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Non-Intervention

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Non-Intervention

    The Anorexia Nervosa Care Pathway for Clinicians

    CONTENTS

     Go to Section Introduction 1

    Assessment For Anorexia Nervosa Module 2

    Self-Help Module 3

    Outpatient Therapy Module 4

    Intensive Treatment Module: Patient’s copy 5

    Intensive Treatment Module: Professional’s copy 6

    Acute Medical Admission Module 7

    Low Intensity Monitoring Module 8

    Active Non-Intervention Module 9

    Management of Self-Harm and Suicide Risk Module 10

    Recovery and Discharge Module 11

    Appendix 1: Rating Scales 12

    Appendix 2: Recording Charts 13

    Appendix 3: Healthy Eating Documents 14

    Appendix 4: Food Diary 15

    Appendix 5: Mental Health (Scotland) Act 16

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    Contents

INTRODUCTION ......................................................................................................................... 1

    What is a Care Pathway? ......................................................................................................... 2

    Aims and Objectives ............................................................................................................... 2

    Development of the Pathway ................................................................................................... 2

    Who is the Pathway for? .......................................................................................................... 2

    Using the Pathway ................................................................................................................... 2

    Clinicians‟ Contact Details ...................................................................................................... 3 ASSESSMENT FOR ANOREXIA NERVOSA MODULE ......................................................... 1

    Anorexia Nervosa Assessment Questions ................................................................................. 3 Probable Diagnosis of Anorexia Nervosa : .............................................................................. 4 Physical Assessment .................................................................................................................. 5 Investigations ........................................................................................................................... 10

    1. Blood Tests ....................................................................................................................... 10

    2. ECG .................................................................................................................................. 10

    3. DEXA Bone Density Scan ................................................................................................. 10 4. X-Ray ................................................................................................................................ 10

    Investigations Record Sheet .................................................................................................... 12

    Guidance on Levels of Risk ..................................................................................................... 13 Action Points ......................................................................................................................... 14

    Recommendations on the Frequency of Physical Monitoring for Outpatients ......................... 15 Eating Disorder Assessment Tool ........................................................................................... 16 A. Questions to make a provisional diagnosis of an Eating Disorder .................................... 16

    B. ‘At Risk’ Screening Questions ............................................................................................ 16 C. Examination key points ...................................................................................................... 17 D. Investigation key points ...................................................................................................... 17 SELF-HELP MODULE ................................................................................................................ 1 Introduction ............................................................................................................................... 2

    Using this Module ................................................................................................................... 2

    What is Self-Help? .................................................................................................................. 2

    How to Negotiate 'the System' .................................................................................................. 2 Preparing to See any Health Professional (Doctor, Nurse, Dietician etc) .................................. 2 What Could go Wrong? ........................................................................................................... 3

    Preparing to See a Therapist or Eating Disorder Specialist ....................................................... 3 What Could go Wrong? ........................................................................................................... 3

    Preparing to Attend a Self-Help Group .................................................................................... 3

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    What to do if you Collapse, Black out or Have a Fit and you have to go to A&E ..................... 4 Some facts about Anorexia Nervosa ......................................................................................... 4 How Common is Anorexia Nervosa? ....................................................................................... 4 What are the Common Symptoms of Anorexia Nervosa? ........................................................ 4 Am I Doing my Body any Harm? ............................................................................................ 4 What Causes Anorexia?........................................................................................................... 5

    Will I Ever Get Better? ............................................................................................................ 5

    Will my General Health be Okay Once I Get Better? ............................................................... 5 What is the Worst That Could Happen? ................................................................................... 5 What is the Best That Could Happen? ..................................................................................... 6 Which Health Professionals are Involved in Treatment for Anorexia? .................................. 6

    NHS Services in Lothian ........................................................................................................... 7 General Information ................................................................................................................ 7

