Eating Disorders Flashcards
What is an eating disorder?
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”
What are the investigations for EDs?
- 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
When are patients with EDs admitted?
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
What is SCOFF?
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?
What is AN?
Eating disorder characterised by deliberate weight loss resulting in weight 15% below expected / BMI < 17.5 with secondary endocrine and metabolic disturbances
What is the epidemiology of EDs?
- 90% female
- Teenage / young adults
- AN = most common cause of admission to child and adolescent psychiatric wards
What is the aetiology of AN?
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
What conditions are associated with EDs?
- Co-morbid depression, substance misuse and personality disorder are common
- RFs = OCD, childhood feeding difficulties
What is the ICD-10 diagnostic criteria for AN?
Must have all 3:
- BMI <17.5 (or weight is ≥15% less than expected)
- Deliberate WL (i.e. laxatives, vomiting, excessive exercise, appetite suppressants, etc.)
- Distorted body image / “Fear of the fat” (i.e. overvalued ideas they are fat, despite being thin)
- Endocrine disorders
What is atypical AN?
- 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
What are the symptoms of AN?
- 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)
What are the complications of malnutrition?
- Fatigue
- Amenorrhoea
- Infertility
- Osteoporosis
- Electrolyte abnormalities
- Cardiac arrhythmias / failure
- Early death
What are the signs of AN?
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
What are the investigations for AN?
- Full psychiatric history (and collateral if possible)
- SCOFF questionnaire for screening
Do you admit a patient with AN?
Screen for immediate admission, otherwise, mostly managed long-term as outpatients.
- A&E > MARSIPAN guidelines (Management of Really Sick Patients with AN)
Describe the referral pathway for AN
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
What is the management of AN upon first presentation to GP?
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)
What are 1st line options for the management of AN?
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)
What are second line options for the management of AN?
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)
What is the pharmacological management of AN?
- If physical symptoms, rapid WL, BMI <13.5
- Fluoxetine (esp. if preoccupations with food)
What is the management of AN in children?
1st line: Family therapy
2nd line: ED-CBT
Describe refeeding
Starts slowly with a low fibre, phosphate rich diet (milk)
What is refeeding syndrome?
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
What is the prognosis of AN?
After 10 years…
- 50% recover
- 10% die (suicide = 1/3rd of deaths)
- 40% ongoing problems
What are bad prognostic factors for AN?
- Very low weight
- Bulimic features
- Later onset
- Longer illness duration
What is BN?
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.
What are RFs for BN?
- Personal / FHx of obesity
- FHx of affective disorders and substance misuse
- Half have a previous history of AN
What is the ICD-10 diagnostic criteria for BN?
(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
What are the signs of BN?
- 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.
What are the differentials for BN?
DDx: upper GI disorder (leading to vomiting), personality disorder, depressive disorder, obesity, rare
Do you admit for BN?
Screen for immediate admission, otherwise, mostly managed in the community
What is the referral pathway for BN?
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
What is the management for BN?
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
What is the prognosis of BN?
After 10 years… (much better than AN)
- 70% recover; 1% died
What are bad prognostic indicators for BN?
- Very low weight
- Severe binging/purging
- Co-morbid depression
What is the management of BED?
-
BED focused guided self-help programmes for adults
If unacceptable or ineffective after 4 weeks: - Consider group CBT-ED
If unacceptable or ineffective: - Consider individual CBT-ED
What biochemical abnormalities can be seen in AN?
- Low K
- Low T3
- Low FSH, LH, oestrogens and testosterone
- Raised cortisol and growth hormone
- Raised cholesterol
- Raised carotene
- Impaired glucose tolerance
What is the most appropriate investigation to decide whether an ED patient needs urgent admission?
ECG
- Assess for cardiovascular instability as EDs can result in electrolyte abnormalities that can impact cardiac stability
