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PSYCHIATRY > EATING DISORDERS > Flashcards

EATING DISORDERS Flashcards

1
Q

How many deaths do EDs cause a year globally?

A

7000
Mental ill ness with the highest mortality rate

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2
Q

Whats the prognosis for anorexia?

A

50% make a full recovery
33% improve
20% have a chronic ED

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3
Q

Whats the prevalence of EDs in women?

A

4% have anorexia nervosa
2% have bulimia nervosa
2% have a binge eating disorder at some point in their life

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4
Q

What age is the risk for EDs highest?

A

Between 13-17

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5
Q

What are the different types of EDs?

A

• Anorexia nervosa
• Anorexia nervosa unspecified
• Anorexia nervosa, restricting type
• Anorexia nervosa, binge eating/purging type
• Bulimia nervosa
• Binge eating disorder
• Pica
• Other specified feeding or ED
• Orthorexia
• Diabulimia

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6
Q

What is pica disease?

A

people compulsively eat 1 or more non food item e.g. clay, ice, paper which have no nutritional value

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7
Q

What is orthorexia?

A
  • an unhealthy obsession with eating ‘pure’ food which leads to an unbalanced diet that often results in malnutrition. This isnt typically driven by poor body image but the need to be healthy.
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8
Q

What is diabulimia?

A

deliberate manipulation of insulin levels in t1 diabetics to control rate which puts them at risk of significant diabetic complications as well as complications of EDs

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9
Q

What are the characteristics of anorexia nervosa?

A

deliberate weight loss, induced and sustained by the patient. The disorder is associated with a specific psychopathology whereby a dread of fatness and flabbiness of body contour persists as an intrusive overvalued idea, and the patients impose a low weight threshold on themselves.

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10
Q

Whats the prevalence of anorexia nervosa?

A

9 in 1000 females
W:m 10:1

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11
Q

What are the 2 types of anorexia nervosa?

A

Restricted type and bing/purge type

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12
Q

What are the main risk factors for anorexia nervosa?

A

female gender
living in western society
Fhx
pre morbid experiences (e,g. Sexual abuse/dieting behaviour in family /occupational pressures to be slim/criticism about weight or eating behaviours)
personal characteristics (e.g. perfectionism/low self-esteem/obsessional traits/anxiety/BPD)
severe life stressors.

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13
Q

What are the clinical features of anorexia nervosa?

A

Refusal to maintain normal BMI
Weight below 85% predicted <17.5kg/m2 (in young people this may present as faltering growth or delayed puberty)
Dieting/restricting eating habits
Rapid weight loss
Disproportion about weight or shape
Denial of problem and resistant to intervention
Social withdrawal; few interests
Fatigue
Enhancing weight loss with excessive exercising, laxatives and self-induced vomiting

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14
Q

What are some physical features of anorexia nervosa?

A

Primary or secondary amenorrhoea
GI symptoms e.g. bloating, nausea and constipation
Dampened immune response, anaemia, easy bruising and bleeding - bone marrow dysfunction
Osteoporosis
Dry, scaly skin and dry brittle hair
Halitosis - really bad breath from repeated vomiting
Fatigue, fainting, dizziness and intolerance of cold
failure of secondary sexual characteristics
bradycardia
cold-intolerance
yellow tinge on the skin (hypercarotenaemia)
Delay in secondary sexual characteristics if pre-pubertal
Lanugo hair
Oedema - caused by congestive HF and low protein
May have difficulty breathing due to weak diaphragm caused by msucle loss
Ataxia, confusion and death from brain atrophy and encephalopathy

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15
Q

What investigations should you do for anorexia nervosa?

A

ESR and TFTs to screen for other causes of weight loss
U&Es (particularly in those who are vomiting, taking laxatives, diuretics or water loading) - often have hypokalaemia, hypomagnaemia, and hypophosphataemia
Weekly blood tests to check FBC, ESR, U&E, creatinine (may be low due to muscle loss)
glucose, LFTs and TFTs in those whose BMI <15
ECG - may show bradycardia or prolonged QTc
Consider DEXA scan in chronic anorexia (after 2 years underweight in adults or 1 year in children)
May have vitamin deficiencies like thiamine

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16
Q

What hormones will be abnormal in anorexia nervosa?

