Eating disorders Flashcards
Anorexia Nervosa Bulimia Nervosa OSFED
Anorexia diagnosis
BMI < 18.5
Persistent pattern of behaviours to prevent restoration of normal weight
Body image distortion
Low body weight/shape central to self evaluation
Intense fear of gaining weight
Subtypes anorexia
Significantly low body weight < 14-18.5
Dangerously low body weight < 14
Restricting pattern
Bu he purging pattern
In recovery with normal body weight - healthy body eight, cessation of behaviours over a year
What is a dangerously low body weight
<14
BMI in anorexia
<18.5
Persistent weight pattern of behaviours to prevent restoration normal weight in anorexia
Dietary restriction
Excessive exercise
Purging - self induced vomitting, diuretics/laxatives/appetite supressants/enemas
Comorbidities anorexia
Depression
Anxiety
OCD
Personality disorders - avoidant, anankastic
Symptoms of starvation
Low mood
Labour mood
Irritability
Anxiety
Extreme distress
Rigidity
Loss libido
Social withdrawal
Poor concentration
Rituals
Compulsive behaviour
Personality changes
Medication for anorexia?
Often ineffective
Increased risk side effects
Is there a family history in eating disorders?
Yes
Risk factors eating disorders
Gender
Early puberty
Type 1 diabetes
Genetic factors
Anorexia - genetics affecting hunger hormones eg ghrelin - tolerate hunger better
Psychological risk anorexia
Temperament traits - perfectionism
Early experience or attachment
Early feeding behaviours
Life events
Low self esteem
Weight shape concerns
Risk social anorexia
Dieting industry
Professions
Upbringing
Acculturation - struggling in new culture
Social media
Which eating disorder has highest mortality of any psychiatric condition?
Anorexia
Physical risks of anorexia
Starvation
Compensatory behaviours
Falsifying weight
Related to re-feeding syndrome
More chronic problems - osteoporosis
Complications from mismanagement of diabetes
Lagopthalmos
Tape eyes to sleep as eye muscles to weak from hydration
Vomiting physical affects
Enamel erosion
Swollen parotid glands
Gastric and oesophageal trauma
Bloods when vomiting
Low chloride
Low potassium
Metabolic alkalosis
Amylase and bicarbonate increase
Treat hypokalemia
Hypokalemai sumtpksm
Muscle cramps
Tingling
Fatugue
Paliptiations
U wave on ECG
Laxatives effects
Increased water and electrolyte loss
Dehydration
Electrolyte imbalance - u Musial
Rectal bleeding
Abdominal bleeding
Rebound constipation - pseudo obstruction - reduce by 10% per week
Over exercise signs and symptoms
Physical exhaustion
Muscle damage injuries
Elevated Creatinine kinase
Rhabdomyolysis
Cardiac or ECG abnormalities
Bradycardia, heart block
Falsifying weight
Weights in shoes/hair/arm purse
Attempts tamper with scales
Excessive fluid
Reason for excess fluid intake
Hunger suppress
Anxiety manage
Deliberate weight falsify
What can over hydration cause
Hyponatremia
Re feeding syndrome physiology
Glucose increases, Insulin secreted
Potassium taken into cells with glucose
Phosphate, magnesium, potassium and thiamine all rapidly depleted
Leads to arrhythmia
What does re feeding syndrome cause
Low potassium/phosphate/magnesium
B12 deficiency - wernickes/korsakoffs
Sodium balance - oedema, cardiac failure
Who is re feeding syndrome Particularly high risk for
Very low BMI
Complete restriction/ rapid weight loss
Co-morbid alcohol dependence
Co-morbid physical health problems e.g. sepsis, cancer
Parenteral feeding > NG feeding > Oral diet
Risk to self
Low mood and hopelessness v common
Suicide - chronic anorexia
Self harm - binge and purge
Other risks eating disorders
Driving - difficult concentration, preoccupation with food, mood instability - impulsive
Duties at work
Child care
Activities
Universities - attendance guidance
What BMI shouldn’t drive at
<16
Assess physical risk
Weight height BMI, rate of weight loss
BP incl postural, pulse, temp
ECG
Sit up/squat test - SUSS
FBC, U+Es, KFY, glucose, bone, Mg
What happens to LFTs in starvation
Apoptosis in liver - go up
Sit up test + scoring
Patient lies down on floor and sitsup without using hands
0: Unable
1: Able only using hands to help
2: Able with noticeable difficulty
3: Able with no difficulty
Squat test
squats down and rises without using hands
Kings college guidelines
Symptoms of anorexia/ bulimia
Lenugo hair - fine hair all over body (anorexia)
Swollen parotid glands
Russells sign - nodules on knuckles from purging
Globe haemorrhages of eye
Erythema ab igne - laxatives + hot water bottle
Russell’s sign
Calluses on hands from vomiting
Erythema ab igne
Mottling of skin when use hot water bottle - excess use of laxatives
Anorexia recovery
50% full recovery
30% improve
20% remain chronically I’ll
Early intervention model - 60% full recovery
Why early intervention important
Different illness stages 1 brain plasticity and thought compulsion hardwiring
Management nutrition
Dieticians and OT
Regular eating and snacks
Food prep, soho, cook
Eating in different situations and environments
Psychoeducation
Aim weight gain per week
0.5-1kg per week
Food restrictions to do with eating disorders
Vegetarianism’s and veganism
No vegan NG feeding - moral?
