Eating Disorders Flashcards
What is anorexia nervosa?
Eating disorder characterised by deliberate weight loss, intense fear of fatness, distorted body image and endocrine disturbances.
What are the two subtypes of anorexia nervosa?
Restrictive type
Bing eating/purging type
What is the ICD10 diagnostic criteria for anorexia nervosa?
Refusal to maintain or achieve normal body weight, BMI <17.5
Intense fear of gaining weight or becoming fat
Body shape disturbance
Undue influence weight and shape on self evaluation
Amenorrhoea
What are some risk factors for anorexia nervosa?
Female Occupational eg dancer Perfectionism OCPF personality disorder Young dieting behaviours
What are some of the predisposing factors to AN?
Genetics, family history
Female, early menarche
Sexual abuse
Premorbid anxiety or depressive disorder
Low self-esteem
Perfectionism, obsessional/anankastic personality
Bullying at school, stressful life events
What are perpetuating factors to AN?
Starvation leads to neuroendocrine changes that perpetuate anorexia.
Perfectionism and obsession
Occupation, western society
How long must symptoms be present for a ICD10 diagnosis of AN?
Present for at least 3 months, there must be the absence of recurrent episodes of binge eating, and preoccupation with eating/craving to eat.
What are the differences between anorexia nervosa and bulimia nervosa?
AN - significantly underweight, BN normal
AN - more likely to have endocrine abnormalities
BN has strong cravings for food, episodes of binge eating
What is noted in AN on MSE?
Appearance thin weak, slow, anxious, may try to disguise emaciation.
Speech slow, slurred or normal
Mood can be low with co-morbid depression or euthymic
Thought - preoccupation with food, overvalued ideas about weight and appearance
Perception - no hallucinations
Cognition normal or poor if physically unwell
Insight - often poor
What investigations should be requested in AN and what are the results?
Bloods FBC - anaemia, leukopenia U&Es increase in urea and creatinine if dehydrated, decrease in ions TFTs low T3 and T4 LFTs decrease in albumin Lipids increase in cholesterol Increase in cortisol Decrease in LH and FSH Decrease in glucose Check amylase as pancreatitis is a complication
Venous blood gas - metabolic alkalosis if vomiting, metabolic acidosis if using laxatives
DEXA scan rule out osteoporosis
ECG for arrhythmias such as sinus bradycardia, prolonged QT
EAT questionnaires
What are the differentials for AN?
Bulimia nervosa Eating disorder not otherwise specified Depression Obsessive-compulsive disorder Schizophrenia Organic causes of low weight Alcohol or substance misuse
What are the complications of anorexia nervosa?
Metabolic - hypokalaemia, hypercholesterolaemia, hypoglycaemia, deranged LFTs and electrolytes
Endocrine - increase in cortisol, GH, decrease in TFTs and LH/FSH, amenorrhoea
GI - enlarged salivary glands, pancreatitis, constipation, peptic ulcers, hepatitis
CV - cardiac failure, ECG abnormalities, arrhythmias
Renal failure and stones
Seizures, peripheral neuropathy
Iron deficiency anaemia, thrombocytopenia, leucopenia
Dry skin, brittle nails, infections, suicide
What is the management of AN?
Biological
Treatment of medical complications e.g. electrolytes
SSRIs for co-morbid depression or OCD
Psychological Psycho-education CBT Cognitive analytic therapy Interpersonal psychotherapy Family therapy
Social
Voluntary organisations
Self-help groups
Risk assessment for suicide and medical complications
Treatment as an inpatient - for weight gain of 0.5-1kg/week or as an outpatient of 0.5 kg/week
Hospitalisation necessary for severe anorexia, BMI <14, severe electrolyte abnormalities and psychiatric reasons e.g. suicidal ideation
In cases where insight is clouded, use of MHA or Children Act may be needed
What is refeeding syndrome?
Life threatening syndrome results from food intake - whether parenteral or enteral after prolonged starvation or malnourishment.
Due to changes in phosphate, magnesium and potassium.
Occurs as result of insulin surge following increased food intake.
Fluid balance abnormalities, hypokalaemia, hypomagnesaemia, hypophosphataemia, abnormal glucose metabolism.
Phosphate depletion causes reduction in cardiac muscle activity, can lead to cardiac failure.
What is the treatment/prevention of refeeding syndrome?
Identify high risk
Immediately prior to feeding and during first 10 days supplement with oral thiamine, Vit B, multivitamins
Start nutritional support under supervision of dietician; max 10kcals/kg/day and increase gradually
Check baseline electrolytes, correct as appropriate
Restore circulatory volume, monitor fluid balance
What bloods test results characterise refeeding syndrome?
Low phosphate, magnesium and potassium
Low thiamine
High glucose
What is bulimia nervosa?
An eating disorders characterised by repeated episodes of uncontrolled binge eating, followed by compensatory weight loss behaviours and overvalued ideas regarding ideal body shape and weight.
