Anorexia nervosa Flashcards
Screening questions for anorexia
o Have people ever given you a hard time about being too thin or losing too much weight?
o Are you afraid of gaining weight?
o Do you do anything to try and keep your weight as it is?
o How do you think your body looks?
o Did others say you were thin, but you
thought you looked fat?
o Did your weight or the shape of your body have a big effect on your opinion of yourself?
o How much did you think about the health risks of weighing so little?
DSM criteria for anorexia + specifiers
A) Restriction of energy intake relative to requirements, leading to significant low body weight
B) Intense fear of gaining weight OR persistent behaviour that interferes with weight gain
C) Body image disturbance - Lack of
recognition of the seriousness of the current low body weight
Specifiers
- Restricting type - restriction of calories/
excessive exercise without binging/purging - three month period
- Binge-eating/purging type - recurrent episodes of binge eating/purging over a three month period e.g. self-induced vomiting, misuse of laxatives/diuretics/enemas
what are additional physical symptoms to ask about in anorexia
- Menstrual history
- “When you were there thin and losing weight did you start missing your menstrual
periods?” - Menstrual history - onset, LMP, oral
contraceptive use - Energy levels, cold tolerance, fainting
- Brittle nails, hair thinning, breaking or falling out
- lanugo hair : Soft, downy hair covering the body
- Constipation and abdominal pain, bloating
- Arrhythmia, low HR, dehydration
- Fractures
what are the physical health features of anorexia (CNS, Endocrine, Electrolyte abnormalities, Cardiovascular, MSK, Skin hair, Mouth, Haematological, bulimia spec
CNS
- Hypothermia
- Cortical pseudoatrophy with enlargement of the subarachnoid space -cause disturbances of concentration, memory and personality
Endocrine
- Stress hormones - elevated cortisol and adrenaline
- Thyroid - euthyroid sick syndrome (reduced T3 T4 in response to energy conservation
- Secondary amenorrhoea - severe weight loss supresses the HPA axis leading to hypogonadotrophic hypogonadism
- Impaired glucose tolerance
Electrolyte Abnormalities e.g. hypokalaemia
Cardiovascular
- Bradycardia, Postural hypotension
- Arrhythmia
Musculoskeletal
- Osteoporosis
- Stress fractures
Skin & Hair
- Dry skin , - Brittle nails
- Poor wound healing
- Hair loss, lanugo body hair
- Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
Mouth
- Sialadenosis with dystrophy
Haematological
- pancytopenia secondary to bone marrow suppression
Bulimia-specific
- oesophagitis and/or gastritis
- parotitis (salivary gland swelling)
- Dental - caries due to frequent vomiting
what is the typical MSE for someone with eating disorder
Appearance & Behaviour - baggy clothing to disguise weight loss, physical overactivity and restlessness
- Speech & Language - speech focused on food, fear of fatness
- Mood & Affect - mood may be low due to malnutrition or comorbid depressive illness
- Thought Form - beliefs about food and weight may be fixed and intense
- Thought Content - preoccupation with food, fear of fatness
- Perception
- Cognition
- Insight & Judgement - sees self as fat despite low/normal weight, insight usually markedly impaired regarding own physical state and the need to gain weight
- Risk - check for suicidal ideation
What are the differentials for eating disorder
Anorexia nervosa
- Bulimia nervosa
- Binge-eating disorder
-comobid depression, anxiety, OCD
Eating disorder not otherwise specified
- Does not meet the criteria for anorexia or bulimia nervosa
- Often as severe and long-lasting as classical conditions, poses the same risks
- Most common diagnosis
Parts of exam for anorexia Ix - blood and urine, ECG for anorexia
EXAM
- Obs (incl lying and standing BP
- Height, Weight, BMI
- Peripheral circulation- CRT, cyanosis
- examine skin, dental status
- Peripheral/ sacral oedema
- pubertal status
- Signs of binging/purging
- Evidence of deliberatie self harm
Ix (note labs may be normal in early stages)
FBC - pancytopenia
U&E - including Ca Mg and PO4
- hypo K, Na, Cl.
VBG -pH, elevated Bicarb (metabolic alkalosis - vomiting)
LFT - Increased AST/ ALT
Amylase
Glucose - hypogylcaemia, sometimes insulin resistance
hormone, LH, FSH, testosterone/Oestradiol down.
