Anorexia & Bulimia Flashcards
Describe presentation of anorexia nervosa [+]
Features of anorexia nervosa include:
- Weight loss (e.g., 15% below expected or BMI less than 17.5)
- Amenorrhoea (absent periods)
- Lanugo hair (fine, soft hair across most of the body)
- Enlarged salivary glands
- Hypotension (low blood pressure)
- Hypothermia (low body temperature)
- Mood changes, including anxiety and depression
- Amenorrhea (absence of periods) occurs due to disruption of the hypothalamic-pituitary-gonadal axis. There is a lack of gonadotrophins (LH and FSH) from the pituitary, leading to reduced activity of the ovaries (hypogonadism).
- Cardiac complications include arrhythmia, cardiac atrophy and sudden cardiac death.
- Low bone mineral density is another complication.
Describe the physiological abnormalities seen in anorexia nervosa [+]
- hypokalaemia
- low FSH, LH, oestrogens and testosterone
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia
- low T3
SCOFF screening questionnaire
- The SCOFF questionnaire is a short and simple tool that can be used in primary care to help identify patients that may be suffering with an eating disorder.
It should not be used alone but as part of a wider assessment of a patient at risk for an eating disorder.
What is in this questionnaire? [5]
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry you have lost Control over how much you eat?
O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life?
Two or more positive responses is considered indicative of anorexia nervosa or bulimia nervosa.
Describe the dx of AN [3]
Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned:
1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
A comprehensive physical examination of AN should be completed with the permission of the patient.
Describe what should be included in this examination? [+]
The patients height, weight and BMI should be recorded
- In those under the age of 18, the BMI should be plotted on a centile chart.
Evaluate the patient’s hydration status
- dehydration can be significant, and may warrant inpatient management.
Vital signs:
- bradycardia, hypothermia and postural blood pressure drop are all red flags for severe disease.
Sit-up, Squat–stand test: tests the patient’s ability to sit up from lying and to squat down and stand back up. Scored from 0-3 with increasing risk with lower scores:
* 0: unable to complete action
* 1: requires the assistance of upper limbs
* 2: noticeable difficulty
* 3: no difficulty
Which investigations should you use for AN patients? [4]
ECG:
- bradycardia, prolonged QT interval or arrhythmias are all signs of high-risk disease requiring urgent review.
Blood sugar:
- significant malnutrition can result in hypoglycaemia (also consider diabetes as a cause of unexplained weight loss).
Blood tests:
- consider FBC, LFTs, renal function, bone profile, magnesium, thyroid profile.
- This allows review for anaemia, electrolyte disturbance and thyroid dysfunction amongst other abnormalities. In severe malnutrition mild derangement of liver function tests is common.
Additional:
- pregnancy test should be considered where appropriate. Hormonal panels may be indicated in women with menstrual dysfunction. Further tests may be required depending on the given individual presentation.
What is the treatment plans for children / YAs [2] and adults [3] for anorexia
In children and young people
- NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. It typically consists of 18-20 sessions over a 1-year period. Sessions separate from family or carers may also be facilitated
- The second-line treatment is cognitive behavioural therapy.
For adults with anorexia nervosa, NICE recommend we consider one of:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED).
- This is a specialised form of CBT, consisting of 40 sessions over 40 weeks - with twice-weekly sessions initially
- patient forms a personalised plan to help them understand and cope with their feelings and disease.
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- consists of 20 sessions, weekly for the first ten weeks, then tailored to the patient
- Aims to help patients develop a non-anorexic identity.
specialist supportive clinical management (SSCM).
- consists of 20 sessions, a therapist helps the patient understand the relationship between their feelings, eating behaviour and disorder. Looks to establish a weight goal and encourage healthy eating.
NICE guidelines 69 (updated 2020) advise anorexia-nervosa-focused family therapy (FT-AN) is considered first-line for AN.
What are the three stages? [3]
First phase:
- the focus is to ensure a ‘good therapeutic alliance’ between the patient, their therapist and family/carers.
Second phase:
- focuses on helping the patient develop independence appropriate to their age and development with the help of family/carers
.
