Eating disorders Flashcards
ICD-10 Diagnostic criteria for anorexia nervosa
- Deliberately keeping weight below 85% of expected
restricted dietary choice - Excessive exercise
- Induced vomiting, use of appetite suppressants and diuretics.
- Dread of fatness – intrusive overvalued idea
Endocrine effects: - Menstruation stops or puberty is delayed if menarche not yet achieved
In men can manifest as loss of sexual interest/potency
Epidemiology of anorexia nervosa
About 1 in 250 females and 1 in 2000 males
1 fifteen-year-old girl in every 150
1 fifteen-year-old boy in every 1000.
Mean age of onset 16-17
RFs of anorexia
Social pressure
Perfectionist character traits
Reversing or halting effects of puberty.
Family:
Attitudes to food in family to food and body shape
Refusing food as a way of being heard in families.
Some genetic links
Depression may be a trigger for binges.
Aetiology of Anorexia
Low self-esteem
Occupation and interest (e.g. ballet dancers)
Anxiety disorders
Past or present events:
life difficulties
sexual abuse
physical illness
upsetting events - a death or the break-up of a relationship
important events - marriage or leaving home
What happens to anorexia patients when they get to CAMHS?
Multidisciplinary assessment:
Psychiatrist
Psychologist
Family therapist
Paediatrician
Dietitian
Decision about whether to treat in the community or as an inpatient
General principles of treatment for anorexia
- Outpatient setting ideally, unless physical health concerns – medical ward for stabilisation
- Tier 4 for psychological input and monitoring (MEED Guidelines)
- Psychological therapies
- Weight gain
- Medical – physical health monitoring and medication
Weight restoration in anorexia
0.5 kg/week in outpatients
0.5-1 kg/week in inpatients
Feeding against the patient’s will is possible under the MHA, but requires expertise
Psychological treatments for ED
Psychological treatments:
Cognitive analytic therapy (CAT),
Cognitive behaviour therapy (CBT),
Interpersonal psychotherapy (IPT),
Focal psychodynamic therapy
Family therapy(especially important in children)
Used in both community and inpatient settings
Medication for anorexia
Multivitamins, thiamine, phosphate may be required
Antidepressants for low mood and/or OCD symptoms (mood often improves as weight increases)
Olanzapine for agitation and anxiety, some evidence that it may promote weight gain
Quetiapine has also been used
Prognosis of anorexia
Recover completely 43%
Chronic eating disorder 20%
Improved but some residual symptoms 36%
Die 5%
What could show a lower mortality in anorexia prognosis
Early age of onset
Short duration between onset of symptoms and start of treatment
What could show increased mortality in prognosis of anorexia
- Lower weight at presentation
- Presenting at 20 - 29 years.
- Alcohol misuse
- Repeated admissions for anorexia
- Admissions for other psychiatric disorders
Mortality and anorexia
Anorexia has the highest mortality of any psychiatric condition with a Standardised Mortality Ratio of 5.86 … in other words a sufferer’s risk of mortality is nearly 6 x higher than healthy peers – all causes
At least half of these deaths due to medical comps
Early detection and effective nutritional intervention are key to improving outcomes. Those who achieve early rapid weight gain have been shown to have better treatment outcomes in studies than those that do not.
What are the comorbidities in anorexia linked to
We KNOW AN is classified as a MH disorder but could many of the mental health disturbances we see accompanying AN including depression, anxiety, DSH be a result of the direct effects of starvation on the brain
As a result of these studies, it has been postulated that many of the profound social and psychological effects of anorexia may result from undernutrition itself, and recovery depends as much on re-nourishment as psychological treatment.
First and second rule of patient admission for anorexia
DO NOT BE REASSURED BY PATIENT LOOKING OR FEELING WELL
Normal blood tests DO NOT provide reassurance of safety
Medical admission criteria for anorexia
Significant weight Loss
% median BMI < 70%
rate of weight loss
Resting bradycardia < 50 bpm
Postural tachycardia > 35 bpm Postural drop in systolic BP > 20 Hypothermia < 35.5 degrees
Severe Abdominal pain
Escalating parental Concern
Automatic admission for anorexia
BMI less than 70%
Why is the rate of weight loss important?
