Eating Disorders Flashcards
What is the most common cause of admissions to child and adolescent psychiatric wards?
Anorexia Nervosa
What are leading causes of death in anorexia nervosa?
starvation and suicide
PACES: Prognosis in anorexia nervosa
1/3 recover, 1/3 partial, 1/3 chronic
What is anorexia defined as?
A disorder characterised by:
Deliberate weight loss (restricted dietary choice, excessive exercise, purging and use of appetite suppressants/diuretics)
Morbid dread of being overweight (intrusive overvalued idea)
Disturbance of bodily function (endocrine and metabolic)
Triad in anorexia nervosa
Deliberate weight loss
Morbid dread of being overweight
Disturbance of bodily function
Specific features of anorexia nervosa
Significant weight loss that is self-induced
Perception of being too fat, with an obsessional dread of becoming fat
Endocrine disturbance
Endocrine abnormalities seen in anorexia nervosa
Amenorrhoea
Loss of Libido
Investigations for anorexia nervosa
Examination: weight, height, lanugo hair, BP, squat test
Bloods and UDS
Low: ESR, Hb, Plt, WCC, Na, K, Ph, T4
High: GH, cortisol, cholesterol, LFT
ECG: bradycardia, arrhythmia, prolonged QT
DEXA: osteoporosis (if > 2-year history)
Rating Scale – eating attitudes test
PACES: What rating scale do you use in anorexia nervosa?
eating attitudes test
What is raised on the bloods in anorexia nervosa?
GH, cortisol, cholesterol, LFT
What is low on the bloods in anorexia nervosa?
ESR, Hb, Plt, WCC, Na, K, Ph, T4
What may be seen on examination of anorexia nervosa?
weight, height, lanugo hair, BP, squat test
What comorbid psychiatric illnesses often coincide with anorexia nervosa?
Depression, OCD and substance misuse are common
Management of anorexia nervosa
Engagement
Psycho-education
Treat comorbid psychiatric illness
Depression, OCD and substance misuse are common
Nutritional management and weight restoration
Psychotherapies
Overview of 1st Line Options
CBT-ED
Maudsley Anorexia Nervosa Treatment in Adults (MANTRA)
Specialist Supportive Clinical Management (SSCM)
1st line options for psychotherapy in patients with anorexia nervosa
CBT-ED
Maudsley Anorexia Nervosa Treatment in Adults (MANTRA)
Specialist Supportive Clinical Management (SSCM)
1st line management in children with anorexia nervosa
1st line: Family Therapy
Review 4 weeks after treatment, then every 3 months
When is medical treatment needed in anorexia nervosa?
Particularly important if there are physical complications, rapid weight loss or BMI < 13.5
When is inpatient treatment necessary for anorexia nervosa?
May be necessary if:
BMI < 13 or extremely rapid weight loss
Serious physical complications
High suicide risk
When may the mental health act be needed in anorexia nervosa?
Mental Health Act may be needed to enable compulsory feeding
What is a huge complication of feeding management in anorexia nervosa? How do we try and prevent this?
Refeeding syndrome, prevent by advising gradual weight gain of 0.5-1kg a week
What is refeeding syndrome caused by?
an intracellular shift of ions due to switching to carbohydrate metabolism
Clinical features of refeeding syndrome
fatigue, weakness, confusion, high blood pressure, seizures, arrhythmia, heart failure
What features of anorexia nervosa would suggest a severe referral pathway? What is the severe referral pathway?
Features: BMI < 15, rapid weight loss, evidence of system failure
SEVERE 🡪 Urgent referral to CEDS (community eating disorder service)
What features of anorexia nervosa would suggest a moderate referral pathway? What is the moderate referral pathway?
Features: BMI 15-17, no evidence of system failure
Moderate 🡪 Routine referral to CEDS
What features of anorexia nervosa would suggest a mild referral pathway? What is the mild referral pathway?