Final phase:
- focuses on the end of treatment and any concerns the patient or family/carers may have. It also looks at the prevention of relapse and how to seek help should that occur.
The alternatives are CBT-ED or adolescent-focused psychotherapy for those who do not want FT-AN or in those in whom it has been ineffective.
What are the cardiac complications of anorexia? [4]
bradycardia
hypotension
prolonged QT interval, increasing the risk of sudden cardiac death
Mitral valve prolapse may also occur.
Describe the endocrine abnormalities see in anorexia [4]
Endocrine abnormalities:
* Amenorrhoea is common due to hypothalamic dysfunction.
* Other endocrine disturbances include thyroid dysfunction (hypothyroidism) growth hormone resistance, cortisol excess and insulin resistance.
Describe the GII abnormalities see in anorexia [4]
Gastroparesis, constipation, and liver dysfunction are frequently observed. Superior mesenteric artery syndrome may also develop.
What is the prognosis of anorexia?
AN has the highest mortality rate among psychiatric disorders. The standardised mortality ratio is estimated to be around 5.86, indicating that individuals with AN are almost six times more likely to die prematurely than those without.
About 50% of individuals with AN achieve full recovery while around 20-30% remain chronically ill. The remaining patients may experience partial recovery but continue to struggle with body image issues or disordered eating patterns.
Describe the clinical features of bulimia nervosa [+]
Features of bulimia nervosa include:
* Erosion of teeth
* Swollen salivary glands
* Mouth ulcers
* Gastro-oesophageal reflux
* Calluses on the knuckles where they have been scraped across the teeth (called Russell’s sign)
Alkalosis can occur after repeated vomiting of hydrochloric acid from the stomach.
TOM TIP: Unique examination findings in bulimia make it a popular spot diagnosis in exams. A teenage girl with an average body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas may indicate bulimia.
What are the two types of bulimia? [2]
Purging Type:
- This subtype is characterised by regular engagement in self-induced vomiting or misuse of laxatives, diuretics, or enemas during the current episode.
Non-Purging Type:
- In this subtype, the individual employs other inappropriate compensatory behaviours, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or misuse of laxatives, diuretics, or enemas.
The severity of Bulimia nervosa is also categorised based on the frequency of inappropriate compensatory behaviours (as per DSM-5):
What determines mild, moderate, severe and extreme bulimia? [4]
Mild: An average of 1-3 episodes per week.
Moderate: An average of 4-7 episodes per week.
Severe: An average of 8-13 episodes per week.
Extreme: An average of 14 or more episodes per week.
Describe the electrolyte disturbances seen in BN [+]
Electrolyte imbalances:
- Chronic purging by vomiting or laxative abuse can lead to hypokalaemia (low potassium levels), hyponatraemia (low sodium levels), and hypochloraemia (low chloride levels). These imbalances can have serious cardiovascular and neuromuscular consequences.
Metabolic alkalosis due to vomiting, and metabolic acidosis due to laxative abuse may occur. Hypomagnesaemia (low magnesium levels) may also be seen.
Describe the investigations used for BN [+]
Psychological Assessment
- Semi-structured interviews: The Eating Disorder Examination (EDE) is considered the gold standard for diagnosing eating disorders including BN.
- Self-report questionnaires: Tools such as the Bulimia Test-Revised (BULIT-R) or Eating Disorders Inventory (EDI) can be used to supplement clinical interviews and provide additional information about symptom severity and related psychological features.
Laboratory Investigations
* FBC: anaemia or infection
* U&Es: hypokalaemia; AKIs
* LFTS: malnutrition or alcohol abuse
Radiological Investigations (not routine)
- DEXA scan
- Gastrointestinal imaging
ECG
Both the DSM-V and ICD-11 can be used as frameworks to aid the clinical diagnosis of bulimia nervosa. The DSM-V criteria below can be used to help make the diagnosis of bulimia nervosa by meeting which criteria? [+]
Recurrent episodes of binge eating, characterised by both:
- Eating an abnormally large amount of food in a discrete period of time.
