Eating disorders Flashcards
1
Q
classifications of eating disorders ?
A
- anorexia nervosa
- Bulimia Nervosa
- Binge eating disorder
- avoidant restrictive food intake disorder
- other specified feeding and eating disorder
2
Q
anorexia nervosa
A
- self imposed weight loss of 15% body weight
- intense fear of weight gain even when underweight
- a feeling of being too fat even when thin - body image distortion
3
Q
bulimia nervosa
A
- recurrent episodes of binge eating i.e large amount of food and loss of control while eating
- recurrent compensatory weight loss behaviour (e.g vomitting, laxative use/ over-exercise
- binging and behaviours for 1 week in 3 months
- self evaluation unduly influenced by body shape and weight
- not in context of criteria for AN i.e low weight
4
Q
avoidant restrictive food intake disorder (ARFID)
A
- an eating/ feeding disturbance with significant weight loss
- significant dietary deficiency
- dependence on enteral feeding/ oral supplements
- marked interfence with psychosocial functioning
- no evidence of weight/ shape concerns
5
Q
what are the 3 profiles of avoidant restrictive food intake disorder (ARFID)?
A
- low interest
- sensory
- fear
6
Q
presentation of ARFID ?
A
- negative sensory reaction to food e.g taste, texture, smell
- fear of eating after a negative experience such as vomiting or choking
- little appetite or interest in food/eating
- people often report ‘always been picky eater’
7
Q
epidemiology of ARFID ?
A
- typically previously seen in children and adolescents, but now recognized in adults- either: previously misdiagnosed as AN? more common now? or both
- boys > girls but women > men
- unknown prevalence as yet but one study showed 6-13% in specialist services
- higher risk of ARFID with: autism spectrum disorder, ADHD, anxiety disorders, OCD
8
Q
demographics - anorexia nervosa
A
- AN prevalence 0.5-1%
- AN typically begins in teenage years
- higher prevalence middle/upper classes (? more likely to seek help/ or higher focus on success/ perfectionism)
- ‘westernized disease’, higher rates in models, ballet dancers, athletes, military,
9
Q
demographics - Bulimia Nervosa, Binge eating disorder
A
- Bulimia nervosa
- prevalence: 1-3%
- onset late teens/20s
- higher incidence sport/body conscious activities - Binge eating disorder
- prevalence: 3%
- onset usually older - 30s/40s/50s
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10
Q
why do people get eating disorders?
A
- genetics
- personality type: e.g obsessive-compulsive, perfectionistic, impulsive
- weight loss rewarded by feelings of control, positive feedback from others, media, role models
- family influence: poor conflict resolution, person feels misunderstood, or unheard in family, abuse
11
Q
why do people get eating disorders? (relationship to anxiety)
A
- eating disorder behaviours reduce anxiety partly by numbing of feelings. these effects are mediated via certain chemicals including adrenaline, enorphins, serotonin, dopamine, and ketones
- examples include:
1. the adrenaline rush of starvation - feeling light headed, ‘high’
- binging on high sugar/ high carb foods - pleasurable/ anxiety reducing or brain numbing
- vomitting relieves the anxiety of feeling full, and the physical effort causes tiredness/ sleepiness
12
Q
physical consequence of Eating disorder
A
- anorexia nervosa has highest mortality and physical morbidity of any psychiatric disorder
- up to 10% mortality with anorexia at 10 years from;
1. starvation
2. secondary physical complications
3. suicide - bulimia nervosa and binge eating disorder also have higher mortality than normal - e.g metabolic effects and weight
13
Q
potential consequence of anorexia nervosa ?
