Eating Disorders Flashcards
Describe the epidemiology of eating disorders?
- F > M (90% are female) - Typical: “perfectionist, high-achieving young women, low self-esteem”
- Lifetime incidence Age of onset:
- Anorexia nervosa = 0.6% 16-22
- Bulimia nervosa = 1.0% >22
- Co-morbid depression, substance misuse, OCD
What is the most common eating disorder?
- In clinic = Anorexia nervosa
- In general = Binge Eating Disorder (BED)
What is Binge Eating Disorder (BED)?
Binge eating without vomiting
- Can be described as Bulima without the vomiting
Describe the aetiology of anorexia nervosa.
- Biological
- Genetics = 58% heritability
- Psychosocial
- Psychological = perfectionist with low self-esteem
- Social = social pressures - models, athletes, dancers
- Personal = previous AN, child abuse
- Family = parental overprotection, family enmeshment
- FHx
- Obesity
- Depression
- Substance misuse
Describe the aetiology of Bulima nervosa.
- Biological
- 5-HT dysregulation
- Genetics - 54% heritability
- Psychosocial
- Psychological = perfectionist with low self-esteem
- Social = social pressures - models, athletes, dancers
- Personal = previous obesity, child abuse
- Family =disturbed family dynamics, parental weight concern, high parental expectation
- FHx
- Obesity
- Depression
- Substance misuse
What are the appropriate investigations for a suspected eating disorder?
-
Examination = weight, height, lanugo hair, BP
- Squat test (test for proximal myopathy)
- Bloods and urine drug screen = exclude medical causes, i.e. hyperthyroidism
- ECG = bradycardia, arrhythmia, long-QT
- DEXA = osteoporosis (if > 2-year history)
- Rating Scale = eating attitudes test
What ECG changes can be seen in patients with bulima nervosa?
Long QT
What factors may lead to an immediate admission of a patient with an eating disorder?
- BMI low (not defined by NICE; approx. BMI <13)
- WL >1kg/week
- Septic-looking signs
- HR <40bpm + long QT
- Suicide risk
What is the diagnostic criteria for Anorexia nervosa?
- BMI <17.5 (or weight is ≥15% less than expected)
- Deliberate weight loss
- “Fear of the fat”/Distorted body image
- Endocrine dysfunction (amenorrhoea (F) or impotence (M), loss of libido, delayed puberty)
What are the risk factors for Anorexia nervosa?
- OCD
- Childhood feeding difficulties
- FHx
What is atypical anorexia nervosa?
- Sub-diagnostic features of anorexia nervosa
- e.g. young boys that are losing weight to have a ‘six-pack’ but are currently at a healthy weight
What are the signs a symptoms of anorexia nervosa?
State ones that are specific to binge-purge type (in italics)/
- General = lethargy, cold intolerance, cytopenia/anaemia, infections, dry skin/brittle hair and nails, lanugo hair (hair that covers face of newborns, downy and unpigmented in type), oedema, Russell’s sign (callous/cut knuckles from self-induced vomiting)
- CVS = bradycardia, postural hypotension, arrhythmias (2nd to hypokalaemia)
- GI = constipation, pain (ulcers), Mallory-Weiss tears, nutritional hepatitis
- Reproductive = amenorrhoea, infertility, loss of libido
- MSK = osteoporosis, proximal myopathy, Hx of fractures
- Neurological = peripheral neuropathy, delirium, coma, intense fear of gaining weight
- DDx = medical causes of WL, depression, bulimia nervosa, psychosis
What blood results occur in nutrional hepatitis?
- Low protein
- Raised bilirubin
- Raised LDH
- Raised ALP
What are the features of severe anorexia nervosa?
- BMI <15
- Rapid weight loss
- Evidence of system/organ failure
What are the features of moderate anorexia nervosa?
- BMI 15-17
- No evidence of system/organ failure
What are the features of mild anorexia nervosa?
- BMI >17 (still <17.5 or 15% of expected)
- No additional co-morbidites
What screening tool may indicate an emergency admission for anorexia nervosa?
MARSIPAN guidelines (Management of Really Sick Patients with AN)
Define Refeeding syndrome.
Potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding
What blood test results would you expect in someone with refeeding syndrome?
- Low phosphate
- Low magnesium
- Low potassium
- Low thiamine
- Salt and water retention
What are the signs and symptoms of refeeding syndrome?
- Fatigue
- Weakness
- Confusion
- High blood pressure
- Seizures
- Arrhythmia
- Heart failure
What is the prognosis of anorexia nervosa?
