Eating disorders Flashcards

1
Q

ICD-10 diagnosis of bulimia nervosa?

A

binge eating-persistent preoccupation with eating and irresistible food craving
counteracting weight gain (compensatory behaviours)-vomiting, laxatives, exercise, appetite suppressants, thyroxine, diuretics, insulin omission
overvalued idea-fear of fatness, low target weight

There is often, but not always, a history of an earlier episode of anorexia nervosa, the interval ranging from a few months to several years.

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2
Q

how do anorexia and bulimic patients differ in their appearance?

A

bulimic patients often of normal weight, so not always obvious to others that they are unwell
anorexia-patients appear thin

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3
Q

ICD-10 diagnostic criteria for anorexia nervosa?

A
all 4 of the following to be present:
low body weight (weight maintained at least 15% below expected weight, or BMI less than 17.5)
intentional weight loss-dieting, excessive exercise, self induced vomiting-often without the preceding overeating seen in bulimia nervosa, or use of laxatives-purging and diuretics to achieve weight loss, and use of appetite suppressants e.g. chewing gum and cigarettes
body image distortion-overvalued idea- worry of getting fat-intense fear, low target weight, believe they are overweight even when they know they are not
endocrine disturbance (amenorrhoea, raised GH and cortisol, decrease T3)
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4
Q

4 features that occur with repeated vomiting in an eating disorder?

A

calluses on the back of the hands-russell’s sign
eroded dental enamel
salivary gland enlargement
oesophageal tears-mallory-weiss-haematemesis

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5
Q

physical complications of an eating disorder?

A
osteoporosis
liver failure
anorexic hepatitis
arrhythmias
hypotension
bradycardia
heart failure-in severe AN as loss of muscle mass, including heart muscle
peripheral oedema
seizures
depression
cold intolerance
amenorrhea and infertility
dry, yellow coloured skin
dizziness
muscle weakness
abdominal pain
constipation
BM suppression-decrease Hb, WCC, PLT
extreme irritability
peripheral neuropathy
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6
Q

features in the history of an eating disorder which suggest medical risk?

A

excess exercise with low weight
blood in vomit
inadequate fluid intake combined with poor eating
rapid weight loss
factors which disrupt ritualised eating habits e.g. journey, holiday, exam.

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7
Q

how can medical risk be screened for in patients with an eating disorder?

A
examination of muscle strength
pulse
BP
peripheral circulation
core temperature
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8
Q

types of anorexia nervosa as split using DSM-IV criteria?

A

restricting-patients maintain a low body weight only by restricting their dietary intake
purging- pts can lower their body weight by self induced vomiting, or using laxatives and diuretics

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9
Q

what behaviour associated with eating might anorexic patients display?

A
food avoidence
order to eating
own plate and cutlery
separation of food on plate
slow eating
eating alone
setting daily calorie limits
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10
Q

what is atypical anorexia nervosa?

A

Disorders that fulfil some of the features of anorexia nervosa but in which the overall clinical picture does not justify that diagnosis. For instance, one of the key symptoms, such as amenorrhoea or marked dread of being fat, may be absent in the presence of marked weight loss and weight-reducing behaviour. This diagnosis should not be made in the presence of known physical disorders associated with weight loss.

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11
Q

problems assoc with chronic laxative abuse in anorexia nervosa?

A

chronic constipation

disruption to magnesium levels, producing an atonic bowel

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12
Q

core psychopathology in anorexia nervosa?

A

disturbance of body image, believes they are overweight despite all evidence to the contrary
fear of fatness
valuation of self-worth as a function of weight and body shape, rather than usual values of society

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13
Q

what blood test results may be found in an anorexic patient?

A

FBC: low Hb, MCV may be raised, low WCC, low PLT
low glucose
low albumin
Us and Es: raised urea, low Na+, low K+
LFTs: raised bilirubin, ALT/AST, ALP and GGT

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14
Q

when might the MHA be required in the tment of anorexia nervosa?

