Eating disorder: anorexia nervosa

Question 1

What is the most common causes of admission to child and adolescent psychiatric wards?

Answer 1

Anorexia nervosa is the most common cause of admissions to child and adolescent psychiatric wards.

Question 2

Who is most affected by anorexia nervosa? How common is it?

Answer 2

90% of patients are female

predominately affects teenage and young-adult females

prevalence of between 1:100 and 1:200

Question 3

What are the features of anorexia nervosa?

Answer 3

Intense fear of gaining weight

Restriction of diet

• Pattern of behaviours to maintain low weight
• BMI <85% of expected, or rapid loss
• Amenorrhoea >3months in women

Distorted self-perception of weight

DSM-5: (no mention of amenorrhoea, BMI)

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.

Question 4

What are the features of anorexia nervosa on examination?

Answer 4

• reduced body mass index
• bradycardia
• hypotension
• enlarged salivary glands

Question 5

What are the physiological changes found in laboratory investigations in anorexia nervosa?

Answer 5

• Low:
  
  • hypokalaemia
  • low FSH, LH, oestrogens and testosterone
  • low T3
• High Gs and Cs:
  
  • raised cortisol and growth hormone
  • impaired glucose tolerance
  • hypercholesterolaemia
  • hypercarotinaemia

Question 6

What is the management of anorexia nervosa?

Answer 6

ALWAYS MDT APPROACH

For adults with anorexia nervosa, NICE recommend we consider one of:

• individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
• specialist supportive clinical management (SSCM).

Question 7

What is 1st line and 2nd line management for children and young people with anorexia nervosa?

Answer 7

ALWAYS MDT APPROACH

1. In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment.
2. The second-line treatment is cognitive behavioural therapy.

Question 8

What is the prognosis of anorexia nervosa?

Answer 8

The prognosis of patients with anorexia nervosa remains poor.

Up to 10% of patients will eventually die because of the disorder.

Question 9

What are the complications of starvation on each system?

Answer 9

Cardiovascular

• Bradycardia and hypotension
• Arrhythmia, sudden death
• Peripheral oedema

Respiratory

• Spontaneous pneumothorax
• Respiratory failure

Gastrointestinal

• Constipation
• Pancreatitis
• Hepatitis
• IBS

Metabolic/Haematologic

• Electrolyte derangement
• Hypoglycaemia
• Refeeding syndrome
• Pancytopaenia
• Hypothermia

Endocrine

• Amenorrhoea, infertility
• Osteoporosis
• Arrested growth

Neurological

• Cognitive impairment
• Cerebral atrophy

Dermatological

• Dry skin, brittle nails + hair
• Alopecia
• Lanugo hair
• Pruritis

Question 10

What is the risk assessment of anorexia called?

Answer 10

MARSIPAN

Question 11

What does the MARSIPAN screening consist of?

Answer 11

“MAnagement of Really SIck Patients with Anorexia Nervosa”

Guides admission decisions

Criteria:

• BMI
• Obs
• Hydration status
• ECG
• Muscle weakness
• Electrolytes
• Mental health/behaviour

Question 12

Who is involved in the MDT in eating disorders?

Answer 12

• Medical
• Psychology (systemic therapy)
• Dietician
• OT

Question 13

Which electrolytes become low in refeeding syndrome?

Answer 13

Phosphate

Potassium

Magnesium