Eating Disorders Flashcards
General Hx taking
Weight and height
- premorbid, current, lowest, target
HPI
- onset, progression
- restrictions
- feeling about eating
- stressors
- any binge eating, methods of compensation after
- concomitant mood
Anorexic symptoms
- concern abt weight
- weight loss methods
- period irregular or stopping
Bulimic symptoms
- excessive or out of control eating
- guilt after eating
- vomiting
- use of drugs to help control weight
Psychiatric symptoms
- depression
- suicide/self harm (RISK)
- anxiety
Physical symptoms
- menstrual hx, delay pubertal events
- syncope
- palpitations
- fatigue
- muscle weakness
- sensitivity to cold
Physical examination
BMI
Skin - lanugo hairs, loss of head hair, Russell’s sign, drying and scaling skin
Dentition - erosion, cavities
CVS - postural hypotension, bradycardia
GI - constipation
MS - muscle wasting, pathological fractures
Others - core temp (hypothermia), dehydration, swollen parotids (frequent vomiting), nutritional status
Investigation
CBC - normocytic anaemia U&E - raised urea due to dehydration; hypoK, hypoNa, hypoMg, hypochloremia alkalosis due to vomiting LFT - abnormal Glucose - hypoBG Lipids - hypercholesterolemia TFT Amylase - raised in vomiting ECG
Differential diagnosis for LOW
Anorexia nervosa Bulimia nervosa Medical causes of low weight Depression Obsessive-Compulsive disorder Psychotic disorders Alcohol or substance abuse Dementia
Approach to weight loss
Rule out physical/medical cause
Rule out other psychiatric disorder causing LOW e.g. substance, affective, psychotic, anxiety
+abnormal attitude to body weight, shape and size
–> BMI <17.5 –> anorexia
–> BMI normal
+ no weight loss and binging –> bulimia (purging)/ binge eating disorder (no purging)
+ rapid weight loss –> subclinical AN
Anorexia nervosa 厭食症 - main features and criteria
LOW WEIGHT (major difference from bulimia
- overvalued ideas about body shape and weight
- preoccupation with being thin; intrusive dread of fatness
Criteria
- restriction of energy intake causing significantly low weight (<17.5 kg/m2)
- intense fear of gaining weight EVEN THOUGH AT SIGNIFICANTLY LOW WEIGHT
- disturbance/ DISTORTED in way in which one’s body shape is experienced, persistent lack of recognition of the seriousness of low body weight
- –> have evidence, everyone says thin but still don’t agree
Restricting type = no binging or purging in last 3 months (only dieting, exercising, fasting)
Bulimic type (purging or non-purging) = have binging +/- purging (vomiting, laxatives, diuretics)/ non-purging (only intensive exercise) in last 3 months
Weight loss not due to thyrotoxicosis, T1DM, TB, malignancy, hypopituitarism
Aetiology of AN
Multifactorial and individual specific
- personality, coping, self-esteem, family, peer, relationships, stress, media
- biological - 5HT metabolism implicated
Non-fat phobic attributions
Not actively trying to lose weight
Stomach bloating, stomach pain, no hunger, no appetite, fear of food
90% are fat-phobic now
Other features of AN - premorbid, comorbidities
Premorbid personality
- obsessionality –> but egosyntonic and not intrusive (e.g. keeping checking mirror, weighing – feels better after but keeps doing it happily)
- perfectionism/rigid/arrogant
- low self esteem
Psychiatric comorbidities
- anxiety disorders may preceded (GAD, SAD)
- depression concurrent or after
AN converting to BN vs Bulimic type of AN
Bulimic type of AN
- still grossly underweight, amenorrhea
AN convert to BN
- AN return to normal weight, period return then change to BN
- approx 50%
- non-purging bulimic type more likely to change to BN
Management of AN - inpatient vs outpatient, immediate management and Ix, long term Mx
Inpatient if:
- RISK – e.g. BMI <13-14
Attend to physical condition if abnormally thin (emaciation) or purging present (electrolyte imbalance)
Assess suicide risk and comorbidities
Ix in hospital: weight, height, BMI, vitals, hydration, ECG, BG, U&E
Long term
- SSRI (although no medication proven to be effective)
- Slowly increase calorie intake, negotiate target weight and plan –> target to increase weight 0.5-1kg/wk
- MOTIVATION ENHANCEMENT THERAPY (when physical condition ok; ineffective when starved) –> externalise problem (patient themselves versus AN), promote self-motivation for change, avoid confrontation, enhance sense of control, understand the function of AN to the patient (explore issues of self-esteem, perfectionism)
- Patient psychoeducation (balanced eating, complications, nature of eating disorders)
- FAMILY PSYCHOEDUCATION
- “Contract” about eating after discharge/ objective consequences –> decrease family conflict and stress
Poor prognostic factors for AN
Marked degree of weight loss Older age of onset Chronicity Presence of binging/purging Marked fat phobia Comorbidity FHx
Refeeding syndrome
Risk when eating after >5 days of starvation
HypoPO4, hypoK, hypoNa, hypoMg, metabolic acidosis, thiamine deficiency
–> muscle weakness, seizures, oedema, cardiac dysrhythmias (insulin rise = shift of K and PO4 into cells = hypoK –> DANGEROUS), hypotension, delirium
Bulimia nervosa 暴食症
Preoccupation with eating and irresistible craving of food, resulting in BINGE EATING
Sense of lack of control, followed by feelings of shame and disgust
Counteract with purging, fasting or exercising
Criteria:
- Recurrent episodes of binge eating characterised by
- eating an amount of food that is definitely larger than what most individuals would eat
- sense of LACK OF CONTROL over eating during the episode - Recurrent inappropriate compensatory behaviours to prevent weight gain
- purging: vomiting, laxatives, diuretics, other medications
- non-purging: fasting, excessive exercise - AT LEAST ONCE A WEEK FOR 3 MONTHS
- Self evaluation is influenced by body shape and weight
- Doesn’t occur exclusively during episodes of AN
Binging vs Over-eating - must clarify in Hx!!
Strong sense of lack of control Do in private Preceded by negative emotional state Followed by inappropriate compensation Objectively large amount of food
