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
What is Bulimia nervosa?
Recurrent episodes of binge eating with compensatory behaviours and overvalued ideas about ‘ideal’ body shape and weight
May be a past history of anorexia and body weight may be normal
Aetiology of bulimia
Similar to anorexia
Evidence for associated personal/family hx of obesity
Family hx of affective disorder and/or substance misuse
Prognosis of bulimia?
Generally good, unless there are signficant issues of low self-esteem ro evidence of a severe personality disorder
Screening tool for eating disorders in primary care?
SCOFF questions
1) do you make yourself sick because you feel uncomfortably full
2) do you worry you have lost control over how much you eat
3) have you lost more than 1 stone in a 3 month period
4) do you believe you are fat when others say you are too thin
5) would you say food dominates your life
2+ indicates further more detailed hx is indicated
ICD-10 criteria for bulimia?
Persistent preoccupation with eating
Irresistible craving for food
Binges
Attemps to counter the ‘fattening’ effect of food (self-induced vomiting, abuse of purgatives, periods of starvation, use of drugs e.g. diuretics, appeptite suppressants)
Morbid dread of fatness, with imposed low weight threshold
Physical signs of bulimia?
Similar to anorexia
Specific problems related to purging:
* arrythmias
* cardiac failure
* electrolyte disturbances such as hypokalaemia
* oesophageal erosions, GORD
* oseophageal/gastric perforation
* gastric/duodenal ulcers
* pancreatitis
* constipation/steatorrhoea
* dental erosion
* leukopenia
swollen salivary glands
Calluses on knuckles where they have been scraped across the teeth = Russel’s sign
DDx for bulimia
Upper GI disorder
Brain tumour
Other mental disorder: PD, depression, OCD
Drug related increased appetite
other causes of recurrent overeating e.g. menstrual related disorders
Treatment for bulimia?
Full assessment: extent, risk assessment etc
Usually managed as an outpatient
Pharm: medication should not be used as a sole treatment, most evidence for high- dose SSRIs: Fluoxetine 60mg
Psychotherpay: guided self help as first step, CBT, fmaily therapy for young people
Eating disorders are strongly correlated to other Psych conditions. In a history, what other conditions should you screen for?
Personality disorders
OCD
Anxiety
What is a binge eating disorder?
How does it differ to anorexia or bulimia?
Binge eating disorder = haev episodes of excessive overeating.
This is not a restrictive condition like anorexia or bulimia, pts are likely to be overweight.
What may binge eating 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”
What are electrolyte abnormalities seen in refeeding syndrome?
Hypomagnesaemia
Hypokalaemia
Hypophosphataemia
Apart from electrolyte abnormalities, what are patients at risk of with refeeding syndrome?
Cardiac arrythmias
Heart failure
Fluid overload