Eating Disorders

Question 1

Define eating disorder

Answer 1

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.

Question 2

Define Anorexia Nervosa

Answer 2

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.

Question 3

Define Bulimia Nervosa

Answer 3

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.

Question 4

Define binge-eating disorder

Answer 4

Recurrent episodes of binge eating in the absence of compensatory behaviours. Episodes are marked by feelings of lack of control.

Question 5

Define EDNOS

Answer 5

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

Question 6

Define avoidant restrictive food intake disorder

Answer 6

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

Question 7

Define diabulimia

Answer 7

an eating disorder in a person with diabetes, typically type I diabetes, wherein the person purposefully restricts insulin in order to lose weight

Question 8

Define orthorexia

Answer 8

an unhealthy obsession with eating “pure” food. Food considered “pure” or “impure” can vary from person to person

Question 9

Define pica

Answer 9

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

Question 10

What are the risk factors for an eating disorder

Answer 10

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).

Question 11

What is the epidemiology of eating disorders

Answer 11

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.

Question 12

What are the psychological symptoms of Anorexia Nervosa

Answer 12

Intense fear of gaining weight
Pre-occupation with food and weight
Distortion of body image
Low self-esteem, perfectionism

Question 13

What are the behavioural symptoms of anorexia nervosa

Answer 13

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

Question 14

What are the physical symptoms of anorexia nervosa

Answer 14

Amenorrhoea/oligomenorrhoea
Loss of libido
Delayed onset puberty
Dry skin
Hair loss
Weakness, fatigue
Constipation
dizziness, fainting

Question 15

What are the behavioural symptoms of Bulimia nervosa

Answer 15

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

Question 16

What are the psychological symptoms of Bulimia Nervosa

Answer 16

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

Question 17

What are the physical symptoms of Bulimia Nervosa

Answer 17

Bloating
Fullness
Lethargy
Gastro-oesophageal reflux
Abdominal pain
Sore throat

Question 18

What are the symptoms of Binge-eating disorder

Answer 18

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

Question 19

What are the signs of anorexia nervosa on examination

Answer 19

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)

Question 20

What is the Sit up-squat-stand (SUSS) test

Answer 20

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.

Question 21

What are the signs of bulimia nervosa on examination

Answer 21

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+)

Question 22

What investigations should be done for a suspected eating disorder

Answer 22

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

Question 23

What are the potential results for the following investigations in patients with an eating disorder: ECG, FBC, U&Es, LFTs, glucose, TFTs

Answer 23

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

Question 24

What are the red flags for admission for a patient with an eating disorder

Answer 24

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

Question 25

What is the immediate management for eating disorders

Answer 25

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)

Question 26

What are the guidelines for anorexia nervosa management

Answer 26

RC of psychiatrists - MARSIPAN/Junior MARSIPAN management of patients with AN

Question 27

What is the overall management for mild/moderate/severe anorexia nervosa

Answer 27

Mild: monitor/advice/support for 8 weeks, Beat charity support
Moderate: routine referral to CEDS (community eating disorder service)
Severe: urgent referral to CEDS

Question 28

What is the overall management for mild/moderate/severe bulimia nervosa

Answer 28

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

Question 29

What interventions are available for anorexia nervosa

Answer 29

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

Question 30

What interventions are available for bulimia nervosa

Answer 30

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

Question 31

What interventions are available for binge-eating disorder

Answer 31

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.

Question 32

What does social management of eating disorders involve

Answer 32

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

Question 33

What pharmacological treatment is available for eating disorders

Answer 33

First line: Fluoxetine to help reduce impulsivity, physical symptoms, rapid weight loss

Question 34

What is refeeding syndrome

Answer 34

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

Question 35

What is the treatment for refeeding syndrome

Answer 35

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

Question 36

What are the complications of anorexia nervosa

Answer 36

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

Question 37

What are the complications of bulimia nervosa

Answer 37

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

Question 38

What is the prognosis for anorexia nervosa

Answer 38

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%

Question 39

What is the prognosis for bulimia nervosa

Answer 39

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.

Question 40

What is the prognosis for binge eating disorder

Answer 40

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).