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Eating Disorders Flashcards

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1
Q

What is an eating disorder?

A

A pattern of abnormal food intake that reduces someones ability to maintain adequate nutrition

Begins with dieting which becomes…

  • Anorexia nervosa - MOST COMMON in ED clinics
  • Bulimia nervosa
  • Binge Eating Disorder (BED) - MOST COMMON generally

Typical: “perfectionist, high-achieving young women, low self-esteem”

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2
Q

What are the investigations for EDs?

A
  • Examination > weight, height, BP, squat test (for proximal myopathy)
  • Bloods and urine drug screen > must exclude medical causes, i.e. hyperthyroidism
    Low: ESR (or normal), Hb, platelets, WCC, Na+, K-, PO42-, T4, glucose
    High (“G’s and C’s” raised): cortisol, cholesterol, carotenaemia, GH, glands (salivary), LFTs
  • ECG: bradycardia, arrhythmia, long-QT [BN]
  • DEXA: osteoporosis (if > 2-year history)
  • Rating Scale – eating attitudes test
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3
Q

When are patients with EDs admitted?

A

Immediate admission for high-risk patients… use MHA if required:

  • BMI <13
  • WL >1kg/week
  • Septic-looking signs (<34.5C; BP <80/50; cold peripheries, thrombocytopenic / purpuric rash)
  • HR <40bpm + long QT
  • Suicide risk
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4
Q

What is SCOFF?

A

ED screening tool, if ≥2 = explore further

NOT DIAGNOSITC

  • 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?
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5
Q

What is AN?

A

Eating disorder characterised by deliberate weight loss resulting in weight 15% below expected / BMI < 17.5 with secondary endocrine and metabolic disturbances

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6
Q

What is the epidemiology of EDs?

A
  • 90% female
  • Teenage / young adults
  • AN = most common cause of admission to child and adolescent psychiatric wards
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7
Q

What is the aetiology of AN?

A

Biological

  • Genetics
  • FHx > obesity, depression, substance misuse

Psychosocial

  • Psychological theories > perfectionism, low self-esteem (when life is uncomfortable, AN provides comfort in the ability to be able to control something)
  • Sociocultural > social pressures (esp. models, athletes, dancers)
  • Personal history > previous AN, child abuse
  • Family > parental overprotection, family enmeshment
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8
Q

What conditions are associated with EDs?

A
  • Co-morbid depression, substance misuse and personality disorder are common
  • RFs = OCD, childhood feeding difficulties
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9
Q

What is the ICD-10 diagnostic criteria for AN?

A

Must have all 3:

  1. BMI <17.5 (or weight is ≥15% less than expected)
  2. Deliberate WL (i.e. laxatives, vomiting, excessive exercise, appetite suppressants, etc.)
  3. Distorted body image / “Fear of the fat” (i.e. overvalued ideas they are fat, despite being thin)
  4. Endocrine disorders
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10
Q

What is atypical AN?

A
  • 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
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11
Q

What are the symptoms of AN?

A
  • Underweight
  • Nervous about weight
  • Distorted perception
  • Excessive exercise
  • Restricted eating
  • Loss of libido
  • Obsessional thoughts and rituals

(WL induced by diet restriction and one or more of: self-induced vomiting, excessive exercise, appetite suppressants or diuretics, laxatives)

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12
Q

What are the complications of malnutrition?

A
  • Fatigue
  • Amenorrhoea
  • Infertility
  • Osteoporosis
  • Electrolyte abnormalities
  • Cardiac arrhythmias / failure
  • Early death
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13
Q

What are the signs of AN?

A

They may:

  • Be gaunt and emaciated
  • Be dehydrated
  • Have proximal myopathy
  • Have cold extremities
  • Have bradycardia and hypotension
  • Have fine lanugo hair
  • Exhibit peripheral oedema
  • Have parotid gland enlargement and erosion of tooth enamel (secondary to vomiting)
  • Russell’s sign (callous/cut knuckles from self-induced vomiting)
  • Be low in mood
  • There will be preoccupation with food and overvalued ideas about weight and appearance
  • Insight is usually poor
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14
Q

What are the investigations for AN?

A
  • Full psychiatric history (and collateral if possible)
  • SCOFF questionnaire for screening
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15
Q

Do you admit a patient with AN?

A

Screen for immediate admission, otherwise, mostly managed long-term as outpatients.

  • A&E > MARSIPAN guidelines (Management of Really Sick Patients with AN)
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16
Q

Describe the referral pathway for AN

A

N.B. no ‘watchful waiting’ period ever used > refer immediately > pathway depends on severity:

Severe = Urgent referral to CEDS

  • Features: BMI <15, rapid WL, evidence of system failure

Moderate = Routine referral to CEDS

  • Features: BMI 15-17, no evidence of system failure

Mild = Monitor / advice / support for 8 weeks

  • Features: BMI >17, no additional co-morbidity
  • Routine referral to CEDS if failure to respond
17
Q

What is the management of AN upon first presentation to GP?

A

Alongside one of the 3 referral pathways…

1. Engage and educate

  • Stop laxative/diuretic use as it doesn’t reduce calorie intake

2. Signpost support

  • Beat Eating Disorders, MIND, NHS

3. Treat co-morbid psychiatric illness

  • Depression, OCD, substance misuse

4. Plan going forward

  • Regular follow-up and RV
  • Nutrition and weight restoration (set target weight + make eating plan to gain 0.5-1kg/week)
  • CBT-ED, MANTRA or SSCM (or family therapy if <18yo)
18
Q

What are 1st line options for the management of AN?