A

High - GH, glucose, cortisol, cholesterol, carotinaemia, ghrelin
Low - K+, GnRH/FSH/LH/FSH/oestrogens/testosterone, T3, Na+, leptin

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17
Q

What is mild, moderate, severe, extreme anorexia nervosa?

A

Classified by BMI
Mild 17-18.5
Moderate 16-17
Severe 15-16
Extreme <15

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18
Q

What has replaced MARSIPAN?

A

Medical emergencies in eating disorders (MEED)

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19
Q

When should anorexia nervosa patients have urgent admission to a general hospital?

A

Electrolyte imbalances
Severe dehydration
Evidence of end-organ failure
Bradycardia <40bpm
ECG changes
>1kg weight loss in a week on 2 consecutive weeks
Significant suicide risk

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20
Q

What psychological management can be offered to those with anorexia nervosa?

A

Under 18s - anorexia-nervosa-focussed family therapy is first line
Over 18s - CBT-ED is first line (Maudsley anorexia nervosa treatment for adults workbook, special supportive clinical management or eating-disorder-focused psychodynamic therapy can be offered)

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21
Q

Whats the aim of CBT-ED?

A

aim to reduce the risk to physical health and any other symptoms of the ED, encourage healthy eating and reaching a healthy body weight, enhance self-efficacy, create a personalised treatment plan, include self monitoring of dietary intake and associated thoughts and feelings and include homework

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22
Q

Whats the weight regain rate recommended for anorexia nervosa pt?

A

0.5-1kg per week
This requires 3500-7000 extra calories a week

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23
Q

What are some physical methods of managing anorexia nervosa?

A

Daily U&Es and ECG oral supplementation for electrolyte imbalances
Bisphosphonates if osteopenia or osteoporosis
Regular dentil assessment if regularly purging
Dietician input

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24
Q

What are some predictors of poor outcome for anorexia nervosa?

A

• late age of onset (late teens +)
• Already ill for several years at presentation (>6 years)
• Disturbed relationship between pt and family members
• Premorbid obesity
• VERY low body weight on admission
• Bulimic behaviour
• Male gender

25
Q

When is feeding against someone’s will done?

A

As a last resort in care and management
It should only be done in the context of MHA or children act and the legal basis for such action must be made perfectly clear

26
Q

What are some complications of anorexia nervosa?

A

Hypokalaemia, hyponatraemia
Hypotension
Cardiac problems
Anaemia and thrombocytopenia
Hypoglycaemia
Osteopenia or osteoporosis
Lack of growth
Infertility, amenorrhoea, loss of libido
Increased number and severity of infections
Renal calculi
AKI or CKD
Anxiety and mood disorders

27
Q

What proportion of deaths in anorexia nervosa does suicide make up?

A

20%

28
Q

What is atypical anorexia?

A

Disorders that fulfil some of the features of anorexia nervosa but in which the overall clinical picture does not justify that diagnosis.
For instance, one of the key symptoms, such as amenorrhoea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behaviour. This diagnosis should not be made in the presence of known physical disorders associated with weight loss.

29
Q

What is bulimia nervosa?

A

A syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or use of purgatives.
This disorder shares many psychological features with anorexia nervosa, including an overconcern with body shape and weight.
There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval ranging from a few months to several years.

30
Q

What are some compensatory weight loss behaviours that may be used in bulimia nervosa?

A

Self induced vomiting
Restricting intake
Fasting
Intensive exercise
Abuse of laxatives/diuretics/thyroxine or amphetamines
Diet pills

31
Q

Whats the prevalence of bulimia nervosa?

A

10-15 per 1000 females
Lifetime female prevalence of 2%
F:m 10:1

32
Q

What are risk factors for bulimia nervosa?