Set point concept
Work towards a threshold that is genetically predisposed
Can go up but can go down
Psychoedycation - teach patient to trust body
Management of ED
Nutritional
Psychoeducation
Medical management anarexia
Reseeding syndrome
Monitor physical parameters
Olanzapine - antipsychotic (weight gain is side effect!
No mer for anorexia itself
NG feeding
Bed rest be chair rest
Frequency monitoring bloods/investigations/IBD
Important bone investigations
DEXA scans, calcium supplements
Treatment setting
GP, community, day service
Medical ward
When admit to ward
Medically unstable
High risk re-feeding syndrome
Specialist eating disorders unit
Psychological management EDs
MANTRA/SSCM
CBT
Psychodynamic therapy
MANTRA
Maudsley Anorecia Nervosa Treatment
Bulimia psychological help
Self help
CBT if severe
Ego syntonic condition
Feel like illness is part of you - ingrained into personality and identity, difficult to challenge
Ego dystonic condition
Recognised as intrusive/excessive
Don’t want but have it
Motivation to chan her
Ambivalence - universal
Stages of change - prochaska +
Low risk and ready to change
Standard treatment
High risk and ready to change
Intensive treatment
Low risk not ready to change
Motivational work
Discharge
MHA - anorexia detain what need
2 doctors and an AMP (mental health social worker)
Risk of self neglect
When can medical treatments be given against will
Symptom or manifestation treatment - NG feeding
Blood tests
Fluids
Anorexia capacity
Difficult to assess
Severe anorexia normally don’t have capacity but coherent and articulate
Fluctuates hourly
Irrespective of capacity can be detained and treated under MHA if stay criteria are met
MEED
Medical emergency eating disorders
BMI of 13
Admit to hospital
I’d have eating dirsoder what can sepsis look like
V slightly raised WCC and neutrophils and temp - baseline is much lowe than normal so increase
What is bulimia Nervosa?
Not significantly underweight
Preoccupation with body shape/weight which strongly influences self evaluation
Episodes of binge eating
Recurrent compensatory behaviours
How often does a binge have to be to be a disorder
Once a week for a month
Binge eatind disorder diagnosis
Frequent binges
Distressing and accompanied by negative emoitons - guilt/disgust
Not ass with compensatory behaviours
Discrete period of time
Subjective loss of control
More food than ususal
Bone density
DEXA scan
Osteopenia vs osteoporosis
Calcium supplement
Alendornic acid
Restore bone density need weight restoration
Stages of anorexia
Beliefs - body image distortion, fear of weight gain
Behaviour - dietary restriction, exercise, purging
Physical consequences - starvation, medical complications
What models for stages of change are there?