ECG
QT and PR interval prolongation - risk of sudden death
ESR, TFT and coeliac screen if first presentation
Other nutritional testing
- iron studies, B12, red cell folate, Vit D and zinc
Urinalysis
- Ketone
- pH, specific gravity (high pH , low specfic gravity if water loaded)
Additional testing
Hormone - elevated cortisol and growth
High blood cholesterol, low blood protein and albumin
What is the acute management of anorexia/ eating disorder - how to decide wehre?
Hx - including collateral
- weight loss, food restriction, exercise, bulimia symptoms
Exam and Ix
Immediate safety
- comorbid depression high suicide risk
-severe malnutrition
Admission to gen med if medically unstable
- vital signs unstable, <70% ideal body weight or BMI <15
- acute medical complications
- cardiovascular complications
-hypoglycaemia
-electrolyte disturbance
Mild/ early - manage and monitor weekly in primary care
Moderate/ severe - refer to specialist eating disorder services and monitor weekly
what is the prognosis of eating disorders
Average duration of illness is 5-6yrs
- Chronic, relapsing disease - outcomes vary from complete recovery to symptom fluctuation to releases to progressive deterioration
- Mortality
- 5-20% total
- Cumulative mortality rate (5% per decade)
- Most commonly due to severe cachexia/ starvation, cardiac failure or suicide
What is the management of anorexia and conditions around outpatient care
Psycho
- CBT - individual eating disorder focused CBT, BN focused guided self help for adults before CBT
- psychodynamic psychotherapy
- family based therapy - first line for children and young people
Bio
- limited evidence for pharmacological treatment for eating disorder alone - SSRI fluoxetine 60mg is approved for bulimia
?olanzapine
- Nutritional support with dietician
- monitor weight gain (graded) supplements multivitamines, thiamine, B-complex, ensure and fortsip depending on BMI and nutritional intake
- need agreement with patient and caregivers on target weight development and # of meals + family supervision at home
- treat comorbidities
What is refeeding syndrome presentation and treatment
- Pathogenesis - very rapid increase in daily food intake can cause massive insulin release leading to displacement of magnesium, potassium and phosphate (extracellular to intracellular shift)
- Presentation - oedema, tachycardia (torsades de pointes, delirium, epileptic seizures, ataxia, HF, sudden death.
- hypophosphataemia, hypothermia, prolonged QT
- Management - electrolyte substitution
- Prophylaxis - monitor same U&E levels daily for first 1-4 days then twice weekly, limit initial dietary intake to 1000-1500kcal/day
- as IP start on phosphate 1 tab twice daily for 2 weeks, multivitamin 1 tab bd for 3 monhts
Explain anorexia to layman
- You came here today because someone was worried about your eating patterns/ your physical health / fear of in
- It is not uncommon for people to want to be in control of their body weight and shape, much like how you talked about …eg. restricting the amount of food that you eat, however if this gets to the point where there is an extreme fear of putting on weight, it starts to be most consistent with a condition called Anorexia nervosa.
- Anorexia can distort the way you view your body is not how it is in reality this can lead to excessive weight loss which can cause serious damage to your physical health
- Genetic factors, poor self esteem, perfectionist personality and traumatic life events can predispose someone to developing anorexia.
- Anorexia, like other eating disorders, can take over your life and can be very difficult to overcome. But with treatment, you can gain a better sense of who you are, return to healthier eating habits and reverse some of anorexia’s serious complications.
- Treatment for anorexia involves addressing both your physical and mental health. This is mainly talking therapies for example CBT can help to challenge some of the underlying beliefs about our body image and can helping people regulate and better cope with emotions.
- Treatment also involves addressing any problems with your physical health and supporting you in changing your eating pattern which may involve seeing us fairly regularly
What is body dysmorphic disorder brief
A psychological disorder that centres on a patient’s obsession with physical flaws (minor or imagined).
- Shares some traits with OCD
- Excessive exercise, obsessive grooming, extreme cosmetic procedures
- Critical/unsatisfied with appearance, fear of deformity
- Anxiety and depression
- Avoiding social situations
- Fear of being judged
- Subtype - muscle dysphoria