A

Parental and childhood obesity
Family dieting
FHx of EDs
Severe life stresses e.g. abuse
Parental and premorbid psychiatric disorder or substance misuse
Parental high expectations, low care and overprotection
Criticism about eating habits or body weight
Pressure to be thin
Personal characteristics - perfectionism, low self esteem, obsessional traits, anxiety, BPD
It has been shown to have a genetic component in the cause based on twin studies and adoption studies. There is strong evidence for a social component; rates of bulimia are higher for individuals in societal that hav higher exposure to media. Often seen among athletes and models.
Commonly associated with OCD, depression and anxiety.

33
Q

Whats the common pattern in bulimia nervosa?

A

Cyclical - they set unrealistic goals for themselves and when they dont reach those goals they binge. To attempt to fix the binge they purge.

34
Q

What are the core features of bulimia nervosa?

A

Regular binge eating, loss of control eating during binges (DSMV says binge eating must occur at least once a week for 3 months)
Attempts to counteract the binges
BMI >17.5kg/m2
Preoccupation with weight, body shape and body image
Preoccupation with food and diet

35
Q

What are some physical symptoms of bulimia nervosa?

A

Bloating and fullness
Lethargy
Heartburn and reflux
Abdominal pain
Sore throat and dental problems
Halitosis
Swollen salivary glands
Oedema if laxative/diuretic abuse
Russell sign
Erosion of dental enamel

36
Q

What is ruddell’s sign

A

Calluses on the back of the hand due to teeth on induced vomiting

37
Q

What investigations should be done for bulimia nervosa?

A

FBC - all may be normal other than hypokalaemia
Renal function and electrolytes should be checked

38
Q

Whats the treatment for under 18s with bulimia nervosa?

A

Bulimia-nervosa-focussed family therapy first line

39
Q

Whats the treatment for over 18s with bulimia nervosa?

A

Evidence-based bulimia-focused guided self-help programme with direct encouragement from healthcare professionals
CBT-ED if the above is ineffective after 4 weeks

40
Q

Whats the prognosis of bulimia nervosa?

A

up to 80% make a full recovery without treatment. If recovery hasn’t occurred after 5 years, they’re more likely to develop a chronic disorder. 10-15% go on to develop anorexia.

41
Q

What are some complications of bulimia nervosa?

A

Haematemesis
Metabolic abnormalities e.g. hypochloraemic, hypokalaemic metabolic alkalosis following excessive vomiting
Electrolyte imbalances leading to cardiac arrhythmias, renal impairment or muscular paralysis
Dental erosions
Painless enlargement of salivary glands
Tetany and seizures (hypocalcaemia)

42
Q

What is atypical bulimia nervosa?

A

Disorders that fulfil some of the features of bulimia nervosa, but in which the overall clinical picture does not justify that diagnosis. For instance, there may be recurrent bouts of overeating and overuse of purgatives without significant weight change, or the typical overconcern about body shape and weight may be absent.

43
Q

What is binge eating disorder?

A

Characterised by frequent and recurrent binge eating episodes with associated negative social and psychological problems, without episodes of purging.

44
Q

What are the features of binge eating disorder?

A

Eating fast in a short space of time
Making themselves uncomfortably full
Eating large amounts when not hungry
Subjective loss of control over food intake
May be planned in advance - purchasing of special binge foods
Eating alone or secretly due to embarrassment over amount of food consumed
Dazed mental state during binge
Feelings of shame, guilt or disgust following a binge

45
Q

How is bulimia nervosa managed?

A

encouraged to follow an evidence-based self-help programme. Healthcare professionals should provide direct encouragement and support. First line
Group CBT-BED (16 weekly 90-minute group sessions over 4 months)
Individual CBT-BED

46
Q

What is T1de?

A

Type 1 diabetes disordered eating service

47
Q

What are the proposed diagnostic criteria for eating disorders in type 1 diabetes?

A
  1. Intense fear of gaining weight, or body image concerns, or fear of insulin promoting weight gain
  2. Recurrent inappropriate direct or infirtec restriction of insulin and/or other compensatory behaviour to prevent weight gain
  3. Presenting with a degree eof insulin restriction, eating or compensatory behaviours that cause harm to health OR clinically significant diabetes distress OR impairment in daily functioning.
48
Q

How might type 1 diabetics use their condition to manage weight?