What is the vicious cycle of BN?
Sense of compulsion to eat
Binge eating
Fear of fatness
Compensatory weight loss behaviours e.g. vomiting, using laxatives, exercising excessively, alternating with periods of starvation.
What are the risk factors for bulimia nervosa?
Female sex Family history Early onset puberty Childhood obesity Co-morbid mental illness Abuse as a child Low self-esteem Environmental stressors
What should be screened for alongside EDs?
Depression Anxiety Deliberate self-harm Substance misuse Emotionally unstable personality disorder
What are the ICD10 clinical features of BN?
Bulimia Patients Fear Obesity Behaviours to prevent weight gain Preoccupation with eating Fear of fatness Overeating - at least two episodes per week over a period of 3 months
Other features include normal weight, depression and low self-esteem, irregular periods.
Signs of dehydration
Consequences of repeated vomiting and hypokalaemia
What are the subtypes of BN?
Purging - self-induced vomiting, laxatives, diuretics and enemas.
Non-purging - less common, excessive exercise or fasting after a binge.
What are the investigations for BN?
Bloods - FBC, U&Es, amylase, glucose, TFTs, magnesium, calcium, phosphate
Venous blood gas - metabolic alkalosis
ECG hypokalaemia - prolonged PR, flattened or inverted T waves, prominent U waves
What are the differentials for BN?
AN
EDNOS eating disorder not otherwise specified
Kleine Levin syndrome - sleep disorder in adolescent males characterised by recurrent episodes of binge eating and hypersomnia
Depression
OCD
Organic causes of vomiting e.g. gastric outlet obstruction
What are the complications of repeated volume?
Russell’s sign - calluses on knuckles due to knuckles making contact with incisor teeth when inducing gag
Bilateral parotid swelling
Dental erosion
What are the physical complications of repeated vomiting?
CV - arrhythmias, mitral prolapse, oedema
GI - M-W tears
Dehydration, hypokalaemia
Dental - erosion
Endocrine - amenorrhea, irregular menses, osteopenia
Aspiration pneumonitis
Cognitive impairment
What is the management of BN?
Biological
Trial of antidepressant should be offered, can decrease freq of binge eating/purging.
Fluoxetine high dose 60mg
Treat medical complications
Psychological
Psychoeducatio
CBT-BN
Interpersonal therapy
Social Food diary to monitor eating and purging Techniques to avoid binging e.g. eating in company, distractions Small regular meals Self-help programmes
BN patients usually have good insight, hospital treatment if suicide risk or severe electrolyte imbalances
What typically occurs in a binge?
Subjective loss of control Large amounts, typically calories laden, 'forbidden foods' Associated guilt afterwards Secretive Alone Hiding the evidence
What predicts a good outcome in recovery of EDs?
Motivation to change Short duration of illness Level of severity Onset during adolescence Good family function Lack of comorbid conditions
What should individual CBT-ED programmes for adults with AN include?
Up to 40 sessions over 40 weeks; twice-weekly sessions in first 2/3 weeks
Reduce risk to physical health
Encourage healthy eating
Cover nutrition, mood regulation, body image concern
Personalised treatment plan
Explain risks of malnutrition
Self monitoring of dietary intake and associated thoughts and feelings
What is MANTRA?
7 core modules conducted over 20-40 sessions
Use of MANTRA workbook
non-anorexic identity
What should CBT-ED for binge eating disorder include?
16-20 sessions
Determine how dietary and emotional factors contribute to their binge eating
Weekly monitoring of binge eating behaviours, dietary intake and weight
Share weight record
Address any body image issues
What should a treatment plan for those with diaebetes misusing insulin in EDs consist of?
Gradual increase in amount of carbs in diet if medically safe so insulin can be started at a lower dose
Gradual increase in insulin doses
Adjusted glycaemic load and carb distribution, prevents rapid weight gain
Psychoeducation
Diabetes education interventions
Test glucose before all supervised meals
What are important considerations for those who are vomiting with their ED
Have regular dental and medical reviews
Avoid brushing teeth immediately after vomiting
Rinse with non-acid mouthwash after vomiting
Avoid highly acidic foods and drinks
What should be offered by GPs to those not receiving ongoing treatment for their ED?
Weight or BMI Blood pressure Relevant blood tests Any problems with daily functioning Assessment of risk - related to both physical and mental health ECG, for those with purging behaviours and/or significant weight changes Discussion of treatment options Consider bisphosphonates if osteoporosis
What should an examination in anorexia nervosa include?
Height, weight, BMI Core temperature Peripheral examination - circulation, oedema CV exam - pulse, BP Test muscle power
Could find bradycardia, hypotension, peripheral oedema, gaunt face, lanugo hair, scanty pubic hair, acrocyanosis (hands, feet red or purple)
What parameters suggest severe anorexia in adults - over 18?