Features: BMI > 17, no additional co-morbidity
Mild 🡪 monitor/advice/support for 8 weeks, recommend support from BEAT, routine referral to CEDS if failure to respond
Biochemical hallmark of refeeding syndrome
Hypophosphataemia
What is bulimia nervosa characterised by?
Repeated bouts of overeating (bingeing)
Excessive preoccupation with the control of body weight, leading to a pattern of overeating followed by vomiting or using purgatives
Overconcern with body shape and weight
Cycle of bulimia nervosa
Prodrome
Often preceded by a background of dieting in an attempt to lose weight
Preoccupation with being too fat
Bingeing Episode
Eating excessive amounts of food in one sitting without control due to hunger, depression, anxiety, loneliness or boredom.
Compensation
Punishment for failing ‘dietary rules’ with attempted counteraction of fattening effects of food by vomiting, alternating periods of starvation, use of drugs (e.g. appetite suppressants, laxatives and diuretics)
Cycle Repetition
Feelings of shame and guilt which prompt further dietary restriction
Signs on examination specific to purging
Purging Signs (e.g. scarring of hands (Russell’s sign), dental caries)
What is Russel’s sign?
Scarring of hands due to purging
Investigations for bulimia nervosa
Examination: weight, height, lanugo hair, BP, squat test
Bloods and UDS
ECG
Rating Scale – eating attitudes test
PACES: What rating scale is used for bulimia nervosa?
eating attitudes test
Management of bulimia nervosa
Treat medical complications
Consider Bulimia Nervosa-Focused Guided Self-Help Programme for adults
If unacceptable or ineffective after 4 weeks, consider individual CBT-ED
SSRIs (Fluoxetine)
Reduce bingeing and purging by enhancing impulse control
Treat comorbid psychiatric illness
Depression, self-harm and substance misuse are common
Management of bulimia nervosa in children
offer family therapy (FT-BN)
What programme can be considered for adults with bulimia nervosa?
Bulimia Nervosa-Focused Guided Self-Help Programme
What features warrant a severe referral in bulimia nervosa? What is the severe referral process?
Features: daily purging with significant electrolyte imbalance, comorbidity
SEVERE –> Urgent referral to CEDS
What features warrant a moderate referral in bulimia nervosa? What is the moderate referral process?
Features: frequent binging and purging (>2/week), no significant electrolyte abnormality, some medical consequences (e.g. chest pain)
Moderate –> monitor/advice/support for 8 weeks, recommend self-help, consider SSRI, routine referral to CEDS if failure to respond
What is the mild referral process in bulimia nervosa?
Mild 🡪 recommend self-help, recommend BEAT, monitor/advice/support for 3 months, routine referral to CEDS if no improvement/deterioration
Summary of bulimia nervosa management
Referral for specialist care is appropriate in all case
BN-focused guided self-help for adults
If unacceptable, contraindicated or ineffective after 4 weeks, consider ED-focused CBT (CBT-ED)
Children should be offered BN-focused family therapy (FT-BN)
Consider a trial of high-dose fluoxetine
What SSRI may be used in bulimia nervosa? Why?
Fluoxetine, reduces bingeing and purging by enhancing impulse control
What biochemical sign is a tell tale sign of bulimia nervosa?
Hypochloraemia
How does weight differ in anorexia to bulimia?
Anorexia is low weight, bulimia is normal weight
How often do symptoms need to appear for in order to meet the criteria for bulimia?
To meet criteria for Bulimia, behaviour has to occur at least once a week for three months
What gland is enlarged in bulimia? What is this known as?
Enlarged parotid gland, sialadenosis
What is binge eating disorder?
Compulsive overeating excessively large amounts of food
What is the management of binge eating disorder?
Psychotherapy 1st line or CBT
What medications can be used for binge eating disorder?
Meds that can be used include lisdexamfetamine (ADHD stimulant) and topiramate (seizure medication)
