1- Mental health conditions (Eating disorders, self-harm and suicide) Flashcards
main eating disoders
- anorexia nervosa
- bulimina nervosa
define AN
Anorexia nervosa (AN) is an eating disorder characterized by deliberate weight loss, an intense fear of fatness, distorted body image, and endocrine disturbances.
prevalence of AN
- F>M (10:1)
- Mid-adolescence most common age of onset
Risk factors for AN
- Genetics. Changes in specific genes may put certain people at higher risk of anorexia. Those with a first-degree relative — a parent, sibling or child — who had the disorder have a much higher risk of anorexia.
- Dieting and starvation. Dieting is a risk factor for developing an eating disorder. There is strong evidence that many of the symptoms of anorexia are actually symptoms of starvation. Starvation affects the brain and influences mood changes, rigidity in thinking, anxiety and reduction in appetite. Starvation and weight loss may change the way the brain works in vulnerable individuals, which may perpetuate restrictive eating behaviors and make it difficult to return to normal eating habits.
- Transitions. Whether it’s a new school, home or job; a relationship breakup; or the death or illness of a loved one, change can bring emotional stress and increase the risk of anorexia.
Aetiology of AN
presentation of AN
- BMI <17.5
- Fear of weight gain and preoccupation with food
- Endocrine disturbance e.g. amenorrhoea
- Emaciated
- Deliberate weight loss with reduced food intake or increased exercise
- Distorted body image
- Depression and obsessions
physical exam findings in AN
- Fatigue
- Hypothermia
- Bradycardia
- Arrhythmia
- Peripheral oedema
- Headaches
- Lanugo hair
diagnosis/investigations for AN
1) History
2) MSE
3) Risk assessment
4) Specific investigations
history taking for AN- question to ask
o ‘What would be your ideal target weight?’ (overvalued ideas about weight)
o ‘Some people find body shape and weight to be very important to their identity. Do you ever find yourself feeling concerned about your weight?’ (fear of weight gain)
o ‘The obvious methods people use to lose weight are to eat less and exercise more. Are these things that you personally do?’ (deliberate weight loss)
o ‘When women lose significant weight, their periods have a tendency to stop. Has this happened in your case?’ (amenorrhoea)
o Also ask specifically about physical symptoms of anorexia nervosa e.g. fatigue and headaches.
MSE for AN
Risk assessment for AN
esp Suicide and Self-harm
Investigations for AN
1) Bloods
i. FBC (anaemia, thrombocytopenia, leukopenia)
ii. U&Es (dehydration)
iii. VBG (metabolic alkalosis due to vomiting), acidosis due to laxatives)
2) DEXA
3) ECG (sinus bradycardia and prolonged QT)
4) Questionnaires e.g. eating attitude test (EAT)
DD for AN
- Bulimia nervosa.
- Eating disorder not otherwise specified (EDNOS): see Key facts 3.
- Depression.
- Obsessive–compulsive disorder.
- Schizophrenia: Delusions about food.
- Organic causes of low weight: Diabetes, hyperthyroidism, malignancy.
- Alcohol or substance misuse.
complications of AN
main:
- arrythmia due to hypokalaemia
- osteoperosis
- infections
- suicide
Management of AN: principles
- Risk assessment for suicide and medical complication
- psychological treatment >6 months
- steady weight gain
- hospitalisation if BMI is below <14 or severe elctrolyte abnormalities or suicidal ideation
- may require MHA
weight gain as treatment for AN
The aim of treatment as an inpatient is for a weight gain of 0.5–1 kg/week and as an outpatient of 0.5 kg/week.
BIOPSYCHOSOCIAL management of AN
define bulimia nervosa
Definition
Bulimia nervosa (BN) is an eating disorder characterized by repeated episodes of uncontrolled binge eating followed by compensatory weight loss behaviours and overvalued ideas regarding ‘ideal body shape/weight’.
prevalence of BN
- Occurs in young women (14-40)
- 1-2%
- BN has equal socioeconomic class distribution
pathophysiology of BN
- Similar to AN e.g. genetic component
- When patients with BN binge due to strong cravings, they tend to feel guilty and as a result undergo compensatory behaviours such as:
o Vomiting
o Laxatives
o Exercising - Can result in large fluctuation in weight
Risk factors of BN
- Female sex
- Sexual abuse as child
- Parental obesity
- History of eating disorder or mood disorder
- Early onset puberty
- T1DM
- Childhood obesity
- Low self esteem
- Obsessional personality
- Environmental stressors
- Developed country
- Profession e.g. dance
presentation of N+BN
- Self induced vomiting
- Starvation
- Drugs e.g. laxative and diuretics and appetite suppressants
- Excessive exercise
- Senses of compulsion
- Poor self perception
- Overeating at least two episodes a week
Other features
- Normal weight
- Depression and low self-esteem
- Irregular periods
- Signs of dehydration
- Consequences of repeated vomiting and hypokalaemia
subtypes of bulimia nervosa
- purging
- non purging
complications of BN
diagnosis and investigations for BN
1) History
2) MSE
3) Risk assessment
4) Investigations
history for BN
- Have you ever feel that your eating is getting out of control?’ (binge eating)
- ‘After an episode of eating what you later feel is too much, do you ever make yourself
- sick so that you feel better?’ (compensatory self-induced vomiting)
- ‘Have you ever used medication to help control your weight?’ (self-induced purging)
- ‘Do you ever feel a strong craving to eat?’ (preoccupation with food)
- ‘Do you ever get muscle aches?’, ‘Do you ever have the sensation that your heart is beating abnormally fast?’ (complications of hypokalaemia)
- Ask specifically about complications of repeated vomiting (see Key facts 3).
- Screen for other co-morbid psychiatric conditions (see OSCE tips 1).
MSE for BN
risk assessment for BN
especially self harm
investigations for BN
a. Blood tests: FBC, U&Es, amylase, lipids, glucose, TFTs, Mg, Ca, P
b. Venous blood gas (metabolic acidosis)
c. ECG- arrhythmias due to hypokalamia e.g. inverted T waves and prolonged PR interval
DD for BN
BIOPSYCHOSOCIAL approach to BN
Biological:
- A trial of antidepressant should be offered and can decreasefrequency of binge eating/ purging. Fluoxetine (usually at high dose, 60 mg) is the SSRI of choice.
- Treat medical complications of repeated vomiting, e.g. potassium replacement. Treat co-morbid conditions
Psychological:
- Psychoeducation about nutrition, CBT for bulimia nervosa (CBT-BN is a specifically adapted form of CBT).
- Interpersonal psychotherapy is an alternative.
Social:
- Food diary to monitor eating/purging patterns, techniques to avoid bingeing (eating in company, distractions)
- small, regular meals
- self-help programmes.
BN and inpatient treatment
for cases of suicide risk and severe electrolyte imbalances.
MHA is not usually required as BN patients have good insight and are motivated to change
disease prognosis for AN vs BN
- Approximately 50% of BN patients make a complete recovery in comparison with AN where roughly 20% make a full recovery.
