1- Mental health conditions (Eating disorders, self-harm and suicide)

Question 1

main eating disoders

Answer 1

• anorexia nervosa
• bulimina nervosa

Question 2

define AN

Answer 2

Anorexia nervosa (AN) is an eating disorder characterized by deliberate weight loss, an intense fear of fatness, distorted body image, and endocrine disturbances.

Question 3

prevalence of AN

Answer 3

• F>M (10:1)
• Mid-adolescence most common age of onset

Question 4

Risk factors for AN

Answer 4

• 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.

Question 5

Aetiology of AN

Answer 5

Question 6

presentation of AN

Answer 6

• 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

Question 7

physical exam findings in AN

Answer 7

• Fatigue
• Hypothermia
• Bradycardia
• Arrhythmia
• Peripheral oedema
• Headaches
• Lanugo hair

Question 8

diagnosis/investigations for AN

Answer 8

1) History
2) MSE
3) Risk assessment
4) Specific investigations

Question 9

history taking for AN- question to ask

Answer 9

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.

Question 10

MSE for AN

Answer 10

Question 11

Risk assessment for AN

Answer 11

esp Suicide and Self-harm

Question 12

Investigations for AN

Answer 12

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)

Question 13

DD for AN

Answer 13

• 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.

Question 14

complications of AN

Answer 14

main:
- arrythmia due to hypokalaemia
- osteoperosis
- infections
- suicide

Question 15

Management of AN: principles

Answer 15

• 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

Question 16

weight gain as treatment for AN

Answer 16

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.

Question 17

BIOPSYCHOSOCIAL management of AN

Answer 17

Question 18

define bulimia nervosa

Answer 18

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’.

Question 19

prevalence of BN

Answer 19

• Occurs in young women (14-40)
• 1-2%
• BN has equal socioeconomic class distribution

Question 20

pathophysiology of BN

Answer 20

• 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

Question 21

Risk factors of BN

Answer 21

• 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

Question 22

presentation of N+BN

Answer 22

• 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

Question 23

subtypes of bulimia nervosa

Answer 23

• purging
• non purging

Question 24

complications of BN

Answer 24

Question 25

diagnosis and investigations for BN

Answer 25

1) History
2) MSE
3) Risk assessment
4) Investigations

Question 26

history for BN

Answer 26

• 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).

Question 27

MSE for BN

Answer 27

Question 28

risk assessment for BN

Answer 28

especially self harm

Question 29

investigations for BN

Answer 29

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

Question 30

DD for BN

Answer 30

Question 31

BIOPSYCHOSOCIAL approach to BN

Answer 31

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.

Question 32

BN and inpatient treatment

Answer 32

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

Question 33

disease prognosis for AN vs BN

Answer 33

• Approximately 50% of BN patients make a complete recovery in comparison with AN where roughly 20% make a full recovery.