- After 10 years:
- 50% recover
- 40% ongoing problems
- 10% die (suicide = 1/3 of deaths)
What are the complications of anorexia nervosa?
- Infertility
- Early death
- Osteoporosis
- Cardiac arrythmias
- Cardiac failure
What are some bad prognostic factors for anorexia nervosa?
- Very low weight
- Bulimic features
- Later onset
- Longer illness duration
What is the name of the eating disorder screening questionnaire? Plus what questions are asked within it?
SCOFF - ≥2 = take a full history
- Do you make yourself SICK because you feel uncomfortably full?
- Do you worry you have lost CONTROL over how much you eat?
- Have you recently lost more than ONE stone in a 3-month period?
- Do you believe yourself to be FAT when others say you are too thin?
- Would you say that FOOD dominates your life?
What are the diagnostic criteria for Bulimia nervosa?
- Binging or persistent preoccupation with eating and/or irresistible craving for food
- Purging behaviours
-
Psychopathology
- Feeling of a loss of control
- Morbid dread of fatness
- Patient sets sharply defined weight threshold (well below premorbid weight/healthy weight)
- History of anorexia nervosa
What are the signs and symptoms of Bulimia nervosa?
- Mainly signs of MALNUTRITION - ARE SIMILAR TO AN BUT LESS SEVERE
- General = lethargy, cold intolerance, cytopenia/anaemia, infections, dry skin/brittle hair and nails, lanugo hair (hair that covers face of newborns, downy and unpigmented in type), oedema, Russell’s sign (callous/cut knuckles from self-induced vomiting)
- CVS = bradycardia, postural hypotension, arrhythmias (2nd to hypokalaemia)
- GI = constipation, pain (ulcers), Mallory-Weiss tears, nutritional hepatitis
- Reproductive = amenorrhoea, infertility, loss of libido
- MSK = osteoporosis, proximal myopathy, Hx of fractures
- Neurological = peripheral neuropathy, delirium, coma, intense fear of gaining weight
- DDx = upper GI disorder (leading to vomiting), personality disorder, depressive disorder, obesity
What are the features of severe bulimia nervosa?
- Daily purging
- Significant electrolyte imbalance
- Co-morbidity
What are the features of moderate bulimia nervosa?
- Frequent binging and purging - >2/week
- Some medical consequences - chest pain etc
What are the features of mild bulimia nervosa?
- Infrequent binging and purging - ≤2/week
What is the management of bulimia nervosa?
- Treat medical complications (regular dental review for acid-wear on teeth)
- Treat co-morbid psychiatric illness (depression, OCD, substance misuse)
- Moderate to severe = SSRIs (high-dose (60mg) fluoxetine) to reduce binging/purging + help impulses
- Children: 1st line: Family therapy
- Adults: 1st line: Guided Self-Help Programme (Bulimia Nervosa-Focused
2nd line: CBT-ED - Mild = Guided self-help, recommend Beat charity, monitor for 8 weeks
- Moderate = Guided self-help, recommend Beat charity, monitor for 12 weeks
- Severe = Urgent referral to Community Eating Disorder Service (CEDS)
What is the prognosis of Bulimia nervosa?
- After 10 years:
- 70% recover
- 1% die
What is the management of anorexia nervosa in adults?
- Engage and Educate
- Treat co-morbid psychiatric illness (depression, OCD, substance misuse)
- Signpost support networks (Beat charity, MIND, NHS)
- Weight Restoration and Nutrition Advice
- 1st line
- CBT-ED - Address low self-esteem, perfectionism, control issues
- Maudsley Anorexia Nervosa Treatment in Adults (MANTRA) - Focus on what the cause of the anorexia is
- Specialist Supportive Clinical Management (SSCM) - explore problems of anorexia, nutrition and eating habits and future beyond anorexia
- 2nd line
- Eating-disorder-focussed Focal Psychodynamic Therapy (FPT)
- Adolescent-focussed psychotherapy
- Motivational interviewing
- Family therapy
- Interpersonal therapy
- Pharmacological Therpay = Fluoxetine (especially is preoccupied by food)
- Mild = Monitor/advise/support, Beat charity, monitor for 8 weeks
- Moderate = Routine referral to Community Eating Disorder Service (CEDS)
- Severe = Urgent referral to CEDS
How does the management of anorexia nervosa differ in children?
- 1st line: Family therapy
- 2nd line: ED-CBT
What is the target weight gain for patient with anorexia nervosa?
0.5-1kg/week
