Eating disorders

Question 1

Name the different classifications of feeding and eating disorders

Answer 1

• anorexia nervosa
• bulimia nervosa
• binge eating disorder
• avoidant - restrictive food intake disorder (ARFID)
• pica
• rumination-regurgitation disorder

Question 2

Describe the aetiology of anorexia nervosa

Answer 2

• females > males

- highest incidence 15-19 year olds

Question 3

Describe the diagnostic features of anorexia nervosa

Answer 3

• weight loss or failure to gain weight in children (typically, 85% of less of their expected weight for age and height)
• in adults, a BMI of less than 17.5 indicates a likelihood of anorexia
• in children, this is measured as weight percentage for height (85% or below would indicate anorexia)

Question 4

Describe the other symptoms of anorexia nervosa

Answer 4

• marked fear of fatness
• intense fear of any weight gain
• overvalued ideation r.e. weight
• thinness central to their self worth

Question 5

What are the two subtypes of anorexia nervosa and describe them

Answer 5

Restricting;
- weight loss accomplished primarily through dieting and excessive exercise
- severely restricted calorie intake (less than 500 kcals a day)
- there may be an excessive and often punishing exercise routine
binge-purge;
- still of low weight but regularly engaging in binge eating or purging or both during a current episode
- some do not binge but regularly purge after small quantities of food

Question 6

What is bulimia nervosa?

Answer 6

Recurrent binge eating followed by compensatory behaviours to avoid weight gain, at least once a week for 3 months

Question 7

Describe the features of bulimia nervosa

Answer 7

• experience loss of control at time of binge
• use compensatory behaviour to prevent weight gain
• have conditions relating to teeth, oesophagus, GI, low potassium
• self evaluation is unduly influenced by body shape and weight
• have body image disturbance

Question 8

What is the diagnostic requirements for bulimia nervosa?

Answer 8

Episodes of excessive food consumptions, over a short period of time often to the point of discomfort, accompanied by a loss of control and feelings of guilt and shame at least once a week for 3 months

Question 9

What are other specified feeding and eating disorders (OFSED)?

Answer 9

A group of disorders that do not fit the exact diagnostic criteria for anorexia nervosa, bulimia nervosa or binge eating disorder but mimic them in some ways

Question 10

What are the typical signs for other specified feeding and eating disorders (OFSED)?

Answer 10

• difficulties eating in front og others
• preoccupation with food
• low confidence and self esteem
• negative body image
• irritability and mood swings
• tiredness and difficulty concentrating
• social withdrawal
• feelings of shame, guilt and anxiety

Question 11

Describe atypical anorexia (example of OSFED)

Answer 11

Where someone has all the symptoms a doctor looks for to diagnose anorexia, except their weight remains within a ‘normal’ range

Question 12

Describe purging disorder (example of OSFED)

Answer 12

Where someone purges, for example by being sick or using laxatives, to affect their weight or shape, but this is not as part of binge / purge cycles

Question 13

Describe night eating syndrome (example of OSFED)

Answer 13

Where someone repeatedly eats at night, either after waking up from sleep or by eating a lot of food after their evening meal

Question 14

What is avoidant restrictive food intake disorder?

Answer 14

ARFID sufferers restrict their eating to small amounts of food or avoid certain foods or food groups. This means they of not get all of the nutrients or calories that they need, may need nutritional supplements or enteral feeding

Question 15

What are the signs of avoidant restrictive food intake disorder?

Answer 15

• eating far less food than needed to stay healthy, or missing meals completely
• sensitivity to aspects of some foods (texture, smell or temperature)
• appearing to be a picky eater
• lack of interest in eating
• avoid social events where food is present
• malnutrition or weight loss
• needing to take supplements to meet their nutritional needs

Question 16

What is MaRSIPAN?

Answer 16

Management of really sick patients with anorexia nervosa

Question 17

What are the MaRSIPAN recommendations?

Answer 17

• medical and psychiatric staff need to be aware that adult patients with AN being admitted to a medical ward are often at high risk
• physical assessment in these patients should include BMI and physical examination, including muscle power, blood tests and ECG
• most adults with severe AN should be treated on specialist eating disorder units
• criteria for medical admission involves either the need for treatments not available on a psychiatric ward (such as IV infusion)
• the role of the primary care team is to monitor such patients and refer them early
• the in-patient medical team should be supported by a senior psychiatrist
• the inpatient medical team should contain physician and dietician with specialist knowledge

Question 18

What is considered a high risk BMI?

Answer 18

<13 or rapid weight loss of >1kg per week

Question 19

Describe what could be seen on general examination of a patient with anorexia nervosa

Answer 19

• general appearance; cachexia, signs of dehydration, lanugo, bruising, hair loss, dry skin, cold intolerance, russells signs, salivary gland enlargement
• low HR, low BP and low temp
• L&S BPL orthostatic hypotension
• reduced muscle power
• sit up squat stand test

Question 20

What changes can be seen on ECG in patients with anorexia nervosa?

Answer 20

• bradycardia
• raised QTC (>450ms)
• non specific T wave changes
• hypokalaemic changes
• even mild hypokalaemia signifies low body potassium and may herald more severe, fata hypokalaemia episodes after discharge

Question 21

What are the treatment guidelines for anorexia nervsoa?

Answer 21

Offer either;

• individual cognitive behavioural therapy focused on eating disorders (CBT-ED)
• maudsley anorexia nervosa treatment for adults (MANTRA)
• specialist supportive clinical management (SSCM)
• if these are unacceptable, contraindicated or ineffective, offer focal psychodynamic
• in children; offer family therapy focused on anorexia nervosa

Question 22

What are the treatment guidelines for binge eating disorder?

Answer 22

• a guided self help programme focused on binge eating disorder
• if unacceptable, contraindicated or ineffective, offer group cognitive behavioural therapy
• consider individual CBT if group unavailable or patient declines

Question 23

What are the treatment guidelines for bulimia nervosa?

Answer 23

• guided self help focused on bulimia nervosa

- or if unacceptable, contraindicated or ineffective after 4 weeks, consider individual CBT

Question 24

Describe the pathophysiology of refeeding syndrome

Answer 24

• most at risk; severely underweight, rapid weight loss or minimal intake in preceding 7-14 days
• body switches from carbohydrates to fats and protein as its energy source
• intracellular minerals become depleted but serum levels may reamin normal, re-feeding stimulates insulin production which causes potassium / magnesium and phosphate to be taken into cells whilst serum levels falls
• the rapid change in BMR together with serum electrolyte depletion causes the physical symptoms of re-feeding syndrome

Question 25

Describe the treatment / prevention of refeeding syndrome

Answer 25

• be aware of risk
• start with low level energy replacement, with high phosphate content e.g. milk and build up every 2-3 days
• supplement with multivitamin e.g. forceval and thiamine for at least 10 days
• daily monitoring of bloods
• correct electrolyte and fluid inbalances