A
- brain
- preoccupation with food/ calories, fear of gaining weight, headaches, fainting, dizziness, mood swinges, anxiety, depression - hair/skin
- dry skin and lips, brittle nails, thin hair, bruises easily, yellow complexion, growth of thin white hair over body (lanugo), intolerance to cold - heart
- poor circulation, irregular or slow heart beat, very low BP, cardiac arrest, heart failure - blood
- anemia - intestines
- constipation, diarrhea, bloating, abdominal pain - hormones
- irregular or absent periods
- loss of libido
- infertility - kidneys
- dehydration
- kidney failure - bones
- osteopenia and osteoporosis - muscles
- muscle loss, weakness, fatigue
14
Q
Eating disorder symptoms (primary symptoms, psychiatric/ psychological, Social, Physical
A
- primary symptoms
- restricted diet (check amount of food, carbs and fats)
- lack of interest in food/ dislike of taste, smell texture
- vomitting, laxative abuse, diet pills, over exercising, fluid excess to assuage hunger = compensatory weight loss behaviours
- binging
- body image distortion - psychiatric/ psychological
- self punishments/ deliberate self harm/ suicidality (often in response to self critical internal voice
- mood - can be low
- perfectionist personality/ OCD symptoms or traits - Social
- drug and alcohol abuse
- social and vocational - physical
- cessation of menses
- chest pain or palpitations
- sensitivity to cold/ purple extremities
- fatigue/ weakness / dizziness
- stomach complaints
15
Q
treatment pathways Eating disorders - diagnosis not clear
A
- if your assessment is that the patient may have an ED, or the diagnosis is unclear - it is always appropriate to;
1. investigate possible physical causes for symptoms e.g peptic ulcer disease/ malabsorption/ celiac disease - request return visit to re-assess (weight/ symptoms)
16
Q
treatment pathways - eating disorder diagnosed (mild)
A
self help resources, including HSE self care ED App, ‘overcoming binge eating’ by christopher Fariburn
- bodywhys: information and support
- review regularly for monitoring/ support
17
Q
treatment pathways - eating disorder diagnosed (mild-moderate)
A
- refer for psychiatric assessment: specialist ED team if available/ or Local community mental health team
18
Q
treatment pathways - eating disorder diagnosed (severe)
A
- consider need for referral to nearest emergency department for assessment
- discuss case with eating disorder specialist - does the patient have capacity to refuse treatment? possible need for mental health act?
19
Q
treatment - basics
A
- full medical and psychiatric assessment
- optimize co-morbid illness (physical e.g diabetes; psychiatric e.g OCD/depression/ anxiety disorder)
- appropriate feeding/ nutrition regime
- psychotherapy to treat the eating disorder cognitions and the underlying driving issues
- rehabilitation - social/vocational
20
Q
treatment of eating disorders, evidence base recommends a … team approach. …. % of patients treated as ….
A
multidisciplinary
outpatients
21
Q
core clinical team members in treating eating disorders
A
- psychiatrist
- dietician
- psychologist/ psychotherapist
- occupational therapist
- social worker
- other therapists e.g art therapists
- nursing
22
Q
role of psychiatrist in eating disorders?