    Cognitive Behavioural Therapy (CBT) .................................................................................... 7 Cognitive Analytical Therapy (CAT)....................................................................................... 7 Interpersonal Psychotherapy (IPT)........................................................................................... 7 Dialectical Behaviour Therapy (DBT) ..................................................................................... 8 Art Therapy ............................................................................................................................. 8

    Nutritional Support .................................................................................................................. 8

    Waiting List ............................................................................................................................ 8

    Private or Voluntary Services in Lothian................................................................................. 8 Self-Help Resources................................................................................................................. 11

    Self-Help and Support Groups ............................................................................................... 11

    Websites ................................................................................................................................ 11

    Telephone Information and Help Lines .................................................................................. 11 Books and Pamphlets ............................................................................................................ 12

    Resources for Friends and Family.......................................................................................... 14 OUTPATIENT THERAPY MODULE ........................................................................................ 1 Introduction ............................................................................................................................... 2

    Components of Care.................................................................................................................. 2

    1. Core Therapy ....................................................................................................................... 2

    2. Nutritional work .................................................................................................................. 2

    3. Weight Monitoring .............................................................................................................. 3

    4. Brief Risk Monitoring ......................................................................................................... 3

    5. Physical Health Monitoring ................................................................................................. 3

    6. Motivational Work .............................................................................................................. 3

    7. Interpersonal or Family Work .............................................................................................. 4

    Brief Risk Monitoring ............................................................................................................... 5 Therapy Review......................................................................................................................... 7

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INTENSIVE TREATMENT MODULE: Patient’s Copy ............................................................ 1

    Introduction ............................................................................................................................... 2

    The Anorexia Nervosa Intensive Treatment Team (ANITT) .................................................. 2 The Post-Discharge Service ..................................................................................................... 2

    The Intensive Treatment Program ............................................................................................ 3 Intensive Inpatient Programs for Anorexia Nervosa ............................................................... 4 The Priory Hospital Glasgow Eating Disorders Unit ................................................................ 4 The Huntercombe Edinburgh Hospital ..................................................................................... 4 The Young People‟s Unit ........................................................................................................ 5 The Retreat .............................................................................................................................. 5

    Bethlem Royal Hospital, The Gerald Russell Eating Disorders Unit ........................................ 6 St George‟s Eating Disorder Service........................................................................................ 6 Other Inpatient Services .......................................................................................................... 7

    Acute Medical Inpatient Treatment ......................................................................................... 7 INTENSIVE TREATMENT MODULE: Clinician’s Copy........................................................ 1

    Introduction ............................................................................................................................... 2

    The Anorexia Nervosa Intensive Treatment Team (ANITT) .................................................. 2 The Team ................................................................................................................................ 2

    Treatment Philosophy and Therapy ......................................................................................... 2 Evaluation ............................................................................................................................... 3

    The Post-Discharge Service ..................................................................................................... 3

    The Intensive Treatment Program ............................................................................................ 3 Primary Care Liaison Service .................................................................................................. 3

    Entry and Exit Criteria for The Anorexia Nervosa Intensive Treatment Team (ANITT)..... 4

    Entry criteria ............................................................................................................................. 4

    Exit criteria................................................................................................................................ 4

    Brief Risk Monitoring for ANITT ............................................................................................ 5 ANITT Evaluation Forms ......................................................................................................... 7

    Intensive Inpatient Care Admission Form ............................................................................... 9 ACUTE MEDICAL ADMISSION MODULE ............................................................................. 1 Criteria for ‘in extremis’ ........................................................................................................... 2 ‘In Extremis’ Care .................................................................................................................... 3 Inpatient Medical Care ............................................................................................................ 3

    Exceptions ............................................................................................................................... 3

    Using the Mental Health Act ................................................................................................... 3

    Discharge Criteria from Acute Medical Admission ................................................................. 4 LOW-INTENSITY MONITORING MODULE .......................................................................... 1

