Eating Disorders Flashcards
What are eating disorders?
Psychiatric conditions involving unhealthy and distorted obsession with body image and food
What are the different types of eating disorders?
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
Other specific feeding or eating disorder
Avoidant restrictive food intake disorder
What happens in anorexia nervosa?
Person feels they are overweight despite being low body weight
Obsessive calorie restriction to lose weight
Highest mortality of psychiatric conditions
What may a patient with anorexia nervosa use to lose weight?
Diet pills
Laxatives
What are the features of anorexia nervosa?
Weight loss (BMI less than 17.5)
Amenorrhoea
Lanugo hair
Hypotension
Hypothermia
Mood changes
What causes amenorrhoea in anorexia nervosa?
Less adipose tissue, oestrogen production also takes places in adipose tissue, less oestrogen
Disruption of the hypothalamic-pituitary-gonadal axis
Lack of gonadotrophins causing reduced activity of the ovaries
What can happen to the heart in anorexia?
Loss of cardiac muscle
Patients can present with new murmurs due to loss of myocardium
What test can be used to assess muscle wasting in patients with anorexia?
Sit-up-squat-stand test
Patient lies flat on the floor and attempts to situp without their hands and then in squat position
Red flag if patient unable to do this
What are the ICD-11 essential features for anorexia nervosa diagnosis?
Significantly low body weight
- Adults BMI less than 18.5
- Children BMI < 5th percentile or failure to gain weight as expected
- Rapid weight loss, 20% in 6 months
Low body weight not explained by other medical condition or food availability
Persistent pattern of restrictive eating or behaviours to maintain low body weight
- Fasting
- Low calorie food
- Excessively slow eating of small amounts of food
- Hiding food
- Chewing and spitting
- Purging behaviours
Increased energy expenditure
Excessive preoccupation with body, weight and shape
- Repeatedly checking body weight
- Repeatedly looking n the mirror
- Extreme avoidant behaviours
What is bulimia nervosa?
Binge eating followed by purging by induced vomiting or taking laxatives
What are some differences between bulimia nervosa and anorexia nervosa?
People with bulimia tend to have normal body weight
Weight can fluctuate
What are the features of bulimia nervosa?
Teeth erosion
Swollen salivary glands
Mouth ulcers
Gastro-oesophageal reflux
Calluses on knuckles where they have been scraped across teeth (Russell’s sign)
Why does alkalosis occur in bulimia?
Repetitive loss of hydrochloric acid from the stomach
What are the essential features of the ICD-11 for bulimia nervosa diagnosis?
Frequent, recurrent episode of binge eating
- Once a week or more for at least a month
Repeated inappropriate behaviours to prevent weight gain
Once a week or more over a period of at least a month
- Self induced vomiting
- Fasting, diuretics, laxatives
- Insulin omission
Excessive preoccupation with body weight
Marked distress about pattern of binge eating and inappropriate compensatory behaviours
Binges can be objective or subjective
- Loss of control over eating
What is the binge-purge cycle?
Strict dieting
Diet slips or difficult situation arises
Binge eating triggered
Purging to avoid weight gain
Feelings of shame and self-hatred
What is binge eating disorder?
Episode where person excessively overeats
Expression of underlying psychological distress
Person typically feels a loss of control
What do binges involve?
Planned binge
Eating very quickly
Unrelated to hunger
Becoming uncomfortably full
Eating in a dazed state
What can trigger a binge eating episode?
- Not eating regularly
- Not eating enough
- Upset or angry
- Broke rule “blown it, may as well carry on
What are the essential features of the ICD 11 for binge-eating disorder?
Frequent, recurrent episodes of binge eating
- Once a week or more over a period of 3 months
- Loss of control
Symptoms and behaviours not accounted for by another medical or mental condition or due to substance use
e.g. not due to Prader-Willi syndrome, depression or EUPD
Marked distress about pattern of binge eating
What is the binge eating disorder cycle?
Restrict dietary intake
Think about food, feel deprived, empty, hungry
Binge eating triggered overwhelming urge
Binge
Feelings of shame and self loathing
What eating disorders come under other specified feeding and eating disorders?
- Atypical anorexia
- Bulimia nervosa- low frequency
- Binge eating disorder- low frequency
- Purging disorder
- Rumination-regurgitation disorder
- Pica
What are the ICD-11 essential features for avoidant-restrictive food intake disorder?
Avoidance or restriction that results in
- Weight loss
- Nutritional deficiencies
- Dependence on oral supplements or tube feeding
Significant impairment in personal, family, social or other important areas of functioning, due to avoidance or distress relate to anything involving in eating
Preoccupation not motivated by weight or shape
What are some non-essential features of avoidant-restrictive food intake disorder?
- Lack of interest in eating, low appetite or unable to recognise hunger
- Avoidance of foods with certain characteristics e.g. smell
- Concern about consequences e.g. choking, vomiting
- May have no identifiable cause
- No difficulty eating foods in their preferred range
- Underweight or normal weight
- Impact family functioning
What do blood test findings in restrictive eating disorders show?
Anaemia
Leucopenia
Thrombocytopenia
Hypokalaemia
Caused by reduced bone marrow activity
Hypercholesterolaemia in anorexia
What can severe cases of eating disorders require?
Compulsory admission for observed refeeding and monitoring for refeeding syndrome
Why do some individuals develop eating disorders?
- Coping mechanism for difficult emotions, distraction and numbing
- Help individual feel protected, confident and less anxious
- Sense of being special
- May present a barrier to engaging with treatment
What are the predisposing factors of eating disorders?