A

CBT-ED

  • 1-2-1, eating disorder focussed
  • 40 weekly sessions
  • Address low self-esteem, perfectionism, control issues

Maudsley Anorexia Nervosa Treatment in Adults (MANTRA)

  • 20 sessions
  • Focus on what the cause of the anorexia is

Specialist Supportive Clinical Management (SSCM)

  • 20 weekly sessions; led by practitioner
  • Explore problems of anorexia
  • Educate on nutrition and eating habits (and how that leads to symptoms)
  • Explore a future beyond anorexia (i.e. how to get back into work)
19
Q

What are second line options for the management of AN?

A

If all of 1st line unacceptable:

  • Eating-disorder-focussed Focal Psychodynamic Therapy (FPT)
  • Adolescent-focussed psychotherapy (AFP)
  • Motivational interviewing
  • Family therapy (involves whole family) – 20 sessions over 1-year; indications: Short history of illness, Onset young (less than 19yo)
  • Interpersonal therapy (improve social functioning and interpersonal skills); indications: Longer history of illness, Onset older (later-onset disease)
20
Q

What is the pharmacological management of AN?

A
  • If physical symptoms, rapid WL, BMI <13.5
  • Fluoxetine (esp. if preoccupations with food)
21
Q

What is the management of AN in children?

A

1st line: Family therapy
2nd line: ED-CBT

22
Q

Describe refeeding

A

Starts slowly with a low fibre, phosphate rich diet (milk)

23
Q

What is refeeding syndrome?

A

The potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (due to insulin release)

> Defined by low phosphate mainly

  • Biochemical: low phosphate, low magnesium, low potassium, low thiamine, salt and water retention
  • Importance: low K = arrhythmias, low PO4 = hypophosphatemic HF
  • S/S: fatigue, weakness, confusion, high BP, seizures, arrhythmia, HF
24
Q

What is the prognosis of AN?

A

After 10 years…

  • 50% recover
  • 10% die (suicide = 1/3rd of deaths)
  • 40% ongoing problems
25
Q

What are bad prognostic factors for AN?

A
  • Very low weight
  • Bulimic features
  • Later onset
  • Longer illness duration
26
Q

What is BN?

A

A type of ED characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives / diuretics / exercising.

27
Q

What are RFs for BN?

A
  • Personal / FHx of obesity
  • FHx of affective disorders and substance misuse
  • Half have a previous history of AN
28
Q

What is the ICD-10 diagnostic criteria for BN?

A

(1) Binging or persistent preoccupation with eating and/or irresistible craving for food

  • A ‘non-purging’ bulimia sub-type does exist

(2) Purging behaviours

  • Attempts to counteract “fattening” effects of body
  • Purging includes… diuretics, excessive exercise, laxatives, insulin therapy, vomiting

(3) 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 AN

(4) Binging and purging at least once a week for 3m

29
Q

What are the signs of BN?

A
  • Weight may be normal
  • Signs of vomiting: dental erosion, finger calluses, calluses on the dorsum of the hand (Russell’s sign), parotid/salivary gland swelling
  • Menstrual abnormalities occur in 50% > amenorrhoea despite a normal weight

> There is more insight than in anorexia and patients are often keen for help.

30
Q

What are the differentials for BN?

A

DDx: upper GI disorder (leading to vomiting), personality disorder, depressive disorder, obesity, rare

31
Q

Do you admit for BN?

A

Screen for immediate admission, otherwise, mostly managed in the community

32
Q

What is the referral pathway for BN?

A

N.b. no ‘watchful waiting’ period ever used > refer immediately > pathway depends on severity:

Severe:
Urgent referral to CEDS

  • Features: daily purging, significant electrolyte imbalance, co-morbidity

Moderate
Guided self-help, recommend Beat charity, monitor for 8 weeks

  • Features: frequent binging and purging (>2/week), some medical consequences (chest pain)
  • Routine referral to CEDS if failure to respond

Mild
Guided self-help, recommend Beat charity, monitor 12 weeks

  • Features: infrequent binging and purging (≤2/week)
  • Routine referral to CEDS if failure to respond
33
Q

What is the management for BN?

A

Upon first presentation to GP:
Alongside one of the 3 referral pathways…

  • 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) > reduce binging/purging + help impulses
  • Plan going forward (with regular follow-up and review):

Children:

  • 1st line: Family therapy

Adults:

  • 1st line: Guided Self-Help Programme (Bulimia Nervosa-Focused)
  • 2nd line (if 1st line ineffective for 4 weeks / declined): CBT-ED

N.B. never use SSRI bupropion > can cause seizures

34
Q

What is the prognosis of BN?

A

After 10 years… (much better than AN)

  • 70% recover; 1% died
35
Q

What are bad prognostic indicators for BN?

A
  • Very low weight
  • Severe binging/purging
  • Co-morbid depression
36
Q

What is the management of BED?

A
  1. BED focused guided self-help programmes for adults
    If unacceptable or ineffective after 4 weeks:
  2. Consider group CBT-ED
    If unacceptable or ineffective:
  3. Consider individual CBT-ED
37
Q

What biochemical abnormalities can be seen in AN?

A
  • Low K
  • Low T3
  • Low FSH, LH, oestrogens and testosterone
  • Raised cortisol and growth hormone
  • Raised cholesterol
  • Raised carotene
  • Impaired glucose tolerance
38
Q

What is the most appropriate investigation to decide whether an ED patient needs urgent admission?

A

ECG

  • Assess for cardiovascular instability as EDs can result in electrolyte abnormalities that can impact cardiac stability

Psych (18 decks)

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