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    Rationale for Low-Intensity Monitoring .................................................................................. 2 Suitability for Entry to Low-Intensity Monitoring.................................................................... 2 Recommendations for Low-Intensity Monitoring .................................................................... 2 Record of Low-Intensity Monitoring ........................................................................................ 3 ACTIVE NON-INTERVENTION MODULE ............................................................................. 1 Rationale for Active Non-Intervention ..................................................................................... 2 Suitability for Entry to Active Non-Intervention ...................................................................... 2 Recommendations for Active Non-Intervention ....................................................................... 2 Active Non-Intervention Case Conference Form ..................................................................... 3 MANAGEMENT OF SELF-HARM AND SUICIDE RISK MODULE ..................................... 1

    Suicide in Anorexia Nervosa ..................................................................................................... 2

    Questions to Help Assess Current Risk : .................................................................................. 2 Managing the Level of Risk..................................................................................................... 2

    Safety Plan .............................................................................................................................. 3

    RECOVERY AND DISCHARGE MODULE.............................................................................. 1 Definition of Recovery ............................................................................................................... 2

    Complete Recovery Criteria .................................................................................................... 2

    Advice at the point of Discharge ............................................................................................... 2

    Relapse.................................................................................................................................... 2

    Fertility and Pregnancy ............................................................................................................ 3

    Osteoporosis ............................................................................................................................ 3

    Other Medical Problems .......................................................................................................... 3

    APPENDIX 1 Eating Disorder Rating Scales ........................................................................... 1

    Eating Attitudes Test (E.A.T.) .................................................................................................. 3

    Body Shape Questionnaire (B.S.Q.) .......................................................................................... 5 Beck Depression Inventory (BDI II) ...................................................................................... 7 Beck Anxiety Inventory (BAI) .................................................................................................. 9

    Clinical Outcomes in Routine Evaluation (CORE) ................................................................ 10 APPENDIX 2 Recording Charts ............................................................................................... 1 Weight and Height Conversion Charts .................................................................................... 2 Body Mass Index (BMI) Ready Reckoner ................................................................................ 3 BMI Chart ................................................................................................................................. 4

    EAT / BSQ Chart ...................................................................................................................... 5

    BDI-II / BAI Chart .................................................................................................................... 6

    CORE Chart .............................................................................................................................. 7

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    APPENDIX 3: Healthy Eating Documents .................................................................................. 1 Working Towards Weight Restoration and Healthy Eating ................................................... 2

    Healthy Eating Getting the Balance Right ............................................................................ 4 APPENDIX 4 Food Diary .......................................................................................................... 1 APPENDIX 5 Use of the Mental Health Act with Anorexia Nervosa ...................................... 1

    Guidance Notes from English Mental Health Act Commission Guidance Note 3 ............... 2

    Guidance on the Treatment of Anorexia Nervosa under the ................................................... 2 Mental Health Act 1983 (Issued August 1997) ......................................................................... 2 Notes on Assessment of Capacity .............................................................................................. 7

    Assessment of Capacity in the Presence of Anorexia Nervosa ................................................ 7

    Decisions for the Clinician ...................................................................................................... 8

    Section Papers ........................................................................................................................... 9

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     INTRODUCTION

    Contents of this section:

    What is a Care Pathway? ......................................................................................................... 2 Aims and Objectives ............................................................................................................... 2 Development of the Pathway ................................................................................................... 2 Who is the Pathway for? .......................................................................................................... 2 Using the Pathway ................................................................................................................... 2 Clinicians‟ Contact Details ...................................................................................................... 3

     INTRODUCTION CAN-CP Version 1.1 25.01.05 ? ANITT 2005 1

    INTRODUCTIONCAN-CP Version 1.1 25.01.05 ? ANITT 2005 1

Introduction

    Welcome to the Comprehensive Anorexia Nervosa Care Pathway (CAN-Care Pathway) for the diagnosis and management of Anorexia Nervosa.

    What is a Care Pathway?

    Care Pathways are documents which guide clinicians and their patients so that the best available care is offered, documented and audited. The results of audit, and new research as it emerges can be used to improve and update the document.