A
- full psychiatric, eating disorder and medical history
- physical work up: bloods including FBC, U and E, glucose, LFTs, amylase, vitamin D, TSH, Iron studies, Phosphate, magnesium
- ECG, DEXASCAN
- regular physical monitoring
- prescribe medication
23
Q
role of dietician and psychology/ psychotherapist
A
- dietician
- assessment and monitoring with weight restoration regime: target range given, regular and balanced meals, ‘chaining’ for ARFID, nutritional supplements, NG/PEG feeding - psychotherapy/ Psychology
- assessment/ formulation
- therapies: Cognitive behavioural therapy - enhanced (CBT-E) for BN, BED, Maudsely Model of Anorexia Nervosa treatment for adults (MANTRA) for AN, Cognitive Remediation therapy (CRT)
24
Q
role of social worker, occupational therapist, creative therapist, and nursing in eating disorders
A
- social worker
- family involvement/ family therapy/ vocational/ social/ safety and risk issues - occupational therapist
- rehabiliation/ relapse prevention/ discharge preparation - creative therapist such as e.g art therapist
- Nursing
- community and inpatient nurses who provide a wide range of nursing care
25
Medications for eating disorders
1. no medication can treat anorexia nervosa or ARFID, but medication can be used to treat co-morbid depression, anxiety, OCD
2. bulimia nervosa and binge eating disorder can be treated with SSRIs, particularly SSRIs: fluoxetine in high doses to treat binging and vomitting (BN and BED) - up to 80 mg, depression, anxiety, OCD
3. bone support: calcium and vitamin D, bone strengthening (e.g fosamax, Prolia)
4. Nutritional supplements (e.g fortisip, Calogen): the patient can often not ingest enough food to restore weight in an acute AN without supplements in early treatment phase. the patient has chronic severe and enduring AN, and supplements prevent life-threatening deterioration
5. antipsychotics e.g risperidone, Quetiapine: can reduce internal voice and anxiety
6. Sedation/ anti anxiety: benzodiazepines, most usually inpatients, and especially at meal times
7. Vitamins and minerals
- B12, parenteral if admitted acutely with AN
- Magnesium, phosphate to treat re-feeding syndrome
- potassium - vomiting/ chronic low weight
26
Referral for eating disorder admission
1. low body weight (consider if BMI < 14)
2. severity of symptoms
- rapid weight loss
- unable to follow a basic nutrition plan due to severity of ED cognition
- uncontrollable binging and vomitting with hypokalemia
3. significant concomitant disorder e.g depression and/or suicidality
4. failure of out-patient treatment and significant illness
27
course of illness - eating disorders
- early intervention significantly impacts on positive prognosis
- roughly 1/3 recover, one third and one third have significant ongoing symptoms
- patients do die, or have enduring significant morbidity (psychological/ physical)
- emphasis of treatment is cure, but if significant illness- improvement of coping strategies and maximise quality of life
- there is a tendency of symptom to return under stress even in recovery
28
Eating disorder checklist
Ask about:
1. normal days diet
2. compensatory weight loss behaviours: vomitting, laxatives, exercise, diet pills, fluid loading
3. sensory issues re food, lack of interest in food
4. binging
5. body image
6. periods
7. Mood/ suicidality / drug alcohol
8. effect of the ED on the persons life
29
Managing the acutely unwell patient with an eating disorder - lessons
1. hypokalemia recurs quicly because total body potassium is very low. Check K+ regularly after discharge and ensure treatment referral
2. consider compulsory admission when patient in high risk category refuses
3. make your risk assessment without delay
30
Assessing risk checklist - eating disorders
1. BMI
- high risk: <14
- Medium risk: 14-16
- low risk: >16
**can still be high risk if high BMI (if high BMI before significant weight loss)
2. high risk BMI, or lower risk and any of below
- weight loss 1kg consecutive 2 weeks
- minimal/ no nutrition x 5 days
- pulse < 40, QTc > 450
- low BP with dizziness
- temperature< 35C
- abnormal bloods: Na+ <30, K+ < 3, glucose < 3, increased transaminases, urea, or creatinine
31
mental health act (adult)
action:
1. authorized officer or family member applies to GP for admission under the MHA
2. GP completes form 5 and contacts psychiatric unit
3. Patient brought to the unit (by assisted admission if necessary)
4. patient transferred to local general hospital
5. despite detention under the MHA, patient refused treatment
action:
1. application to high courts to treat
32
irelands mental health act allows restraint for:
1. administration of medication e.g in acutely disturbed patient, if there is a risk to self or others
- however, the repeated daily restraint required over potentially months of re-feeding is not permitted
33
mental health act - children and adolescents
section 25 under the MHA can be used to look for an order to treat at the district court if it is a young person of 16 years or 17 years, or if the parents are unable or unwilling to give consent for treatment
34
National clinical programme in eating disorders (NCPED)
- very limited access to eating disorders treatment nationally
- almost no adult services, child and adolescent services more developed but still limited
- very ill patients sent to private hospitals in the UK paid for by the HSE
- with development of national clinical programmes - eating disorders were amongst 3 disorders prioritized
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