Eating disorders Flashcards
Anorexia sx
Body image disturbance
Fear of fatness
Low BMI
Mild >17
Moderate 16-17
Severe <16
Extreme <15
Binge eating/purging type - weight loss achieved through induced vomiting and laxatives/diuretics
Bulimia sx
Cycle binge eating (larger than normal amount of food, uncomfortably full, lack of control over eating during episode), guilt then purging/fasting/excessive exercise ->once per week at least
Core self identity issue
Impulsivity
No long term weight suppression like AN
Risk assessment
Risk of refeeding syndrome (must mention) – little to no nutritional intake for several days, abnormal biochemistry, rapid weight loss
Risk of medical destabilisation/medical instability (must mention) – syncope, seizures, SOB, muscle cramps, hypothermia, hypoglycaemia, ECG changes, etc.
* Cold intolerance, amenorrhea, dizziness
Risk of suicide and active self-harm (must mention) – usual, e.g. past suicide, active thoughts, etc.
Risk Factors
- Female gender
- Being from the developed world where the ‘thin ideal’ prevails.
- Migrants from the developing world
- Those living in urban areas and undertaking life pursuits where body image concerns predominate, for example, competitive gymnastics and fashion modelling.
- Genetic predisposition
- Early menarche
- Epigenetic changes to DNA structure: food deprivation, severe trauma
- Family history of eating disorders
- Early attachment and developmental difficulties
- Premorbid obesity
- Interpersonal problems
- Dieting or other causes of rapid weight loss
- Rapid weight loss from any cause, including physical illness, can trigger cognitive changes
Psychological factors
- A ‘milieu’ of weight concern in formative developmental years
- Low self-esteem (all eating disorders)
- High levels of clinical perfectionism for those with anorexia nervosa
- Impulsivity for bulimic disorders.
- Emotional and sexual child abuse increases personal vulnerability, most likely through impeding a robust sense of self-worth and adaptive coping. The eating disorder then provides a sense of improved self-esteem and self-control for the individual
- Obsessive thinking about food, in turn precipitating and perpetuating the symptoms of anorexia nervosa
Criteria for Psych Admission (RANZCP)
BMI<14
Cardiac instability / deconditioning
* Postural tachycardia (>20bpm increase)
* Postural hypotension (> 10 mm drop)
* HR < 40 bpm or > 120
* Systolic BP < 90
Temperature – hypothermia < 35.5. or cold/blue extremities.
Blood glucose – hypoglycemia < 3.0.
Abnormal ECG: any arrhythmia, non-specific ST or T wave changes, prolonged QTC.
Significant electrolyte abnormalities
* Sodium < 130
* Hypokalaemia,
* Hypophosphataemia
Other abnormal investigations
* Neutropenia < 1.5
* Reduced albumin
* Elevated liver enzymes
Criteria for Medical Admission
BMI<12
BP<80, >20 postural drop
HR<40 or >120 bpm
Temp<35
Any arrhythmia
BSL<2.5
Na<125
K<3
GFR<60
Albumin<30
LFTs markedly elevated
Neutrophils<1.0
Complications
o EEG – metabolic encephalopathy
o ECG – QTC prolongation, sinus bradycardia
o Endocrine – thyroid, estrogen, testosterone
o Serum chemistry – dehydration, elevated liver enzymes, laxatives = acidosis, vomiting = alkalosis
o Bone mass- reduced bone density, risk of fracture elevated
o Physical – hypercarotenemia, saliva gland hypertrophy, scars and calluses on dorsal surface hand, lanugo, petechial, dental enamel erosions
Mx of complications
- Cardiac (brady, hypotension, tachy, prolonged Qt) - ECG, cardiac monitoring, cardiology consult, nutritional assessment/resuscitation, rehydration
- Endocrine (hypo, amenorrhea) - thiamine in first week, ensure adequate, steady carbohydrate supply, monitor BGL, nutritional restoration until menstruation returns, slow IVF
- Electrolytes - replace K, PO4, Mg
- Anemia - replace iron, B12, folate
- Ostopenia, stress fractures - monitor bone density, Ca and Vit D, specialist referral, nutritional restoration until menstruation returns
- Dental erosions - dental referral
Refeeding - mechanism
-Switch from fasting gluconeogenesis to carbohydrate-induced insulin release triggering rapid intracellular uptake of potassium, phosphate and magnesium into cells to metabolise carbohydrates
* The low body stores of such electrolytes due to starvation, can lead to
rapid onset of hypophosphataemia, hypomagnesia and hypokalaemia. In addition, insulin-triggered rebound hypoglycaemia can occur, exacerbated by the fact that such patients have depleted glycogen stores.
Reducing risk of refeeding (RANZCP)
-Treatment parameters. Multidisciplinary team with experienced dietician, regular review, index of suspicion – allow early identification and tailored response.
-Moderate pace of refeeding - “start low and go slow” (e.g. 6000kJ/1500kcal daily in an adult) due to risk of carbohydrate-induced insulin release triggering rapid intracellular electrolyte uptake – consider NG if risk of refeeding syndrome considered high – recognize risk of underfeeding.
-Low carbohydrate diet/preparations to avoid triggering postprandial rebound hypoglycaemia in people with low glycogen stores.
-Limit oral fluid intake, appropriate to age and weight because excess fluid intake may worsen electrolyte disturbance.
-Other electrolyte monitoring and supplementation. Potassium, Magnesium.
-Ongoing daily monitoring in first 1-2 weeks or until goal energy intake is reached: repeat LFTs, electrolytes, ECG, blood sugar.
Psychological Tx
CBT-Enhanced
* Specialist supportive clinical management (SSCM)
* The Maudsley model of anorexia nervosa treatment for adults
(MANTRA) is a recently developed manualised individual therapy for
adults with anorexia nervosa, drawing on a range of approaches including motivational interviewing, cognitive remediation and flexible involvement of carers. It aims to address the obsessional and anxious/avoidant traits that are proposed as being central to the maintenance of the illness
* Motivation-based therapies (motivational interviewing, motivational
enhancement etc.), interpersonal psychotherapy, cognitive analytic
therapy, focal psychoanalytic and other psychodynamic therapies
* Family therapies (Family Based Treatment (FBT))
Tx in children RANZCP
LIMITS OF EVIDENCE: Psychological therapy is considered essential - limited evidence to direct the best choice or modality- need to tailor evidence to needs and preference of Emily and her parents – this may be specified as a separate point or integrated into other parts of the answer.
INDIVIDUAL APPROACHES: CBT-Enhanced: -CBT; Adolescent Focused Therapy or psychodynamic approaches.
FAMILY APPROACHES: Family Based Treatment/Maudsley Family Therapy have modest evidence, are treatment of choice, particularly for persons under 18 living with family. Other family therapy approaches may benefit. Specific relevance for Emily: parent support of adaptive eating behavior; communication; negotiation of conflict: managing expectations. Medications have only limited evidence for treatment of anorexia.
Nutritional therapy.
Psychological for Bulimia
- CBT
-formulation of processes maintaining disorder
-Introduction of monitoring of key behaviours, establishment of regular
meals and snacks, and within session weighing
-reflection and review phase
-personalised program where the main mechanisms maintaining the eating disorder are addressed. This includes the utilisation of behavioural experiments to address problem behaviours such as body checking
-relapse prevention, looking to future
Meds for Bulimia
-TCA some evidence
-High dose SSRI e.g. fluoxetine 60 - also helpful for binge eating
-Topiramate but can cause paraesthesia, taste perversion
