Eating Disorders Flashcards
What is anorexia nervosa?
Condition most commonly seen in young women
Distortion of body image
Pathological desire for thinness
Self- induced weight loss by variety of methods
Epidemiology of anorexia
1:10 M:F ratio
Mean age of onset women: in between 16-17 and rarely presents for the FIRST time over 30
Mean age of onset M: around 12
Prognosis of anorexia?
Untreated this condition carries one of the highest mortality figuers for any psych illness- 10-15%
If treated, rule of thirds applies: 1/3 full recovery, 1/3 partial recovery, 1/3 chronic problem
Poor prognostic factors: chronic illness, late age of onset, bulimic features (vomitting/ purging)
ICD-10 diagnostic criteria for anorexia?
- Low body weight: 15% + below expected, BMI 17.5 or less
- Self-induced weight loss: avoidance of ‘fattening’ food, vomiting, purging, excesssive exercise, use of appetite suppressants
- Body image distortion: ‘dread of fatness’: overvalued idea, imposed low weight threshold
- Endocrine disorder: HPA axis e.g. amenorrhoea, reduced sexual interest/impotence, raised GH levels, raised cortisol, altered TFTs, abnormal insulin secretion
- Delayed/arrested puberty- if onset pre-pubertal
Ddx of anorexia?
- Chronic debilitating phsyical disease; brain tumour
- GI disorders (e.g. Crohn’s disease, malabsorption)
- Loss of appetite (may be secondary to medication/ drugs)
- Depression/ OCD (features of this may be associated)
- Bulimia
Aetiology of anorexia
Psychodynamic model:
* family pathology- enmeshment, rigidity, overprotectiveness, lack of conflict resolution, weak generational boundaries
* Individual pathology- disturbed body image (dietary problems early in life, parents’ food preocupation, poor sense of identity)
* Analytical model- regression to childhood, fixation on the oral stage, escape from the emotional problems of adolesence
Cardiac complications of anorexia?
- most common cause of death
- Findings may incl:
- significant bradycardia (30-40bpm) and hypotension
- ECG changes (sinus brady, ST segment elevation, T waved flattening), may not be clinically significant unless frequent arrythmias (QT prolongation may indicate an increased risk for arrythmias and sudden death)
- Echocardiogram may show decreased heart size, decreased left ventricular mass and mitral valve prolapse- these reflect malnutrition and are REVERSIBLE
Z2F = arrhythmia, cardiac atrophy and sudden cardiac death
Physical signs of anorexia?
- loss of muscle mass
- dry skin
- brittle hair
- pallor
- fine, downy lanugo body hair
- eroded tooth enamel
- peripheral cyanosis
- atrophy of the breasts
- bradycardia
- hypothermia
- swollen, tender abdomen
- peripheral neuropathy
- osteopenia
- amenorrhoea
Psych symptoms of anorexia?
- Conc/memory/decision making problems
- Irritability
- depression
- low self esteen
- loss of appetite
- reduced energy
- insomnia
- loss of libido
- social withdrawal
- obsessiveness regarding food
Assessment of patient with ?anorexia
- Full psych hx: establish context in which the problems have arisen, confirm the diagnosis of an eating disorder, assess the risk of self-harm/suicide
- Full medical history: focus on the physical consequences of altered nutrition, detail weight changes, dietary patterns and excessive exercise
- Physical exam: determine weight and height, assess for physical signs of starvation and vomiting and appropriate investigations
Investigations in anorexia and what would you expect?
- FBC: anaemia, thrombocytopenia, low WCC, neutropenia
- ESR: investigate raised ESR as may indicate a physical cause
- U&Es, phosphate, magnesium, bicarb, LFTs: raised urea and creatinine (dehydration), hyponatraemia, hypokalaemic/hypochloraemic metabolic alkalosis (from vomiting), metabolic acidosis (laxative abuse); other abnormalities: hypocalcaemia, hypophosphataemia, hypomagnesaemia, raised LFTs
- Glucose: hypoglycaemia
- TFTs: Low T3/T4
- high cortisol and GH
- ECG: sinus brady, raised QT prolongation, signs of ischaemia, arrythmias
Managment of anorexia?
Most people managed as outpatients
Bio: medication should not be used as sole treatment, treat co-morbities e.g. if osteopenic, avoid high risk activities
Psych: CBT- up to 40 sessions over 40 weeks, family therapy for children and younf people, dietetic counselling
What is refeeding syndrome?
- severe electrolye disturbances (low phosphate, magnesium and potassium) and metabolic abnormalites while undergoing refeeding whether orally, eneterally or parenterally
- other clinical features incl cardiac complications (heart failure, arrhythmias), renal impairment, and liver function abnormalities
Who is high risk of re-feeding syndrome?
One or more of the following:
- BMI < 16kg/m2
- Weight loss > 15 % within the last 3-6 months
- Little or no nutritional intake > 10 days
- Low levels of potassium, phosphate,or magnesium prior to feeding
Patient has 2 or more of the following:
* BMI < 18.5 kg/m2
* Weight loss > 10% within the last 3-6 months
* Little or no nutritional intake for > 5 days
* History of alcohol abuse or drugs, incl insulin, chemo, antacids or diuretics
How to manage a pt high risk of refeeding syndrome?
- review or consult with professionals with expertise in this area (e.g. dietitian, eating disorder psychiatrist, physcian with expertise in nutrition) to commence the patient on an appropriate menu plan
- Slowly reintroduce foods with restricted calories
- magnesium, potassium, phosphate and glucose monitoring along woth routine bloods.
- fluid balance monitoring
- Prescribe thiamine, vit B compound strong and multivitamins
- consider daily bloods and ECGs for the first 10 days
