Anorexia Nervosa

Question 1

A 16 year old girl presents with her mother with a history of weight loss and preoccupation with the size of her body. How would you assess and manage?

Answer 1

Impression
Preoccupation with body image and size coupled with weight-loss is in keeping with a provisional diagnosis of an eating disorder, most likely anorexia nervosa given both of these elements.

Would want to consider other forms of eating disorders, as well as other psychiatric differentials
ED:
- Bulimia Nervosa
- Binge-eating disorder (not necessarily assoc with weight loss)

Other psychiatric

• OCD - often co-morbid or assoc with ED
• depression/anxiety
• personality disorder

Would first conduct full assessment with H/E/I before determining an appropriate course of management

Question 2

Anorexia Nervosa - History

Answer 2

History

• SX: ask about body image/perceptions of body, behaviours around eating, time-course of such behaviours, period of weight-loss + quantification and rate of loss, foods that are avoided, calorie goals
• assess for DSM-5 criteria (restricted intake, fear of weight gain, distorted perception of body image)
• screen for ED with SCOFF questionnaire
  
  • do you make yourself Sick
  • do you worry you have lost Control over eating?
  • Have you lost One stone in 3 months?
  • Do you believe you are Fat when others do not?
  • would you say that Food dominates your life?
• complications: amenorrhoea, infertility, other outcomes of low-body weight including: hypotension, bradycardia, cold sensitivity, constipation, protein-deficiency oedema, xerosis (dry, scaly skin, hair loss)
• ask for OCD symptoms (screen anxiety)
• screen for co-morbid psychiatric sx (mania, depressive, anxiety, personality)
• rest of psych and medical history

Question 3

Anorexia Nervosa - Examination

Answer 3

Examination

• general observation + vital signs (wasting, emaciation, etc)
• MSE: signs of psychiatric illness
• anthropometric: height, weight, BMI
• cardiorespiratory examination (bradycardia, hypotension, etc)
• MSK: oedema, myopathy - unstable/gait affected

Question 4

Anorexia nervosa - Investigations

Answer 4

Investigations

• Beside: ECG (?electrolyte disturbances), Urine drug screen
• Bloods: FBC, UEC, LFT, BSL, lipid panel, CMP, ESR/CRP, Coags, nutritional screen, TSH, ßHCG, haematinics (B12, folate, Fe)
• Imaging: consider a bone scone (DEXA), may be osteopenia/porotic

Question 5

Anorexia Nervosa - Management

Answer 5

Management

1) consider setting of management: outpatient vs inpatient. Causes for hospital admission;
- rapid weight loss
- electrolyte imbalances
- significant risk of re-feeders syndrome
- hypothermia
- psychiatric risk (suicide/self-harm)
- refusal to engage with treatment, or failure of outpatient managment

Biological

• psych and paeds consults. may do better on paeds ward, or gen med
• stabilise acute illness due to malnutrition. restart oral/parenteral feeds, safely to minimise risk of ECV increase, oedema, and marked electrolyte derangements + hypoglycaemia
• aim weight gain of 0.5kg p/week, may require observed feeding to
• treat co-morbid conditions (anxiety, depression -> pharmacological therapies)
• treatment incentives, allow certain wishes if x amount of weight gained
• consider starting SSRI treatment if co-morbid anxiety/depression, meds not indicated for anorexia nervosa alone.

Psychological

• psychoeducation (mortality is 5%, most make good recovery [80%])
• CBT
• psychodynamic therapy

Social

• Family therapy: use the maudsley method, only therapy shown to be effective. three phases to therapy
  1) parents to take control of patient’s eating and help them gain weight
  2) parents help child take more control over their eating
  3) help patient work through self-esteem, perfectionism, and relationship with body