- Low self esteem
- Feelings of ineffectiveness or lack of control
- Self-identity
- History of depression/anxiety/mood intolerance
- Personality traits: perfectionism, obsessional
- Interpersonal styles: struggle to recognise cues and emotional state of others
- Emotional processing: difficulty recognising own emotional state expressing emotions, difficulty handling stress
- Thinking styles – cognitively rigid, all or nothing thinking, can’t see bigger picture
- History of bulling and trauma
- Stressful life events
- Difficult interpersonal relationships
- Competitive sports e.g. gymnastics
What factors can perpetuate eating disorders?
Effects of starvation – energy, euphoria
Reduced sex drive – can be positive in terms of avoidance
Feelings of control, protection and safety
Sense of identity
Numbing of emotions
Sense of achievement
Reinforcement from others, positive comments
Social media
What are the psychological effects of starvation
- Brain structure and self-regulatory system changes
- Anxiety and intense negative emotions increase
- Negative and positive emotions are numbed
- Coping ability reduces
- Thinking becomes more rigid- habits and routines more rigid
How are eating disorders assessed?
- Psychiatric assessment
- Medical assessment
- Risk assessment
On physical examination what are the different ranges for BMI, HR, BP, Temperature, hydration and muscle power status?
BMI
RED < 13 or rapid weight loss > 1kg in undernourished patient
Amber- 13-14.9 or rapid weight loss > 0.5kg in undernourished patient
Green- >15 or recent weight loss < 0.5kg/week
Heart rate
RED- < 40
Amber 40-50
Green > 50
BP
RED- Standing < 90, postural drop over 20mmHg or increase in HR over 30bpm
Amber- Standing BP > 90, associated with occasional syncope, postural drop over 15mmHg or increase in HR up to 30bpm
Green- Normal standing BP, no changes
Temperature
RED- < 35.5
Amber- < 36.0
Green- > 36
Hydration
RED- Fluid refusal, severe dehydration (10%)
Amber- severe fluid restriction, moderate dehydration (5%)
Green- Minimal restriction, mild dehydration < 5%
Muscle power
RED- unable to sit up from lying flat, or get up from squat (score 0 or 1)
Amber- Unable to sit up or stand from squat without noticeable difficulty (score 2)
Green- Able to sit up from lying flat and stand from squat with no difficulty
What investigations are used for eating disorders?
FBC
U&Es
LFT
Bone profile
TFT
Magnesium
Glucose
ECG
DEXA scan
What are the red, amber and green ECG readings?
RED- QTc >450ms females and >430 males + another significant ECG finding
Amber- QTc > 450ms females and > 430 male, taking medication known to prolong QTc
Green- Normal
What are the biological adaptions of eating disorders?
Adjusted free T4 to reduce metabolic requirements (sick euthyroid syndrome)
- Reduced resting metabolic rate
- Reduced body temperature
- Bradycardia
When does refeeding syndrome occur?
In patients with extended severe nutritional deficits that start eating again
Why does refeeding syndrome occur?
In prolonged starvation intracellular potassium, phosphate and magnesium are depleted
Electrolytes move from cells to blood to maintain normal serum levels in absence of dietary intake
Cell metabolism reduces to conserve energy, resulting in a loss of intracellular electrolytes e.g. slowed NaKATPase
During refeeding magnesium, potassium and phosphate are shifted out of the blood and sodium shifted into the blood
Carbohydrate intake causes increase in insulin, driving glucose, potassium and phosphate into cells
NaKATPase actively pumps potassium into cells and sodium out of cells
Insulin causes extra sodium reabsorption in the kidneys
What are the overall effects of refeeding syndrome?
Hypomagnesaemia
Hypokalaemia
Hypophosphatemia
Fluid overload (water following extra sodium into extracellular space)
Why can refeeding syndrome be fatal?
Risk of arrhythmia and heart failure
How is refeeding syndrome managed?
Slow reintroduction of food with limited calories
Close monitoring of magnesium, phosphate, potassium and glucose
Fluid balance monitoring
ECG monitoring
Supplementation with electrolytes, particularly B vitamins and thiamine
How is anorexia nervosa treated?
- Psychoeducation
- Weight monitoring, mental and physical health and risk factors
- Involve family or carers
- Aim to help people reach healthy body weight or BMI
- Dietary advice, meal planning
What is psychotherapy?
Adults
- Individual CBT-ED
- Individual Maudsley anorexia nervosa treatment
- Individual specialist supportive clinical management
- Individual focal psychodenamyic therapy (second line)
Children and young people
- Anorexia focused family therapy (first line)
- Individual CBT-ED (second line)
- Individual adolescent focused psychotherapy for anorexia nervosa (second line)
How is bulimia nervosa treated?
- Guided self-help in milder cases
- Up to 20 session of individual CBT-ED
Children and young people
- Bulimia-nervosa focused family therapy
- Individual CBT-ED (second line)
How is binge-eating disorder treated?
- Treatment not about losing weight, but stabilise eating and stop bingeing
- Offered guided self-help programme
If no effect after 4 weeks, group CBT-ED
Last line- individual therapy
How are other specified feed or eating disorders treated?
Use treatment for eating disorder it most closely resembles
Why is anorexia so hard to give up?
Managing emotions
Controlling relationships
Self-esteem
Communication
When is inpatient admission used for eating disorders?
- Patients want to change but not progressing
- Patient in immediate danger
- No adequate treatment locally