    Aims and Objectives

    The main aim of the Pathway is to provide the best care for all patients in Lothian with Anorexia Nervosa through consistency and continuity of treatment. It is intended that the Pathway will provide a guide to the different aspects of care, give the patient a sense of ownership and control over their care, and allow for improved quality of care through the audit process. Development of the Pathway

    The Pathway has been developed by a group in Lothian comprising patients, General Practitioners, Psychiatrists, Psychologists, Nurses, Physicians and Public Health Consultants, who contributed their particular expertise to the design, construction and revision of the Pathway.

    Throughout the document we use the term „the patient‟. We realise that some people would prefer us to speak of „the client‟ or „the service user‟, but research and experience suggest that „the patient‟ is still the most popular term. We have avoided the term „the anorexic‟, which denies the patient an identity outwith their disorder, and is the reverse of what we intend to foster. Who is the Pathway for?

    The Pathway‟s main purpose is as a guide to appropriate care for Anorexia Nervosa, for both

    patients and clinicians. We have produced a patient‟s version and a clinicians‟ version. The patient‟s version contains all the information required for the patient to understand the different aspects of care available and what they are likely to experience. It is intended that the patient‟s version will have appropriate modules and summary information added to it as they progress through treatment, and that this will be held by the patient. The clinician‟s version will contain all

    the modules and recording sheets required for the different treatment phases and options. Using the Pathway

    The patient‟s version will serve as a summary of progress through care as key clinical details will be recorded in it. Such details give the patient a summary of their care which is easily shared with new health professionals when required.

The Pathway is divided into 10 modules, with appendices. The patient is advised to start with the

    SELF-HELP MODULE, which has sections on negotiating „the system‟, basic information on

    Anorexia Nervosa, and where to find more information and support. The clinician is advised to

    start with the ASSESSMENT FOR ANOREXIA NERVOSA MODULE which will direct them to

    the appropriate module depending on the patient‟s presentation.

     Clinicians please see Clinician‟s Contact Details (p.3 of this section) before using the CAN-CP.

     INTRODUCTION CAN-CP Version 1.1 25.01.05 ? ANITT 2005 2

    INTRODUCTIONCAN-CP Version 1.1 25.01.05 ? ANITT 2005 2

    Clinicians’ Contact Details

    All professionals using the Pathway document should provide details and a signature below for

    identification.

     Name and Profession Work tel. Signature and Initials 1.

    2.

    3.

    4.

    5.

    6.

    7.

    8.

    9.

    10.

     Please add this to the front of the patient’s version of the CAN-CP

     INTRODUCTION CAN-CP Version 1.1 25.01.05 ? ANITT 2005 3 INTRODUCTIONCAN-CP Version 1.1 25.01.05 ? ANITT 2005 3

     ASSESSMENT FOR ANOREXIA NERVOSA MODULE

    Contents of this Module:

    Anorexia Nervosa Assessment Questions ................................................................................. 3 Probable Diagnosis of Anorexia Nervosa : .............................................................................. 4 Physical Assessment .................................................................................................................. 5 Investigations ........................................................................................................................... 10

    1. Blood Tests ....................................................................................................................... 10

    2. ECG .................................................................................................................................. 10

    3. DEXA Bone Density Scan ................................................................................................. 10 4. X-Ray ................................................................................................................................ 10

    Investigations Record Sheet .................................................................................................... 12

    Guidance on Levels of Risk ..................................................................................................... 13 Action Points ......................................................................................................................... 14

    Recommendations on the Frequency of Physical Monitoring for Outpatients ......................... 15 Eating Disorder Assessment Tool .............................................................................................. 16

    A. Questions to make a Provisional Diagnosis of an Eating Disorder ......................................... 16 B. „At Risk‟ Screening Questions .............................................................................................. 16 C. Examination key points......................................................................................................... 16

    D. Investigation key points ........................................................................................................ 16

    25.01.05 ? ANITT 2005 1 ASSESSMENT FOR ANOREXIA NERVOSA MODULE CAN-CP Clin Version 1.1

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