BMI 13-15 medium risk, <13 high risk
Rate of weight loss more than 0.5kg per week
Pulse below 40
BP: systolic below 90, diastolic below 70, postural drop greater than 10
Unable to get up from squatting or lying down without using arms for balance or leverage
Core temp below 35
Low K, Na, Mg, PO4, raised urea, cr, transaminases
Prolonged QT on ECG
What are the signs of moderate or severe risk for under 18s with anorexia nervosa?
BMI: medium risk is 70-80% of median BMI (0.4th to 2nd centile) and high risk is <70% (below the 0.2nd centile).
Rate of weight loss: medium risk is suggested by recent loss of weight of 500-999 g per week for two consecutive weeks; high risk is 1 kg or more over the same time frame.
Pulse rate: medium risk if the pulse rate whilst awake is below 50 beats per minute; high risk below 40 beats per minute.
Blood pressures: figures are dependent on age and gender but below the 2nd centile confers medium risk and below the 0.4th centile high risk.
Cardiovascular symptoms: a history of syncope and/or postural drops in blood pressure suggests higher risk.
ECG: an increase in the QT interval of 460 ms for girls or 400 ms for boys suggests medium or high risk, particularly in the presence of other rate or rhythm change.
Core temperature: <36°C suggests medium risk; <35.5°C high risk.
Blood tests: low potassium, sodium, calcium, phosphate, albumin or glucose.
Behaviour: severe restriction of calorie intake, moderate to high levels of excessive exercise, fluid restriction, vomiting, purging, poor insight, violent rebellion against parental input, suicidal behaviour and self-harm.
Squat test: unable to get up from a lying down position or from squatting without using arms for balance or leverage.
What management of physical conditions in anorexia nervosa is it important to consider?
Monitor U&Es, regular ECGs
Oral supplementation for any abnormal electrolytes, IV if severe
Regular assessment by dentist
DEXA scan - do not give oestrogen treatment, bisphosphonates may be useful in adults
When might urgent admission be required in those severely ill with anorexia?
Electrolyte imbalance or hypoglycaemia.
Severe malnutrition.
Severe dehydration.
Evidence of incipient organ failure.
Bradycardia (below 40 beats per minute) or a prolonged QT interval on the ECG.
Very low BMI. Levels of risk are detailed above. BMI alone is not usually enough as a measure of high risk and other factors should be taken into consideration.
Rapid weight loss (eg, more than 1 kg per week for more than two consecutive weeks).
Need for medical stabilisation and refeeding.
Inability or incapacity of parents or carers to provide the support needed.
Significant suicide risk.
What are some of the complications of anorexia nervosa?
Hypokalaemia Hypotension Cardiac problems Anaemia Hypoglycaemia Osteoporosis Constipation Lack of growth in teens Infertility Infections Renal calculi, AKI, CKD Alcohol dependency Anxiety
What is the NICE guildeine for management of BN in under 18s?
Bulimia nervosa focused family therapy as a first line - 18-20 sessions involving family support, monitoring, regular eating, reducing compensatory behaviours
Or individual CBT-ED
What management of physical aspects of bulimia should be considered?
If vomiting freq or taking large quantities of laxatives have fluids and electrolytes balance freq assessed. Regular dental reviews and hygiene. Reduce laxatives slowly Screen for osteoporosis Check no insulin misuse
What can be some of the complications of bulimia?
Haematemesis
Metabolic complications
Dental erosions
Painless enlargement of salivary glands, tetany, seizures.
What is binge-eating disorder?
People lose control of eating, have reoccurring episodes of eating unusually large amounts of food
Recurrent binge eating, no purging behaviour
What are the features of binge-eating disorder?
Binge eating and no purging
Feeling of lack of control over the amount of food consumed
Three of - eating faster, eating until uncomfortably full, eating large amounts when not hungry, eating alone due to embarrassment, feeling of disgust after
What is the treatment of binge-eating disorder?
Psychotherapy - self guided CBT, psychotherapy
If CBT ineffective alone, SSRIs to reduce impulse, methylphenidate to reduce binge eating episodes
What is avoidant restrictive food intake disorder (ARFID)?
Selective eating disorder
Do not have fear of gaining weight, does not eat enough calories
Dramatic restriction of types or amount of food eaten
Lack of appetite or interest in food
Dramatic weight loss
Upset stomach, abdo pain, GI issues with no other cause
Limited range of preferred foods, picky eating getting worse
What is pica?
Appetite for and ingestion of nonnutritive substances e.g. hair, clay, soil, ice, paint
Persistent ingestion for >1 month, inappropriate for developmental age
What are the complications of pica?
Lead poisoning from paint
Bowel obstruction, perforation
Bacterial or parasite infections
What is the treatment of pica?
Behavioural interventions and nutritional rehabilitation
Pharmacotherapy - SSRI second line