A

Under the New MCA (2005) people lacking capacity may be treated if it is in their best interest, if it is the least restrictive option, if it is not depriving them of their liberty and there is no advanced refusal or objection by a donee or court of protection.
Treatment of people with severe anorexia nervosa who are not consenting to treatment for their mental disorder will in most cases require use of the MHA as it involves deprivation of liberty and compulsory refeeding. Treatment under the Mental Health Act can be given
under Section 2 or 3, if they meet the legal criteria (see Code of Practice) whether or not they lack capacity. If after three months from the start of their detention they either lack capacity or object to treatment, SOAD authorisation is required-second opinion authorised doctor.

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15
Q

management of physical aspects of eating disorders?

A

Where laxative abuse is present, patients should be advised to gradually reduce laxative use and informed that laxative use does not significantly reduce calorie absorption.
Treatment of both subthreshold and clinical cases of an eating disorder in people with diabetes is essential because of the greatly increased physical risk in this group.
People with type 1 diabetes and an eating disorder should have intensive regular physical monitoring because they are at high risk of retinopathy and other complications.
Pregnant women with eating disorders require careful monitoring throughout the pregnancy and in the postpartum period.
Patients with an eating disorder who are vomiting should
have regular dental reviews.
Patients with an eating disorder who are vomiting should be given appropriate advice on dental hygiene, which should include:
avoiding brushing after vomiting; rinsing with a non-acid
mouthwash after vomiting; and reducing an acid oral
environment (for example, limiting acidic foods).
Healthcare professionals should advise people with eating disorders and osteoporosis or related bone disorders to refrain from physical activities that significantly increase their falls risk.

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16
Q

prevalence of anorexia nervosa?

A

0.3% in young females

17
Q

prevalence of bulimia nervosa?

A

1% in young females

18
Q

particular population with a disease that should be screened and assessed for the presence of an eating disorder?

A

young people with type 1 DM and poor treatment adherence

19
Q

psychological interventions for the treatment of anorexia nervosa?

A
cognitive analytic therapy (CAT)
CBT
interpersonal psychotherapy
focal psychodynamic therapy
family interventions focused explicitly on eating disorders

aim to reduce risk and other symptoms related to eating disorder, encourage weight gain and healthy eating, and facilitate physical and psychological recovery.
OP tment for at least 6 mnths (usually 1-2yrs), once weekly psychological sessions.
family interventions should be offered to children and adolescents with the disease.

20
Q

predisposing factors to anorexia nervosa development?

A

complex biopsychosocial interaction
biological: genetic-anorexia nervosa 11 times higher in 1st degree relatives
cerebral abnormalities
5-HT dysregulation-5-HT activation in brain leads to inhibition of food consumption. NT imbalance-5-HT and dopamine- may explain why don’t experience pleasure from foods and other typical comforts.
zinc deficiency

psychological: personality traits-anxious, obsessive, perfectionistic
depression/anixety, low self-esteem, excessive worrying
influence of parental eating disorders
previous adverse expereinces e.g. divorce, loss of a parent, illness in family, school difficulties
childhood sexual abuse
troubled personal relationships
difficulty expressing emotions

social: childhood upbringing and environment
societal pressures and the ‘cult of thinness’
hx of being ridiculed or bullied about their weight

21
Q

maintaining factors in anorexia nervosa?

A

starvation
ongoing precipitating factors
denial
cognitive theory of maintenance-over evaluation of their eating, weight, shape and control, worry of losing control over eating so strictly diet causing low weight and starvation syndrome which increases worry over their weight and eating stimulating dietary restriction and increasing starvation.
becomes part of the pt, can’t envisage themselves without it

22
Q

NICE guidelines on pharmacological tment of anorexia nervosa?

