CAMH

Question 1

Diagnostic criteria for anorexia

Answer 1

BMI < 17.5
Self-induced weight loss
Overvalued idea (dread of fatness)
Endocrine disturbances (delay of puberty or arrest, amenorrhoea -raised GH and cortisol, reduced T3)

Question 2

Diagnostic criteria of bulimia

Answer 2

Binge eating
Compensatory methods (vomiting, laxatives, diurrhetic, fasting, exercise)
Overvalued idea
Other symptoms and complications

eg. Russel’s sign - calluses on back of hands

Question 3

Biopsychosocial management of anorexia

Answer 3

Psychoeducation about nutrition and weight. Family involvement.
Nutritional management and weight restoration (negotiate target weight, eating plans, teaching shopping and cooking skills)

CBT - 20-24 sessions exploring issues of self-control, low self-esteem and perfectionism

IPT - improving social functioning and interpersonal skills

Family therapy

Low threshhold for referring to a specialised eating disorder unit. Especially with patients who have severe anorexia or poor prognostic factors (eg. long duration, late age onset, very low weight, associated bulimic symptoms, personality difficulties, poor social adjustment)

Hospitalisation considered if BMI<13.5, rapid weight loss, electrolyte abnormalities and syncope

NG or IV feed may be necessary

SSRIs may be useful for treating co-morbid depression and OCD
Fluoxetine may be helpful in maintaining weight gain and preventing relapse

Question 4

Management of bulimia

Answer 4

Usually more motivated to improve

Psychoeducation, self-help groups and manuals in mild cases
CBT and IPT if more serious

TCAs and SSRIs (fluoxetine) have been shown to help, but second line

Manage comorbid substance abuse/depression

Question 5

Impact of chronic illness on growth

Answer 5

relatively common cause of abnormal growth:
usually short and underweight

insufficient food
Restricted diet
poor appetite
increased nutritional requirement
malabsorption

eg.
Coeliac
Crohn’s
Chronic renal failure

Question 6

Psychological impact of chronic illness

Answer 6

Spectrum of over-acceptance to denial

Over-acceptance: illness overtakes life, anxiety about slightest symptoms.

In denial - warning symptoms ignored and treatment poorly adhered to

Emotional response to relapse/diagnosis may have similarities to bereavement reaction: shock, denial, anger followed by acceptance and adjustment

Young children behave younger than they actually are.. Regression when stressed. Overactive, clingy and may display sleep and feeding difficulties

Somatisation of worry - eg. recurrent abdominal pain

There is a higher susceptibility to mental health problems (relates to nature of the illness, the stage, the age of the child, the temperament, intellectual capacity and family factors)

Question 7

Characteristics of school refusal

Answer 7

Due to overwhelming anxiety

• child complains of physical concomitants or of hyperventilation
• nausea, headache, not being well: confined to term-time morning, weekdays.. clear up around midday

It may be rational (bullying or educational underachievement) but also disproportionate = school refusal

Question 8

What are the 2 common causes of school refusal

Answer 8

Separation anxiety from parents persisting beyond toddler years (typical <11 years old, can be provoked by illnes, family death or moving house)

Anxiety provoked by some aspects of school

The 2 can coexist

Question 9

Management of school refusal

Answer 9

Aim to gently increase separation from the parents whilst arranging an early school return

Advice and support parents and school about condition
Treat any underlying emotional disorder (depression, anxiety)

Plan and facilitate and early and graded return to school

Help the parents make it more rewarding for the child to go to school than stay at home

Address bullying or educational difficulties