case information
History, mental state, substance
use, physical parameters
Presence of risk factors
Historical, current, contextual,
physical
Presence of protective factors
Historical, current, contextual,
physical
Risk formulation
Nature, severity, imminence,
likelihood, risk
reducing/enhancing
Management plan
Treatment, management,
monitoring, supervision,
The Physical
•
•
•
•
•
•
Starvation and Malnutrition
Other Behaviours
Co-morbidities and complications
Self Harm and Suicide
Re-feeding Syndrome
Past history and factors
Re-Feeding Syndrome
• The major physical risk of treatment
• Cascade of metabolic and electrolyte changes
• Hypophosphataemia, hypomagnesaemia,
hypokalaemia major risks
• Raised risk with n.g. re-feeding
• Very slow initiation feeding
• Take advice
• “Have you considered re-feeding syndrome”
The Psychological
•
•
•
•
•
•
Depression
Anxiety
Personality Disorder
Obsessionality (OCD)
Hopelessness and Frustration
Past history and individual
factors
The Social
• Families and Friends
• Work and studies
• Home environment
• Professionals
• The In-Patient Environment
• The Unexpected
• Past history and factors
Context
•
•
•
•
•
Context always important
Major influence on risk for individual
Major influence on judgement of risk
Part of risk assessment
Will alter most appropriate course of
action
Transitions
• Geographical and Developmental
• Life cycle challenges
• In-patient units
• Travel and relocation
• The Scottish Ombudsmen's Report, 2006
Communication
• Ensuring care plans are a team effort
• Note limitations of them
• Liaison between areas important
• Patients and carers involved
• Recording
Networks
• For patients protective and
maladaptive
•A way for professionals to gain
guidance
•EDSECT
•MCNs
•Benchmarking and audit
Guidelines and Frameworks
• NICE and QIS
• APA
• Specific for context
• Crisis planning
• Consistently reviewed/revised
• CPA/MHA
Taking Advice
•Role of the Gastroenterologist/Physician
•Especially when very high risk
•Co-morbidities
•Second opinions and
consultations
Conclusions
• No simple methods to quantify risk in EDs
• Physical/Psychological complications
common including resulting from
intervention
• Broad assessment important
• Principles risk assessment/management
useful
Conclusions
• Developing appropriate frameworks to the
context you are based in
• Applying the guidelines
• Making use of containing networks and
maintain communication
• Take advice