Anorexia Nervosa

Question 1

ICD10 definition of Anorexia Nervosa

Answer 1

Must have all 3
BMI<17.5 -bmi not part of it anymore
deliberate weight loss (laxative, vomit, exercise, etc)
Fear of fat/distorted body imaged (thinking fat while being thin)
(optional -endocrine dysf-ammenorhea, impotence, loss of libido, delayed puberty)

2 types - restricting, or Binge purge type

and subclinical - looks like AN but technically BMI over limit

Question 2

Aetiology and RF of anorexia nervosa

Answer 2

F>>M
16-22, 0.6% of pop
co-morbid with depression, substance misssuse, OCD
Childhood feeding difficulties
Fhx -58% heritability
Phsych theories -perfectionism, low self esteem -AN is a way to contol a unfortable life
social -social pressure
Previous AN, child abuse
Fammily overprotection

Question 3

Signs and Sx of anorexia nervosa

Answer 3

Sx mostly secodnary to malutrition (restriting subtypes) and/or Binge purge suptype (can have binging, purging and vomit a bit like BN)

SCOFF questionnaire- for AN and BN (>2 take full hx)

co-morbid with depression, substance misssuse, OCD

general - lethargy, aneamia, Infection, dry skin, oedema
LENUgo HAIR
RUSSELS signs (callous/cut knuckles from self-induced vomit)
GI-constipation, ulcers/pain, MALLORY-WEISS TEARS
reproductive -ammenorhea, impotence, loss of libido
MSK - PROXIMAL MYOPATHY (Squat test +ve), osteoporosis
Neuro - peripheral neuropathy, delirium, intense fear of gaining weigh

Ddx- Medical cause of WL (Hyperthyroid, malabsorption, cancer), depression, Bullumia, psychosis, eating disorder not otherwise specified, Body dysmorphic disorder

Question 4

Ix of anoerexia nervosa

Answer 4

Exam -weight, height (BMI), lentugo hair
Squat test

BT-
what can be low –ESR, Hb, platelets, WCC, Na, K, PO, TSH, glucose
High - cortisol, chol, caroteneamia, GH, LFT
ECG
DEXA

Question 5

Mx of anorexia nervosa

Answer 5

Immediate admission (using MHA )
MARSIPAN guidelines 
BMI v low (<13)
WL<1kg/week
septic signs
HR<40
Suicide risk

Immediate refferal scenarios -
Severe -> refere to CEDS ( community eating disorder service) ( BMI<15, weight loss, organ failrue)

Moderate - routine refer to CEDS ( BMI 15-17, no evidence of failure)
Mild - Monitor/advice/support-BMI>17, no additional comorbidity, routine refer to CEDS if needed

Mx at the gp (alongside pathways above)
Engage and educate about some things (eg laxatives dont reduce calories)
Signpost support ( MIND, NHS)
Treat co-morbid MH

Plan future with regualr follow up
nutrition and weight restoration (aim for a weight and gain 0.5/1kh per week)
CBT-ED, MANTRA, SSCM (of family therapy if under 18

CBT-ED -1-2-1-ED focused-40w sessiobs
Maudsley Anorexia nervosa Treatment in adults (MANTRA)-20 sessions
Specialist Supoportive clinical Mx (SSCM)-20 sessions (explore educate and future)

2nd line - If all 1st line suck
Focal psychodynamic therapy
Adolescent focussed psychothe
Motivational interview
fam therapy (if young and short hx of illness)
Interpersonal therapy (long hx of illness and old)

Pharm - fluoxetine if physical sx, BMI v low,

Children -fam therapy
2nd line CBT ED

care of refeeding syndrome (in another card)

Question 6

What is refeeding syndrome

Answer 6

Intracellular shift of (already low) ions due to insulin release upon feeding for the first time in a while

BT - LOW Po4, Mg, K, B1, Salt and water retention
Low K cause arrythmia, Low Po Heart fail

Sx-fatigue, weak, confuse, HTN, seizure, arrythmia, HF

Question 7

Prognosis of Anorexia nervosa

Answer 7

after 10 years
50% recover
10% die (suicude 1/3rd)
40% continue having issues

complications -infertuile, death, osteoporisis, arrytmias

bad prog factors - Low weight, Later onset, bulimuc features, longer illness duration