- A sense of lack of control (e.g. a feeling that one cannot stop eating).
Recurrent inappropriate compensatory behaviours to prevent weight gain
* Self-induced vomiting.
* Misuse of laxatives, diuretics or diet pills.
* Fasting.
* Excessive exercise.
The combination of binging and inappropriate compensatory behaviours occurs, on average for how long? [1]
The combination of binging and inappropriate compensatory behaviours occurs, on average, at least once a week for 3 months.
Describe the dx of BN [+]
The diagnostic criteria for Bulimia Nervosa, as per the ICD-10 and DSM-5, are outlined below. It’s imperative to note that these criteria are not exhaustive and should be used in conjunction with clinical judgement.
ICD-10 Criteria:
* A persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time.
* The patient attempts to counteract the ‘fattening’ effects of food by induced vomiting, purgative abuse, alternating periods of starvation, or use of drugs such as appetite suppressants.
* If the disorder occurs in diabetic patients they may choose to neglect their insulin treatment.
DSM-5 Criteria:
* Recurrent episodes of binge eating characterised by both consuming an amount of food that is definitely larger than most people would eat during a similar period under similar circumstances and a sense of lack of control over eating during the episode.
* Recurrent inappropriate compensatory behaviours to** prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.**
* The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
* Self-evaluation is unduly influenced by body shape and weight.
How does BN differentiate from binge eating disorders (BED) [1]
In BED, binge-eating episodes are not followed by inappropriate compensatory behaviours such as purging or excessive exercise which are hallmark features of BN.
Describe the management of BN in adults [+]
Psychotherapy:
* Step 1 - Bulimia-nervosa-focused guided self-help programmes
* Step 2: Eating-disorder-focused cognitive behavioural therapy (CBT-ED)
* Offer CBT-ED to adults with BN as it has been shown to reduce binge-eating and purging behaviours.
* If CBT-ED is not available or the patient declines, consider other forms of psychological therapy such as interpersonal psychotherapy or dialectical behaviour therapy.
Pharmacotherapy:
* Selective serotonin reuptake inhibitors (SSRIs), specifically fluoxetine, have been approved by the Food and Drug Administration for BN treatment. However, they should be used in conjunction with psychotherapy rather than standalone treatment.
* If SSRIs are contraindicated or not tolerated, consider other types of antidepressants like tricyclics or monoamine oxidase inhibitors after discussing potential side effects and monitoring requirements.
Dietetic Support:
* A registered dietitian can provide valuable input regarding meal planning and nutritional rehabilitation. They can also help address any distorted beliefs about food and weight.
Physical Health Monitoring:
* Routine monitoring of vital signs and electrolytes is crucial due to the risk of complications associated with purging behaviours. Electrocardiogram may be required in some cases.
Inpatient or Day Patient Care:
* Consider inpatient care for patients who are medically unstable or for whom outpatient treatment has failed. The goal should be to stabilise the patient’s physical health while continuing with psychotherapeutic interventions.
How is BN treatment different in children? [2]
Step 1 - Bulimia-nervosa-focused family therapy (FT-BN)
Step 2 - Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
When treating BN via CBT-ED
- The therapist and patient will then work together to set goals for therapy which might include? [5]
- Establishing regular healthy eating patterns: advise the person to not try to diet or restrict food during treatment, because this is likely to trigger binge eating.
- Ongoing weekly monitoring: this includes binge eating behaviours, dietary intake, and weight.
- Identifying binge eating cues (situations, thoughts, emotions)
- Address body image issues.
- Completion of CBT homework in between sessions.
BN suffer which cardiac complication than those without? [1]
Mitral valve prolapse: This is a heart condition that affects the mitral valve’s function. It has been observed more frequently in individuals with bulimia nervosa than in those without.
In the management of anorexia nervosa with comorbid depression, [] can be effective due to its ability to promote weight gain, improve anxiety and depression symptoms, and increase growth hormone release.
In the management of anorexia nervosa with comorbid depression, mirtazapine can be effective due to its ability to promote weight gain, improve anxiety and depression symptoms, and increase growth hormone release.