A

Insulin restriction
Insulin over-injection to cover binge eating

49
Q

What are some red flags for type 1 diabetes associated disordered eating?/

A

• HbA1c >86mmol/mol or erratic BG levels
• Multiple ED or ward admissions for hyperglycaemia or DKA
• Recurrent ketonaemia
• Recurrent severe hypoglycaemia (2+ episodes over 24 months)
• Over exercising
• Impaired awareness of hypoglycaemia
• Extreme dietary restriction or binge eating
• Weight loss history or fear of weight gain
• Body image concerns
• History of ED diagnosis
• Diabetes distress and fear of hypoglycaemia
• Mental health comorbidity
• Secrecy about diabetes management, failure to request regular prescriptions, disengagement from diabetes services
• Poor school/work performance + attendance
• Conflict at home around eating and diabetes management

50
Q

How may those with EDs try to ‘trick the scales’?

A

Water loading
Anti-diarrhoea meds
Heavy clothing
Things in pockets
Coins in socks
Coins sewn into hair scrunichies
Taping money around body

51
Q

Who’s at risk of re-feeding syndrome?

A

nyone who has an ED, is elderly, after a severe illness/major surgery or in children. This happens in anyone who has had a period of starvation and occurs only AFTER commencing re-feeding.

52
Q

When does re-feeding syndrome typically occur?

A

It usually occurs 4 days-2 weeks after commencing feeding.

53
Q

What are the signs of re-feeding syndrome?

A

Patients develop fluid and electrolyte disorders (specifically hypophosphateaemia, hypokalaemia and hypomagnesaemia) along with neurological, pulmonary, cardiac, neuromuscular and haematological complications.
One of the first visible signs is peripheral oedema and hypophosphataemia so this is what we monitor.

54
Q

What is the most common cause of death from re-feeding syndrome?

A

Cardiac arrhythmias
Others - confusion, coma, convulsions

55
Q

Whats the pathophysiology of re-feeding syndrome?

A

In starvation… Body switches from carbs to fatty acids and amino acids for energy.spleen reduces rate of RBC destruction. Intracellular minerals become severely depleted but serum levels remain norma. Insulin secretion is suppressed in fasted state and glucagon secretion is increased
In re-feeding.. insulin secretion resumes due to increased BG = increased glycogen, fat and protein synthesis. This requires phosphate, magnesium and potassium which are already depleted so stores rapidly become used up. Re-feeding also increases baso-metabolic rate. Shifting of electrolytes and fluid balance increases the cardiac workload and HR which can lead to acute HF. Oxygen consumption is also increased which strains the respiratory system and can make weaning from ventilation more difficult if being ventilated.

56
Q

How do we monitor a pt for re-feeding syndrome?

A

• Urea, creatinine, sodium, potassium, phosphate, calcium, albumin and magnesium should be measured daily for 5 days, then day 10 and day 14. (Electrolyte changes usually occur 72 hours into feeding)
• Hydration and nutritional status and daily weight (daily weight would show significant increase if oedema which is a sign of re-feeding syndrome)
• Cardiac status, pulse and ECG

57
Q

How do you treat re-feeding syndrome?

A

• Decrease calories and don’t increase until phosphate has normalised
• Oral phosphate supplements or IV if not tolerated
• start feeding between 1400-2000 kcal per day, rising by at least 200kcal per day until weight restoration is achieved

58
Q

What is BEAT?

A

The UKs eating disorder charity providing info and support for those with EDs
Currently, Beat is very concerned about the level of eating disorder training for medical students. Research shows medical students in the UK receive less than two hours of eating disorder training during their undergraduate degree, and one in five universities do not offer any teaching on eating disorders at all. The lack of undergraduate training means that doctors are often unable to provide appropriate referrals for sufferers when a patient presents, causing delays in treatment and putting patient safety at risk.T his lack of training also means undertrained doctors too often only look at physical symptoms of eating disorders like BMI and do not consider mental health factors.
Beat runs training for healthcare and educational professionals, and offers partnerships with NHS to reduce the burden on service providers. This includes training and peer support groups for carers.

59
Q

Whats the most common cause of admissions to child and adolescent psychiatric wards?

A

Anorexia nervosa

PSYCHIATRY (20 decks)

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