The rapidity of weight loss is as important as its degree in determining risk.
May have a normal BMI
The rapidity of weight loss is as important as its degree in determining risk.
Junior MARSIPAN (MEED) risk assessment tool advises loss of > 1kg/week for 2 consecutive weeks = HIGH RISK
After measurement of height and weight what do we look at next?
Cardiac impairment
After measurement of height and weight , the next thing is to look at is the patient’s cardiac status
Starvation causes loss of cardiac muscle as well as skeletal muscle
A weakened atrophied heart also poses a risk during refeeding due to the risk of precipitation of heart failure and even death
Loss of cardiac muscle and impaired cardiac reserve
Poses risk for refeeding
Cardiac issues with anorexia
HR ≤ 50 bpm
Postural tachycardia ≥ 30 bpm
Postural drop systolic BP ≥ 20 mmHg
Dizziness/ Fainting
Hypothermia in anorexia nervosa
Heat conservation reduced because impaired cutaneous vasoconstriction
Impaired increase in metabolic rate in cold environment
Core temperature < 35.5 0C
Gut issues in anorexia
Abdominal discomfort
Constipation and bloating
Reduced gastric emptying
Reduced gut motility
Impaired pancreatic and gut enzyme secretion
Abdominal pain
Pancreatitis
Superior mesenteric artery syndrome
Long term complications of anorexia
Osteoporosis and increased risk of fractures
Growth stunting and pubertal delay
Neurocognitive
3 week admission model for anorexia
3-week admission model
Rest Monitor Feed
What happens in starvation
Starvation – catabolic state, switch off insulin , use up glycogen ,break down fat and muscle and use gluconeogenesis to produce alternative fuel sauce .
There is Intracellular depletion of water , electrolytes, minerals, vitamins . Extracellular fluid volume shrinks more slowly and actually increases as a percent of body weight. This associated with decreased capacity of the kidneys to excrete a salt and water load. Results in ‘famine oedema’
What is refeeding syndrome?
metabolic syndrome with high mortality . Develops within couple of hrs and highest risk first 5 days but can be up to 2 weeks - UNCOMMON in adolescents – underfeeding more likely to cause problems
What happens in refeeding?
switch to anabolism , Intake Fluid salt nutrients, and now glucose as the main energy source results in huge release insulin leading to rapid cellular uptake K Mg phosphate and use of thiamine in process of glycogen synthesis.
Thus as you can see in the top left hand box you can get sudden drops in potassium, magnesium, phosphate and thiamine which can lead to cardiac arrest or coma
How do you reduce risk of refeeding syndrome?
Who is at Risk ?
low BMI
faster rate of weight loss
Starting meal plan = 1300 KCAL
Re-feeding bloods DAILY for 5 days
Refeeding Supplements
Phosphate Sandoz
Thiamine
Well, what an experience that was! We’ve had J’s appointment withthe Paediatrician now…. The doctor wemet questioned J about anything and everything apart from whatwould be an obvious question, ie. how much do you weigh!!!
We were told “she needs to eat more” (like we didn’t already know that)and she was asked “why don’t you go back to swimming training?”…..not really something one should be advising a teenager who’s 5’ 5”(165 cm)tall and weighs just 5 stone 3lbs (33.4kg) to do…… The doctor also toldher to go to the gym!!!Finally, at the very end of an excruciating 20 mins, she was examined and weighed and then we were told “Oh, I didn’t realise she was so thin!!!!”She is going to be referred but we are not sure where to….. might beCAMHS or might be adult eating disorder service….. fingers crossed that we hear back very soon and get on the right path!”
BMI 12.2/19.5 = percent median BMI of 63%
Pulse rate? 35 bpm
Orthostatic obs? Systolic BP drop 20mmHg
Temp? 35.7oC
Abdo pain? constipated
Bloods - Low WBC, Low TSH
ECG – sinus bradycardia
What should you do?
Admit Feed
