Eating disorders

Question 1

ICD-10 Diagnostic criteria for anorexia nervosa

Answer 1

• 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

Question 2

Epidemiology of anorexia nervosa

Answer 2

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

Question 3

RFs of anorexia

Answer 3

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.

Question 4

Aetiology of Anorexia

Answer 4

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

Question 5

What happens to anorexia patients when they get to CAMHS?

Answer 5

Multidisciplinary assessment:
Psychiatrist
Psychologist
Family therapist
Paediatrician
Dietitian
Decision about whether to treat in the community or as an inpatient

Question 6

General principles of treatment for anorexia

Answer 6

• 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

Question 7

Weight restoration in anorexia

Answer 7

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

Question 8

Psychological treatments for ED

Answer 8

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

Question 9

Medication for anorexia

Answer 9

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

Question 10

Prognosis of anorexia

Answer 10

Recover completely 43%
Chronic eating disorder 20%
Improved but some residual symptoms 36%
Die 5%

Question 11

What could show a lower mortality in anorexia prognosis

Answer 11

Early age of onset
Short duration between onset of symptoms and start of treatment

Question 12

What could show increased mortality in prognosis of anorexia

Answer 12

• Lower weight at presentation
• Presenting at 20 - 29 years.
• Alcohol misuse
• Repeated admissions for anorexia
• Admissions for other psychiatric disorders

Question 13

Mortality and anorexia

Answer 13

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.

Question 14

What are the comorbidities in anorexia linked to

Answer 14

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.

Question 15

First and second rule of patient admission for anorexia

Answer 15

DO NOT BE REASSURED BY PATIENT LOOKING OR FEELING WELL

Normal blood tests DO NOT provide reassurance of safety

Question 16

Medical admission criteria for anorexia

Answer 16

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

Question 17

Automatic admission for anorexia

Answer 17

BMI less than 70%

Question 18

Why is the rate of weight loss important?

Answer 18

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

Question 19

After measurement of height and weight what do we look at next?

Answer 19

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

Question 20

Cardiac issues with anorexia

Answer 20

HR ≤ 50 bpm

Postural tachycardia ≥ 30 bpm
Postural drop systolic BP ≥ 20 mmHg
Dizziness/ Fainting

Question 21

Hypothermia in anorexia nervosa

Answer 21

Heat conservation reduced because impaired cutaneous vasoconstriction

Impaired increase in metabolic rate in cold environment

Core temperature < 35.5 0C

Question 22

Gut issues in anorexia

Answer 22

Abdominal discomfort

Constipation and bloating
Reduced gastric emptying
Reduced gut motility
Impaired pancreatic and gut enzyme secretion

Abdominal pain

Pancreatitis
Superior mesenteric artery syndrome

Question 23

Long term complications of anorexia

Answer 23

Osteoporosis and increased risk of fractures

Growth stunting and pubertal delay

Neurocognitive

Question 24

3 week admission model for anorexia

Answer 24

3-week admission model

 Rest 
 Monitor
 Feed

Question 25

What happens in starvation

Answer 25

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’

Question 26

What is refeeding syndrome?

Answer 26

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

Question 27

What happens in refeeding?

Answer 27

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

Question 28

How do you reduce risk of refeeding syndrome?

Answer 28

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

Question 29

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?

Answer 29

Admit Feed