Eating Disorders Flashcards
Define eating disorder
Eating disorders are characterised by persistent disturbance of eating or eating-related behaviour which leads to altered intake or absorption of food and causes significant impairment to health and psychosocial functioning.
Define Anorexia Nervosa
Restriction of food intake or persistent behaviour which interferes with weight gain and leads to low body weight (BMI for age <5th percentile in children/young adults | BMI <17.5kg for adults)
Anorexia nervosa is associated with body image disturbance and an intense fear of gaining weight.
Define Bulimia Nervosa
Recurrent (at least once per week for 3 months) episodes of uncontrolled eating of an abnormally large amount of food over a short time period (binge eating) followed by compensatory behaviour such as self-induced vomiting, laxative abuse or excessive exercise.
Define binge-eating disorder
Recurrent episodes of binge eating in the absence of compensatory behaviours. Episodes are marked by feelings of lack of control.
Define EDNOS
Eating disorder not otherwise specified - symptoms of an eating disorder such as anorexia nervosa, or bulimia nervosa, which do not meet the precise diagnostic criteria
Define avoidant restrictive food intake disorder
characterised by the person avoiding certain foods or types of food, having restricted intake in terms of overall amount eaten, or both
Beliefs about weight and shape do not contribute to the avoidance or restriction of food intake
Define diabulimia
an eating disorder in a person with diabetes, typically type I diabetes, wherein the person purposefully restricts insulin in order to lose weight
Define orthorexia
an unhealthy obsession with eating “pure” food. Food considered “pure” or “impure” can vary from person to person
Define pica
Someone eats non-food substances that have no nutritional value, such as paper, soap, paint, chalk, or ice.
For a diagnosis of pica, the behaviour must be present for at least one month, not part of a cultural practice, and developmentally inappropriate
What are the risk factors for an eating disorder
Female sex
Adolescence and early adulthood
Being overweight as a child
Anxiety, depression
Perfectionism, low self-esteem, body dissatisfaction, societal idealisation, professional/recreational pressure
Household stress, social isolation, poor social support
FHx eating disorder, psychiatric disorder or substance misuse
Chronic diseases affected by diet (such as diabetes or coeliac disease).
What is the epidemiology of eating disorders
Estimates suggest that over 700,000 people in the UK have an eating disorder, 90% of whom are female
Onset risk is highest in adolescents and young adults
Anorexia nervosa is the leading cause of mortality from any mental health disorder
BED is identified more often in males and at an older age than other eating disorders — it is often associated with obesity.
What are the psychological symptoms of Anorexia Nervosa
Intense fear of gaining weight
Pre-occupation with food and weight
Distortion of body image
Low self-esteem, perfectionism
What are the behavioural symptoms of anorexia nervosa
Selective about food
Avoids eating with others
Avoids eating (not hungry, already eaten)
Refusing foods they used to enjoy
Repeated weighing, measuring
Purging, excessive exercise, appetite suppressant medication or diuretic use
What are the physical symptoms of anorexia nervosa
Amenorrhoea/oligomenorrhoea
Loss of libido
Delayed onset puberty
Dry skin
Hair loss
Weakness, fatigue
Constipation
dizziness, fainting
What are the behavioural symptoms of Bulimia nervosa
Binge eating (eating with a feeling of no control) with compensatory behaviour:
Vomiting
Purging
Fasting
Excessive exercise
Laxative use
Diuretic use
Diet pill use
In-between binges there may be attempts to restrict eating
What are the psychological symptoms of Bulimia Nervosa
Fear of gaining weight (usually a sharp threshold)
Over-evaluation of self-worth
Mood disturbance, symptoms of anxiety
Persistent pre-occupation and craving for food
Feelings of guilt and shame about binge-eating
Self-harm
What are the physical symptoms of Bulimia Nervosa
Bloating
Fullness
Lethargy
Gastro-oesophageal reflux
Abdominal pain
Sore throat
What are the symptoms of Binge-eating disorder
consuming an excessive amount of food in a discreet time period accompanied by a sense of loss of control over eating at that time, where they may eat more rapidly than normal, eat until uncomfortably full or when not hungry and experience significant distress and feelings of guilt and shame
What are the signs of anorexia nervosa on examination
Weight and height: <5th centile, <17.5 BMI
Obs: May show bradycardia, postural tachycardia/hypotension, hypothermia
General: pallor, cold extremities, prolonged CRT, dehydration, lanugo hair (fine hair on face/hands/feet), oedema
+ Sit up-squat-stand (SUSS)
What is the Sit up-squat-stand (SUSS) test
The sit up test — the person lies flat on a firm surface such as the floor and has to sit up without, if possible, using their hands.
The squat test — the person is asked to rise from a squatting position without, if possible, using their hands.