A

medication should NOT be used alone or as primary tment
caution with tment of comorbid conditions e.g. obsessive-compulsive features or depressive features, as these may resolve with weight gain
ensure ADRs discussed, espec. cardiac, and consider carefully due to compromised CV function of many people with AN (*bradycardia and HF?) be aware of drugs that prolong QTc
ensure alert placed in pt’s prescribing record concerning risk of side effects

23
Q

physical management of AN?

A

managing weight gain: aim for 0.5-1.0 kg in IP settings, and 0.5 kg/week in OP, multi vitamin/mineral supplement, physical monitoring, NOT TPN unless significant GI dysfunction.
managing risk: regular physical health monitoring, do NOT give oestrogen to children or adolescents to treat bone density problems as will cause premature fusion of epiphyses stopping growth

24
Q

definition of binging in bulimia nervosa?

A

loss of control, eating much more than what other people around you would consider normal in a very short time period
often not enjoyed and pts experience lots of -ve feeling afterwards stimulating compensatory behaviours e.g. self induced vomiting, laxative use, diuretic use etc.

25
Q

DSM-IV time scale for bulimia nervosa diagnosis?

A

symptoms at least once a week for 3 mnths

26
Q

lifetime mortality in anorexia nervosa?

A

10%-50% from illness itself and 50% from suicide

27
Q

indications for AN patient to be treated as an inpatient?

A

failed to respond to treatments
poor home environment for getting better
AN complications
case complexity-lots of comorbidities

28
Q

components to assessment of pt with suspected eating disorder?

A
weight, BMI, physical symptoms
purging?
FBC
Us and Es
LFTs
thyroid
HR
BP
calcium and phosphate
magnesium
ECG
squat test or sit up test to test muscle strength- stand up from squatting or sit up from lying down respectively.
29
Q

why might patients with bulimia nervosa be susceptible to arrhythmias?

A

abnormal K+ levels (hypokalaemia)-due to vomiting and laxative abuse

30
Q

what is beriberi, why does it occur in anorexic patients?

A

disease caused by thiamine (vit B1) deficiency, occurs in anorexic pts as inadequate vit intake due to dietary restriction
dry beriberi-nerve damage-loss of muscle strength, paralysis, foot drop
wet beriberi-cause of HF-SOBOE, peripheral oedema, bibasal creps on auscultation.

31
Q

general AN management?

A

agree clear tment plan, assign a care coordinator
psychoeducation
self-help resources
problem solving and relaxation techniques
dietary advice
regular physical health monitoring and mental state
consider prep for tment group
give thiamine replacement, espec. once they start eating again
treat comorbidities-remember may resolve with weight gain alone
pharamcological not as sole tment or primary tment

32
Q

psychological interventions for bulimia nervosa?

A

evidence based self help programme as 1st step
CBT for bulimia nervosa (CBT-BN) offered as 4-5 mnth tment of 16-20 sessions for adults
interpersonal psychotherapy alternative to CBT but warn pts takes 8-12 mnths to achieve results comparable with CBT

33
Q

pharmacological interventions for bulimia nervosa?

A

as alternative to 1st step self help tment, or in addition, adults may be offered a trial of an antidepressant drug-can reduce frequency of binges and purges, SSRIs part. fluoxetine 1st choice-60mg daily (higher dose needed for effectiveness compared with depression.)

34
Q

management of physical disorders in bulimia nervosa?

A

ensure fluid and electrolyte balance assessment if frequent vomiting or laxative use
try and treat responsible behaviour but if ineffective, give oral replacement rather than IV

35
Q

when might bulimia nervosa pts require IP tment?

A

often treated as OP
need IP if risk of suicide or severe self harm
ensure tment adapted if poor impulse control, espec. substance misuse

36
Q

Why does osteoporosis occur in AN patients?

A

Aetiology uncertain but could be related to oestrogen lack with oestrogen normally inhibiting osteoclast activity*, and may be linked to high cortisol.

37
Q

Comorbidities assoc with bulimia nervosa?

A

Substance misuse

Affective disorder

38
Q

Comorbidities assoc with both AN and BN?

A

obesity

alcohol abuse