Prochaska and Diclemente
Prochaska and diclemente
Pre-contemplation - no intention on changing behaviour
Contemplation - aware a problem exists but with no commitment to action
Preparation - intent on taking action to adress problem
Action - active modification of behaviour
Maintenance - sustained change new behaviour replaces old
Relapse - fall back into old patterns of beahviour
Prochaska and diclemente
Pre-contemplation - no intention on changing behaviour
Contemplation - aware a problem exists but with no commitment to action
Preparation - intent on taking action to adress problem
Action - active modification of behaviour
Maintenance - sustained change new behaviour replaces old
Relapse - fall back into old patterns of beahviour
High risk not ready to change
Consider use of mental health act
What do low WCC, neutrophils, glucose and high ALT, Alkaline Phosphate and normal, U+Es normal, 45 BPM show?
Starvation
What does low WCC, glucose, potassium and chloride and high bicarb, Creatinine Kinase mean?
Vomitting
Low WCC, neutrophils, glucose and sodium with normal ECG signal what?
What do slightly raised WCC, neutrophils, temp 37.8 degrees and 110BPM signal in an anorexic patient?
Sepsis - lower baseline to start with
Recurrent compensatory behaviours
Purging
Restricting
Exercise
Neglect insulin treatment
What is ARFID defined as?
Abnormal eating/feeding resulting in insufficient quantity/variety of food
Significant weight loss/failure to gain weight
Negatively affective the health of the person/impaired functioning
Not due to concerns about body weight or shape
It isn’t about lack of food availability/effects of meds/substance use/underlying physical health condition
What is the criteria for childhood anorexia?
BMI for age under fifth percentile in children and adolescents
Prepubertal onset – pubertal events delayed/arrested
Men signs of anorexia
Loss of sexual interest or potency
Differences in idealised body shape – muscular strength, definition, physical fitness
Pscyhological risk factors for eating disorders
Temperament traits - Perfectionism
Early experiences/Attachment
Early feeding behaviours
Life events
Low self-esteem
Weight shape concerns
Pscyhological risk factors for eating disorders
Temperament traits - Perfectionism
Early experiences/Attachment
Early feeding behaviours
Life events
Low self-esteem
Weight shape concerns
Social influences on eating disorders
Dieting industry
Professions – models, gymnasts, ballet, fashion, acting
Upringing
Acculturation
Social Media – which is worst platform?
Instagram
How to nutritionally manage anorexia?
Dietiicians and OTs
Regular eating and snacks
0.5-1kg restoration per week aim for
Food prep, cookking, shopping
Psychoeducation
Medical management of eating disorders
Treatment setting:
GP monitoring / Community / Day Service
Medical Ward (medically unstable, or high risk refeeding syndrome)
Specialist Eating Disorders Unit
Nasogastric feeding
Bed Rest vs Chair Rest
Frequency of monitoring bloods/investigations/obs
Observations
Leave
Bone density in eating disorders what do?
DEXA scan
Osteopenia/porosis
Calcium supplement
Alendronic acid
-ONLY WAY to restore density is weight restoration
What can be used off license for anorexia?
Low dose olanzapine
Refeeding syndrome - whats importatn
Gradual calories but dont underfeed
Potassium, phosphate, magnesium, thiamine, vitamin B
How decide if motivation to change?
Ambivalence universal - dont preclude treatment
Stages of change - prochaska and diclemente
Motivational enhancement
Externalissation (egosyntric disorder)
MANTRA stages treatment anorexia
. Getting started and finding motivation for recovery
- Working with support, including families and others
- Improving nutritional health and dietetics
- Understanding anorexia, guided by the vicious flower
- Developing treatment goals (SMART)
- Understanding and relating to emotions helpfully
- Exploring thinking styles, and challenging styles that are rigid, perfectionist, attention to detail
- Developing identity outside of the eating disorder
- Relapse prevention
Phases of SSCM
an initial orientation phase, which focuses on identifying target symptoms and
agreeing goals for weight gain and normal eating
a middle phase in which target symptoms are monitored, and support is focused on
encouraging weight gain via normal eating and reduction of other eating-disordered
behaviours
a final phase, which focuses on ending the intervention and planning the future
What does specialist supportice clinical management of anorexia look like
Knowledge about therapy and purpose
Engagement
Assessment
Pscyhoeducation
Establish and review target symptoms
Monitor weight
Encourage normal eating
Supportive therapy
Maintenance
What is rhabdomyolysis and how treat
Myocyte destruction
Causes raised CK - 5 x is diagnositc level
Fluid rehydration is treatment