What are the signs of bulimia nervosa on examination
Weight and height: usually normal range
Obs
General: Russell’s sign: knuckle calluses from induce vomiting
ENT: dental enamel erosion, Salivary gland enlargement
Cardio: arrhythmia (secondary to hypoK+)
What investigations should be done for a suspected eating disorder
History + collateral history
Bedside: SCOFF, ECG, CBG, urinalysis, pregnancy test (for amenorrhoea)
Blood: FBC, ESR, U&Es, LFTs, glucose, TFTs, oestradiol, LH/FSH, lipid profile
Other: DEXA scan
What are the potential results for the following investigations in patients with an eating disorder: ECG, FBC, U&Es, LFTs, glucose, TFTs
ECG: QT prolongation, bradycardia, arrythmia
FBC: anaemia, leucopenia, thrombocytopenia, pancytopenia
U&Es:
- Vomiting/laxative abuse: Hypokalaemia
- Excess water intake: hyponatraemia
- Dehydration: elevated electrolytes
LFTs: malnutrition → enzyme elevation
Glucose: hypoglycaemia
TFTs: low T3
What are the red flags for admission for a patient with an eating disorder
BMI <15 OR weight loss >1kg a week
Hypothermia
Cardiovascular instability (bradycardia <40, postural tachycardia/hypotension, QT prolongation)
SUSS 2 or less
Suicide or self harm risk
Concurrent infection
Abnormal blood tests - electrolyte imbalance, hypoglycaemia
Refeeding syndrome risk
Syncope
Severe abdominal pain
What is the immediate management for eating disorders
Consider admission
Referral
Children → CAMHS & paediatrics
Adults → CMHT
Arrange regular review to monitor physical and mental health
Realistic weekly weight gain target (usually 0.5-1kg a week)
What are the guidelines for anorexia nervosa management
RC of psychiatrists - MARSIPAN/Junior MARSIPAN management of patients with AN
What is the overall management for mild/moderate/severe anorexia nervosa
Mild: monitor/advice/support for 8 weeks, Beat charity support
Moderate: routine referral to CEDS (community eating disorder service)
Severe: urgent referral to CEDS
What is the overall management for mild/moderate/severe bulimia nervosa
Mild: guided self-help, recommend Beat charity, monitor for 12 weeks
Moderate: guided self-help, recommend Beat charity, monitor for 8 weeks
Severe: urgent referral to CEDS
What interventions are available for anorexia nervosa
First line: Eating-disorder-focused CBT (CBT-ED) - typically up to 40 sessions over 40 weeks (long)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) — typically 20 sessions, with weekly sessions for the first 10 weeks, and a flexible schedule after this.
Specialist supportive clinical management (SSCM) — typically 20 or more weekly sessions (depending on severity)
Focal psychodynamic therapy (FPT)
Motivational interviewing
Children: Family therapy for children and young people (FT-AN) - typically 18-20 session over 1 year
What interventions are available for bulimia nervosa
First line: Bulimia-nervosa-focused guided self-help programmes - 4-9 sessions, 20 mins each over 16 weeks
Second line: individual eating-disorder focused cognitive behavioural therapy (CBT-ED) - 20 sessions over 20 weeks
Children: Bulimia-nervosa-focused family therapy (FT-BN) - typically 18-20 sessions in 6 months
What interventions are available for binge-eating disorder
First-line: Self-help programme with brief supportive sessions
Second-line: group eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Third-line: individual CBT-ED may be considered — typically 16–20 sessions.
What does social management of eating disorders involve
Involve families early and offer information about the illness
Information about health eating and nutrition - contact with dietician
Charities e.g. BEAT for information and support
People with severe AN may require assistance in re0entering education or employment
Support to shop, prepare meals, maintain portion sizes, eat things outside the home (occupational therapist)
+ dental care for bulimia nervosa
What pharmacological treatment is available for eating disorders
First line: Fluoxetine to help reduce impulsivity, physical symptoms, rapid weight loss
What is refeeding syndrome
Due to rapid initiation of food after > 10 days of undernutrition
Characterised by electrolyte imbalance caused by their sudden intracellular movement due to switch from fat to CHO metabolism and associated increased insulin secretion
Biochemical features: Low PO4, Mg, K, and thiamine, salt and water retention
Signs: rhabdomyolysis, respiratory or cardiac failure, low BP, arrhythmia, seizures, sudden death
What is the treatment for refeeding syndrome
consult dietician to develop plan of slow-refeeding with careful increase in calories, monitor PO4 (stop re-feeding if falling), ↑ glucose, ↓K and ↓ Mg. Correct metabolic imbalances (PO). Prescribe thiamine, vitamin B complex and multivitamin. Over 4-7 days, increase dietary intake
What are the complications of anorexia nervosa
Psychological and emotional disturbance (anxiety, social withdrawal, poor quality of life, low mood, suicidal ideation)
Social difficulties
Cardio: Arrhythmias, hypotension
MSK: Loss of muscle strength, loss of bone density → fractures, impaired growth
Endocrine: thyroid abnormalities, incomplete puberty
GI: slowed motility, constipation, upper GI bleeds
Haem: pancytopenia
Neuro: cognitive impairment
Gynae: amenorrhoea, infertility
What are the complications of bulimia nervosa
Psychological and emotional disturbance (anxiety, social withdrawal, poor quality of life, low mood, suicidal ideation)
Social difficulties
Cardio: Arrhythmias, hypotension
Derm: Russell’s sign
Dental: erosion of tooth enamel from vomiting
Endocrine: amenorrhoea, irregular menses, hypoglycaemia, osteopenia.
GI: Mallory-Weiss tears, parotid gland swelling
Metabolic: hypokalaemia, dehydration
Pulmonary: aspiration pneumonia
What is the prognosis for anorexia nervosa
The course is very variable
Complete recovery is less likely the longer the person has the illness.
Estimates suggest that:
46% of people will fully recover
34% improve partially
20% develop chronic anorexia nervosa.
Mortality rates are 5x higher compared to the general population - mortality 10%
What is the prognosis for bulimia nervosa
Bulimia nervosa is associated with better recovery rates and lower mortality than anorexia nervosa.
The course of illness typically consists of cycles of remission and relapse.
Between 30–60% of people with bulimia nervosa make a full recovery with treatment.
What is the prognosis for binge eating disorder
typically there are cycles of remission and recurrence with periods (often many months) where the person is free of the eating disorder.
It is thought that approximately 70–80% of people with binge eating disorders will recover over time (12-year follow-up).
