Eating Disorders Flashcards
What is anorexia nervosa?
-A. refusal to maintain weight above minimally normal predicted weight (i.e. weight loss leading to weight
B. Intense fear or weight gain/fat
C. Distorted body image
What is bulimia nervosa?
-craving for food and uncontrolled binge eating
-morbid fear of fatness
-distorted body image
-Sense of lack of control
-Recurrent, inappropriate compensatory behaviour: purging / vomiting / laxative abuse
-Fluctuating (N or excessive) weight
Binges and compensatory behaviours occur at least 2x/week for 3/12
Epidemiology anorexia?
Onset 13-20
- 1-2% schoolgirls and female students
- 3F:1M
Epidemiology bulimia?
- Onset 15 - 30
- Prevalence 1-3%
- 3F:1M
DDx anorexia?
-psychosis: schizophrenia (delusions about food)
-organic: diabetes (but may coexist)
-Addison’s
-malabsorption
-malignancy
Latter 3 unlikely
DDx bulimia?
- Psychiatric: anorexia
- Neurological: Kleine-Levin, Kluver-Bucy (rare causes overeating)
Management anorexia?
- Exclude other diagnoses and monitor physical health
- Family interventions
- Motivational counselling
- CBT
- Hospitalisation if indications
Management bulimia?
- Medical stabilisation
- CBT: establish regular eating program, address abN cognitions
- SSRIs (fluoxetine best established)
Prognosis anorexia?
-40% recover
-35% improve
-20% develop chronic disorder
-5% death (highest death rate any psych disorder)
Long term risk osteoporosis
Indicators of poor prognosis bulimia?
Poor if:
- low BMI
- high frequency of purging
- 30-40% remission with CBT
Aetiological factors eating disorders?
-GENETIC/FHx: eating disorders, parental obesity, restrictive dieting
-PERSONALITY: anxious, OCD/perfectionistic and depressive traits; alexithymia and low self esteem;
==>anorexia: constricted affect and emotional expressiveness
==> bulimia: impulsive
-BIOLOGICAL: altered brain 5HT
-CHILDHOOD
-CULTURE: value on thinness, media representations, occupation that values thinness (i.e. modelling)
Factors supporting genetic component to eating disorder development?
- twin studies indicate genetic component;
- 1st degree relatives inc risk OCD, depression, obsessional personality, EtOH/substance abuse (bulimia only)
How does 5HT interact with eating disorder pathways? i.e. effect is has leading to eating disorder?
Altered brain 5HT contributes to appetite dysregulation, mood and impulse control
Childhood personal/environmental factors predisposing to eating disorders?
- Sexual, physical or emotional abuse
- Overprotective or overcontrolling environment; or one where food, eating, weight, body shape overvalued
- troubled interpersonal or family relationships
- being ridiculed because of size or weight (i.e. childhood obesity)
- early menarche (
AFx anorexia?
- preoccupation with food (dieting, elaborate meals for others)
- self consciousness about eating in public; socially isolating behaviour
- vigorous exercise
- constipation
- cold intolerance
- depressive and OCD symptoms
Physical signs / complications of anorexia?
- Vitals: hTN, brady, arrhythmia, post drop, hypervent (acidosis), systolic flow murmur
- Emaciated frame
- Psychomotor retardation
- Stupor
- Peripheral shutdown
- Carotinemia
- Russell’s sign
- Easy bruising
- Lanugo
- Cyanosis, anemia
- Parotidomegaly
- Poor dentition
- breast atrophy
- abdo tenderness (gastritis)
- Proximal myopathy
- Peripheral neuropathy
- DSH
- Fractures
- Oedema (low alb; CCF)
What is Russell’s sign?
Scarring/calluses of dorsum of hand. Indicates repeated vomiting
AFx bulimia?
- N or excess weight
- Loss of control / trance like state while binging
- intense self loathing and depression
- multi impulse bulimia: +drug/EtOH abuse, DSH, stealing, sexual disinhibition (poor impulse control pathway)
Physical signs / complications bulimia?
- amenorrhoea
- hypokalemia (dysrhythmias or renal damage)
- consequences of repeated vomiting: hypokalemia, alkalosis, pitted teeth, parotid swelling, scarring of dorsum of hand (Russell’s sign) (oesophageal tears can occur)
Anorexia subtypes?
- Restrictive (minimal food intake, exercise): person has not engage in self-induced vomiting / laxative abuse
- Binge eating-purging type: (episodes binge eating, laxative use, induced vomiting, enemas)
Common co-morbid psych conditions in individuals with anorexia?
- Mood d/o: MDD, chronic dysthymia
- Anxiety: panic d/o, PTSD, OCD, social phobia
- Substance use d/os
- Somatoform d/o: conversion, somatisation
- Personality d/o: OCPD, BPD
Psych indications for admission anorexia?
- Active suicidal plan
- Anorexic cognitions: continuous preoccupation, cooperative only in highly structure Rx
- Other psych d/o req hospital
- Eating: NGT, constant supervision
- Exercise: supervised to restrain
- Compulsive, uncontrolled purging
- Severe family problems
- Treatment availability
Useful investigations in anorexia?
- ECG: if hypoK, widespread U waves, QTC 450
- UEC: usu N (look for hypoK/Mg, hyper bicarb, urea low)
- LFTs (increased)
- Haem (dec HB, WCC, PLT, ESR)
Bicarb changes in anorexia?
->30mmol/L when vomiting
-
Endocrine Ix in anorexia?
- Dec: LHR, LH, FSH
- Dec oestrogen, progesterone
- Dec: T3
- Inc cortisol
- Inc fasting GH
What is refeeding syndrome?
- Starvation: low CHO = low insulin secretion
- body stores K, Mg, PO4 deplete (although serum level maintained)
- Refeeding -> CHO metabolism –> inc insulin –> PO4, K, Mg uptake into cells –> fall in serum concentration
When does refeeding syndrome occur?
3-4 days of refeeding
What is refeeding syndrome associated with?
- hypoK, hypoMg
- Sodium and fluid retention
- Thiamine deficiency
- Hyperglycemia
Serious sequelae refeeding syndrome?
- Acute cardiac failure
- Resp failure
- Wernicke’s encephalopathy
- