Eating Disorders Flashcards
Anorexia nervosa diagnostic criteria
- Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
- Intense fear of gaining weight or becoming fat, even though underweight.
- Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
Epidemiology of anorexia nervosa
90% of patients are female
predominately affects teenage and young-adult females
What do NICE reccomend one of in the treatment of anorexia nervosa
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM).
Treatment of anorexia nervosa in young people
In children and young people, NICE recommend ‘anorexia focused family therapy’ as the first-line treatment. The second-line treatment is cognitive behavioural therapy.
Anorexia nervosa: characteristic clinical signs and physiological abnormalities
Features
reduced body mass index
bradycardia
hypotension
enlarged salivary glands
lanugo hair (fine hair covering the body)
Low BMI
Amennorhea
Physiological abnormalities
**hypokalaemia
**low FSH, LH, oestrogens and testosterone - sex hormones
raised cortisol and growth hormone
impaired glucose tolerance
hypercholesterolaemia
hypercarotinaemia
low T3
Weight loss in anorexia nervosa
Deliberate - induced and sustained by the patient. Disregard of impact on physical health
Importance of ECG in anorexia nervosa
Because of the resulting malnutrition, those with Anorexia Nervosa are predisposed to cardiac
arrhythmias.
An ECG should always be performed in those admitted to hospital with Anorexia Nervosa,
in outpatient treatment or in those with symptoms such as dizziness, fainting or light-headedness.
In the body’s attempts to reduce energy expenditure with minimal calorie intake, bradycardia and
hypotension are commonly seen, as well as a prolonged QT interval. A prolonged QT interval increases the risk of a fatal arrhythmia such as Ventricular Fibrillation.
What is refeeding syndrome and what are the metabolic consequences
Refeeding syndrome describes the metabolic abnormalities which occur on feeding a person following a period of starvation. It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism.
The metabolic consequences include:
hypophosphataemia
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
These abnormalities can lead to organ failure.
Which patients are at risk of refeeding syndrome
Patients are considered high-risk if one or more of the following:
BMI < 16 kg/m2
unintentional weight loss >15% over 3-6 months
little nutritional intake > 10 days
hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)
If two or more of the following:
BMI < 18.5 kg/m2
unintentional weight loss > 10% over 3-6 months
little nutritional intake > 5 days
history of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
NICE recommend that if a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.
Why might refeeding syndrome occur?
If nutritional intake is resumed too rapidly after a period of relatively low caloric intake, the patient is at high risk of refeeding syndrome.
Rapidly increasing glucose levels leads to rapidly increasing insulin levels.
This leads to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces.
This is potentially fatal if refeeding is too rapid.
Symptoms of refeeding syndrome may include edema, confusion and tachycardia. Blood tests initially show hypophosphataemia and it is treated with phosphate supplementation.
Refeeding syndrome symptoms and treatment
Symptoms of refeeding syndrome may include edema, confusion and tachycardia. Blood tests initially show hypophosphataemia and it is treated with
phosphate supplementation.
Slowly reintroducing food with restricted calories
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balance monitoring
ECG monitoring may be required in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
Cardiac complications of anorexia nervosa
Prolonged QT
Cardiac complications include arrhythmia, cardiac atrophy and sudden cardiac death.
What happens on the cellular level in refeeding syndrome
Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition. As the starved cells start to process glucose, protein and fats again they use up magnesium, potassium and phosphorus. This leads to:
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload.
General management of eating disorders
Patient and carer education is key to the condition. Management is centred around changing behaviour and addressing environmental factors:
Self help resources
Counselling
Cognitive behavioural therapy (CBT)
Addressing other areas of life, such as relationships and past experiences
Severe cases may require admission for observed refeeding and monitoring for refeeding syndrome.
SSRI medication may be used ( in children, by a specialist in child and adolescent mental health)
How do patients with anorexia nervosa restrict calories
Minimal food intake
Often the person exercises excessively and may use diet pills or laxatives to restrict absorption of food.
What is bulimia nervosa and what are the features
Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate. The condition involves binge eating, followed by “purging” by inducing vomiting or taking laxatives to prevent the calories being absorbed.
Features of bulimia nervosa:
BMI >17.5
Body image disotoriton
Purging and binge eating
Alkalosis, due to vomiting hydrochloric acid from the stomach
Hypokalaemia
Erosion of teeth
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux and irritation
Calluses on the knuckles where they have been scraped across the teeth. This is called Russell’s sign.
Parotid gland swelling
Unique presenting features of bulimia nervosa
Normal body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas. The presenting complaint may be abdominal pain or reflux.
DSM 5 diagnostic criteria for a diagnosis of bulimia nervosa:
recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances)
a sense of lack of control over eating during the episode
recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
recurrent vomiting may lead to erosion of teeth and Russell’s sign - calluses on the knuckles or back of the hand due to repeated self-induced vomiting
the binge eating and compensatory behaviours both occur, on average, at least once a week for three months.
self-evaluation is unduly influenced by body shape and weight.
the disturbance does not occur exclusively during episodes of anorexia nervosa.
Management of bulimia nervosa
referral for specialist care is appropriate in all cases
NICE recommend bulimia-nervosa-focused guided self-help for adults
If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
children should be offered bulimia-nervosa-focused family therapy (FT-BN)
pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking
What is Russles sign and when is it seen?
Calluses on the knuckles where they have been scraped across the teeth.
Bulimia nervosa
Binge eating disorder
Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress. This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.
Binges may involve:
A planned binge involving “binge foods”
Eating very quickly
Unrelated to whether they are hungry or not
Becoming uncomfortably full
Eating in a “dazed state”
Risk factors for bulimia
Genetic risk factors for bulimia include:
Family history of eating disorders
Family history of mental illness
Family history of impulse control disorders
Psychosocial risk factors for bulimia include:
Prior mental health diagnosis
Poor self-esteem
History of abuse or trauma
Having a career or hobby dependent on appearance
History of engaging in restricting and bingeing cycles
Typical symptoms of bulimia
Engaging in binge eating behaviours
Distress over body image
Frequent bathroom trips following meals
Uncomfortable eating food in the presence of others
Mood disturbance: irritability, depression, suicidal ideation and self-harm behaviours
Differential diagnosis to consider in ?bulimia nervosa
Anorexia nervosa: patients with anorexia often present with a severely low BMI, unlike in bulimia where the BMI is usually normal or raised. In anorexia, there is a restriction of energy intake, whereas in bulimia recurrent episodes of binge eating with compensatory mechanisms are evident.
Body dysmorphic disorder
Depression
Obsessive-compulsive disorder
Relevant investigations in ?bulimia nervosa
Bedside:
Height and weight: to calculate BMI
Basic observations: including blood pressure and heart rate
Urinalysis: may show ketones if the patient has co-morbid diabetes mellitus. Some patients may skip insulin to control their weight. This is often referred to as ‘diabulimia’.
ECG: important to perform if there is a severe deficiency in potassium or magnesium. Features of hypokalaemia include increased P wave amplitude, prolonged PR interval, ST depression and T wave flattening/inversion and prominent U waves.
Relevant laboratory investigations include:
Urea & electrolytes: these may show hypokalaemia and/or increased creatinine. Elevated bicarbonate usually indicates alkalosis due to loss of gastric acid.
Magnesium: may be low
Full blood count: may show anaemia
Liver function tests: may be abnormal as excess exercise can elevate aminotransferases
ICD 11 criteria for bulimia
Preoccupation with controlling body weight
Repeated bouts of overeating
Compensatory behaviours after overeating, including self-induced vomiting, using laxatives and excessive exercise
These binge eating and compensatory behaviours usually occur at least once weekly for three months
Pharmacological management of bulimia
Selective serotonin-reuptake inhibitors (SSRIs) are used for the pharmacological management of bulimia. Fluoxetine is typically used first-line, followed by sertraline if this is poorly tolerated.
These may be used when cognitive behaviour therapy (CBT) isn’t available or when it has been tried and the patient hasn’t seen any improvement.
The medications should be given at a time of day when they are unlikely to be purged.2
SSRIs are also useful in the case of comorbid disorders (e.g. depression and anxiety).
Potential complications of bulimia nervosa
Irregular menstrual cycles and fertility issues
Mental health conditions such as depression and anxiety
Gastric ulcers
Osteoporosis
Heart issues including arrhythmias, heart attacks or failure and cardiomyopathy
What is an eating disorder? What are the most common types?
Eating disorders are mental health conditions in which the person uses the control of food to cope with feelings and/or other situations. This usually involves eating too little or too much, purging behaviours or worrying excessively about body weight or shape.
The three most common eating disorders are:
Anorexia nervosa: an eating disorder characterised by weight loss, inability to maintain appropriate body weight for age/height and often associated with distorted body image. It generally involves the restricting of calories and sometimes also involves excessive (and compulsive) exercise and purging.
Bulimia: often involves bingeing and then purging. People with bulimia often make themselves sick or take medications such as laxatives or diuretics to help them get rid of calories.
Binge eating disorder: involves eating excessive amounts of food in a short period and then having feelings of guilt and upset.
What should be explored in an eating disorder history
Weight history
Eating behaviour
Adaptive behaviours
Physical symptoms including red flags
Psychological symptoms
How to structure weight history
SLIM
S: stages - weight during childhood/adult/teenage years, any time of drastic change
L: loss - any periods of excessive or rapid weight-loss, triggers for any weight loss/gain
I: ideal - what do they think is a health weight, how do they feel currently about their weight
M: Maximum and minimum - heaviest and lightest weights
Questions to establish eating behaviours
Establish what would be a normal day for them and what their beliefs around eating are. It is also helpful to understand if they believe they have a problem:
“What would a typical day’s food intake look like for you?”
“Do you think that your eating habits are similar to your friends and families?”
“Has anyone expressed they are concerned about the amount you are eating?”
Examples of adaptive behaviours in eating disorders
Exercise - how much, what type
Purging - vommiting or medication including insulin
Binge eating - what triggers this?
What physical symptoms of eating disorder are considered red flag features
Rapid weight loss
Heart rate <40
Significant orthostatic changes in systolic BP (>20 mmHg)
History of recurrent syncope
ECG abnormalities (prolonged QTc, arrhythmias, signs of electrolyte abnormalities)
Fluid refusal or signs of severe dehydration (reduced urine output, tachypnoea, tachycardia, reduced skin turgor, sunken eyes)
Low temperature (hypothermia)
Signs of electrolyte disturbance
Unable to stand up from squatting or sit up from laying (SUSS test)
What might you ask a patient with an eating disorder when exploring psychological symptoms
Current mood
Periods of high or low moods
symtpoms of anxiety or panic attack
Obsessive or compulsive thoughts
Thoughts of self harm/plans/obstructive factors
Systems enquired in eating disorder
Neurological: memory, concentration, numbness or weakness in limbs, dizziness on sitting to standing
Respiratory: shortness of breath particularly on exercise
Cardiovascular: palpitations or chest pain
Gastrointestinal: changes to bowel habits, abdominal pain, reflux, bloating
Genitourinary: changes to urinary frequency, changes to or absence of menstruation
Miscellaneous: hair loss or growth, dry skin, lethargy
Eating disorders: family history
Ask the patient if there is any family history of psychiatric disease in first-degree relatives:
Ask about a family history of gastrointestinal disease (e.g. inflammatory bowel disease, coeliac disease) when considering other causes of weight loss.
It may be useful to draw a genogram displaying this information.
Questions which can help establish a patients general social context
“Are you feeling particularly stressed at the moment in any area of your life?” (school, work, home)
“How are your eating habits impacting your family/relationship/friends?”
“Has anyone else commented on your mood or behaviours recently?”
“Have you spoken about your concerns to any friends/family/partner?”
What should be asked in terms of social history in a patient with a suspected eating disorder
Stress
Alcohol
Smoking
Drugs
Caffeine use
Support networks
Why is alcohol history significant in eating disorder patients
In addition to malnutrition secondary to the eating disorder, long-standing alcohol dependency can lead to malnourishment. Folate and B12 deficiency may consequently develop
Can help understand triggers and coping mechanisms
First line management of bulimia
CBT
What test can be used to assess muscle wasting in patients with anorexia nervosa?
The sit-up–squat–stand (SUSS) test is a method used to assess muscle wasting in patients with anorexia nervosa. In the sit-up test, the patient lies flat on a firm surface such as the floor and attempts to sit up without using their hands. In the squat test, the patient is asked to rise from a squatting position without using their hands.
An inability to stand up from a chair without using their hands indicates failure of the squat test, which is a red-flag sign indicating severe muscle wasting.
Which term is used to describe ‘eating non-food items or food items in obscene quantities’?
Pica
What ECG findings are more common in patients with severe Anorexia Nervosa?
A prolonged QT interval (>450ms) is often seen in those with Anorexia Nervosa, secondary to weight loss or electrolyte disturbance. It is important to detect this, as it can predispose to potentially fatal arrhythmias
What electrolyte disturbance may occur in bulimia and how does it present?
Excessive potassium loss occurs as a result of repeated self-induced vomiting and laxative use.
Excessive vomiting can cause metabolic alkalosis due to loss of hydrochloric acid, which in turn increases renal potassium excretion.
Generalised muscle weakness and cramps, fatigue and constipation
Bloods in eating disorders
most things low
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
ICD 10 definition of bulimia nervosa
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. Repeated vomiting is likely to give rise to disturbances of body electrolytes and physical complications. 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.
What is the cause of amenorrhoea in anorexia nervosa?
Anorexia nervosa is complicated by hypothalamic-pituitary dysregulation, including hypothalamic amenorrhea
Pharmacological management of bulimia
pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking
What types of psychotherapy are used in the treatment of anorexia nervosa?
Adults - NICE recommend:
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).
Children and young people - NICE recommend:
first-line treatment: anorexia focused family therapy
second-line treatment: cognitive behavioural therapy
(IPT, Psychodynamic therapy)
Which antidepressants should not be used in anorexia nervosa
For safety, tricyclic antidepressants and monoamine oxidase inhibitors are not recommended, and bupropion is contraindicated.
Why are tricyclic antidepressants potentially dangerous in anorexia nervosa?
patients with anorexia nervosa have an increased risk of suicide,
TCAS have high toxicity in overdose
Increased risk of fatal arrhythmia (both TCAs and AN can cause QT prolongation)
ADEs such as prolonged QT and cardiac dysrhythmias are more likely in people with electrolyte abnormalities or who are malnourished
Anorexia nervosa: Neuropsychiatric and neurological complications
Cerebral dystrophy/atrophy
Cognitive decline/impairment
Desphoria/depression
Anxiety
Sleep disorders
Anorexia nervosa: endocrine and metabolic complications
Amenorrhea
Infertility
Osteopenia/osteoporosis
Thyroid abnormalities
Hypercortisolemia
Low serum albumin
Hypoqlycemia
Neurogenic diabetes insipidus
Secondary hyperaldosteronism
Anorexia nervosa: renal, fluid and electrolyte complications
Dehydration/hypovolemia
Increased BUN
Increased SCr
Decreased GFR
Electrolyte dysbalance” (eg, hypokalemia, hyponatremia,
hypomaqnesemia, hypophosphatemia)
Hypochloremic metabolic alkalosisd
Refeeding syndrome
Anorexia nervosa: cardiac complications
Bradycardia
Hypotension
Orthostatic hypotension
Prolonged QT interval
Arrhythmias
Mitral valve prolapse
Anorexia nervosa: GI complications
Gastroparesis
Constipation
Esophagitis”
Dysphagia
Postprandial discomfort
Postprandial bloating
Elevated liver enzymes
Severe acute pancreatitis
Anorexia nervosa: haematologic complications
Anemia
Neutropenia
Thrombocvtopenia
Decreased ESR
Anorexia nervosa : pulmonary complications
Aspiration
Pneumonia
Emphysema
Why might an ECG show first-degree heart block, tall P-waves and flattened T-waves in a patient with eating disorder
Hypokalemia
Examples of eating disorders
Anorexia nervosa
Bulimia nervosa
Other specified feeding or eating disorder (OSFED)
Avoidant Restrictive Food Intake Disorder (ARFID)
What is significantly low body weight in terms of ?ED
Adult: BMI of less than 18.5
Child BMI<5 percentile
Rapid weight loss (more than 20% total body weight within 6 months)
Diagnostic criteria - anorexia nervosa
Persistent pattern of restrictive eating or other behaviours aimed at establishing or maintaining abnormally low body weight
Significantly low body weight:
Adults: BMI of less than 18.5
Children: BMI-for-age <5th percentile or failure to gain weight as expected
Rapid weight loss (more than 20% total body weight within 6 months)
Low body weight is not better explained by another medical condition or unavailability of food
Excessive preoccupation with body, weight and shape
Low weight is overvalued and central to a person’s self evaluation
Body weight or shape is inaccurately perceived to be normal or excessive
Repeatedly checking body weight using scales
Repeatedly checking body weight using tape measures
Body checking in the mirror
Constantly monitoring the calorie content of food or searching for information on how to lose weight
Extreme avoidant behaviours – refusing to have mirrors at home, avoidance of tight fitting clothes, refusal to know one’s weight, purchasing clothes in specific size
Sub types of AN?
Restrictive sub type: Weight loss an maintenance of low body weight attributed to restricted intaking/fasting
Binge-Purge pattern: Sufferers have episodes of binge eating and purging behaviours
Bulimia Nervosa - ICD 11 Essential Features:
Frequent, recurrent episodes of binge eating:
Once a week or more over a period of at least 1 month
Repeated inappropriate compensatory behaviours to prevent weight gain:
Once a week or more over a period of at least 1 month
Usually self induced vomiting
Fasting, diuretics, laxatives, enemas (to reduce
absorption of food)
Omission of insulin, excessive exercise (to increase energy expenditure)
Excessive preoccupation with body weight or shape
Similar behaviours to AN – weighing, body checking etc
Marked distress about the pattern of binge eating and inappropriate compensatory behaviours
Or significant impairment in personal, family, social, educational, occupational or other important areas of functioning
Symptoms do not meet the diagnostic criteria for Anorexia Nervosa
Binges may be objective or subjective
The core feature is the loss of control over eating
Binge eating is typically experienced as very distressing
Associated emotions: guilt, shame, disgust
Negatively affect the individual’s self evaluation
May be associated with weight gain over time
Individuals may be normal weight or low weight (not enough to meet criteria for AN)
What characterises a ‘binge’
Eating a larger than usual amount of food in a discrete period of time
Usually highly calorific (“bad foods”)
Lack of control during the episode
Eat rapidly and until uncomfortably full
Eating when not hungry
Usually very secretive
What feature of binge eating disorder differs from bulimia?
Binge eating episodes are not regularly accompanied by compensatory behaviours aimed at preventing weight gain.
Features of ARFID
Avoidance or restriction of food intake that results in either or both of:
-The intake of an insufficient quantity or variety of food to meet adequate energy or nutritional requirements that has resulted in significant:
Weight loss
Nutritional deficiencies
Dependence on oral supplements or tube feeding
Has otherwise negatively affected the health of the individual
-Significant impairment in personal, family, social, educational, occupational or other important areas of functioning (e.g. due to avoidance or distress related to participating in social experiences involving eating)
The pattern of eating is not motivated by preoccupation with body weight or shape
Restriction of food may be variable and affected by emotional or psychological factors
May be associated with high levels of distractibility
May be associated with high levels of emotional arousal and extreme resistance at mealtimes – often require lots of prompting and encouragement to eat
Individuals generally do not have difficulty eating foods within their preferred range
May be underweight or normal weight
Can negatively impact family functioning
Mealtimes can be associated with distress (particularly in children)
Variety of reasons for restriction of food intake:
Lack of interest in eating, chronically low appetite or poor ability to recognise hunger
Avoidance of foods with certain sensory characteristics (smell, taste, texture, colour, temperature)
Concern about the perceived consequences of eating (choking, vomiting, health problems) – may be subsequent to a history of an aversive food related experience such as choking or vomiting after eating a particular type of food
May be no identifiable event that has preceded the onset of the disorder
Restricted food intake and consequent weight loss (or failure to gain weight) or other impact on physical health or related functional impairment, are not due to:
Unavailability of food
Are not related to another medical condition (e.g. food allergies, hyperthyroidism) or mental disorder
Are not due to the effects of a substance or medication (including withdrawal effects)
Potential reasons for restriction of food intake in ARFID?
Variety of reasons for restriction of food intake:
Lack of interest in eating, chronically low appetite or poor ability to recognise hunger
Avoidance of foods with certain sensory characteristics (smell, taste, texture, colour, temperature)
Concern about the perceived consequences of eating (choking, vomiting, health problems) – may be subsequent to a history of an aversive food related experience such as choking or vomiting after eating a particular type of food
May be no identifiable event that has preceded the onset of the disorder
Co-morbidity of eating disorders
Depression
OCD
Social anxiety
ASD (AN)
Substance abuse
EUPD
Causes of eating disorders
Genetics
Social/cultural
Biological vulenerability
Biological stress
Psychological vulnerability (e.g. perfectionism)
Psychological stress
Causes of eating disorders
Genetics
Social/cultural
Biological vulnerability
Biological stress
Psychological vulnerability (e.g. perfectionism)
Psychological stress
Biological predisposing factors - eating disorders
Genes
Neurotransmitters
Hormones
Physical illness or allergies
Family history of depression, anxiety or addiction
Eating disorders: psychological predisposing factors
Low self esteem
Feelings of ineffectiveness or lack of control
Self-identity
History of depression/anxiety/mood intolerance
Personality traits: perfectionism, obsessional
Interpersonal styles: struggle to recognise cues and emotional state of others
Emotional processing: difficulty recognising own emotional state expressing emotions, difficulty handlingstress
Thinking styles – cognitively rigid, all or nothing thinking, can’t see bigger picture
Eating disorders: social/enviromental predisposing factors
History of bullying, especially about weight
Trauma – all forms of abuse
Stressful life events – grief, loss
Difficult interpersonal relationships
Conflict within the family
- High expectations
- Stressful family circumstances
- Overprotection
Taking part in competitive sports – dancing, gymnastics
Growing up in a household that places value on appearance and dieting
Eating disorder: precipitating factors/triggers
Biological: puberty, physical illness/trauma, dieting and weight loss
Psychological: mood/anxiety, sense of lack of control in other areas of life
Social/environmental: interpersonal problems - conflict, lonlieness, transitions - taking on a new role with expectations and responsibilities
Grief/loss
Social media/diet culture
Psychological effects of starvation
Brain structure and self regulatory system (in the forebrain) changes
Anxiety and intense negative emotions increase
Both negative and positive emotions are numbed
Coping ability reduces
Thinking becomes more rigid and routine
Biological perpetuating factors in ED (maintaining)
Effects of starvation – energy, euphoria
Reduced sex drive – can be positive in terms of avoidance
Social perpetuating factors in ED (maintaining)
Reinforcement from others – positive comments
Eliciting care from others
Ability to avoid transitions, events, responsibilities
Social media/the media/diet culture
Reduced functioning of the self-regulation system in eating disorders
Decreased effect
Thinking about social situations
Emotional regulation
Decision making
Flexibility
Ability to plan
Increased effect
Compulsive behaviours
Avoidance
Anxiety
Sensitivity
History of eating disorder
When first became concerned about weight/food?
Any food fads, dieting, physical illness that have affected weight in the past?
Have they restrained their eating? If so when, to what extent and why?
History of weight change since onset of eating disorder
Highest & lowest ever adult weight
Stable weight as an adult? Were they restricting at that time?
Ideal weight
Eating disorder assesment:
Hx of eating disorder
Current pattern of eating
Mechanisms of weight control
Attitudes to weight and shape/body image
Current mood or anxiety symptoms
Physical symptoms: feeling tired/week/faint, feeling cold, palpitations, chest pain, SOB, abdominal symptoms, lanugo hair, oedema in feet hands/face, period and bone changes
General mental health assesment
Below what BMI should patients be advised not to drive
Under 15
MEED guidance (replacing MARSIPAN) colours
Red <13 or recent rapid weight loss of >1kg/week in an undernourished patient -highest risk of decompensation
Amber: 13-14.9 or recent weight loss of 0.5-1kg/week in an undernourished patient
Green: >15 or recent weight loss of <0.5kg/week or fluctuating weight - lower risk of decompensation
Physical appearance features of AN
Cachexia, signs of dehydration, lanugo hair, salviary gland enlargement
How might baseline observations vary in a patient with AN
Lower body temperature
Lower blood pressure
Lower HR
Sit up and stand test (SUSS)
0: Unable to sit up from lying flat
1: Able only using hands to help
2: Able with notable difficulty
3: Able without difficulty
INvestigations in underweight patients?
Bloods: FBC, U&E, LFTs, bone profile, magnesium, glucose
ECG
DEXA Scan
Consequences of refeeding syndrome
Sodium retention + ECF with thiamine deficiency can lead to congestive cardiac failure
Deficiencies of K+ PO4-, Mg2+ associated with life threating cardiac arrythmias
Neurological problems such as delirium, neuropathy, or seizures can develop in some patients
Poor ventilatory function due to respiratory muscles weakness can result in respiratory failure
Rhabdomyolysis due to hypophosphataemia not only causes muscle weakness and myalgia but can also be complicated by renal failure due to myoglobinuria
Infrequently, thrombocytopaenia and impaired blood clotting can also be a consequence of phosphate deficiency
What food type carries the highest risk of refeeding syndrome?
Carbohydrate
Why is anorexia so hard to treat
Egodystonic nature
Recovery of anorexia nervosa
50-60%
Prognosis worse if no recovery in first 3-5 years (physiological and psychological changes)
What is the ratio of suicide to physical causes as a result of death from AN??
1:4
(1 in 5 suicide, 4 in 5 physical causes)
?AN investigations prior to referal to ED team
• ECG – potential for conduction defects, prolongation of QTc, consequences of electrolye abnormalities.
• Bloods:
• Hormone: low LH, FSH & oestradiol
TFT – low T3, normal T4, normal TSH (low T3 syndrome)
Mild increase cortisol
• FBC: normocytic, normochromic anaemia.
Potential low WCC and low platelets
• U&E’s:hypokalaemic (if vomiting)
Potential hyponatraemia and hypokalaemia (if using laxatives)
Hypophosphataemia
Hypomagnesemia
• Other:Hypercholesterolaemia
Potentially DEXA scan (usually organised by Eating Disorders team if necessary)
NICE recommended treatment for AN
• Monitoring of weight & dietary counselling
• Vitamin and mineral supplementation
• Psychological treatment: CBT-ED (Cognitive
behavioural therapy for eating disorders). MANTRA
(Maudsley Anorexia Nervosa Treatment for Adults).
Specialist Supportive Clinical Management.
• Admission to hospital if physical health severely
compromised.
What is an overvalued idea
solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life
What is an overvalued idea
solitary, abnormal belief that is neither delusional nor obsessional in nature, but which is preoccupying to the extent of dominating the sufferer’s life
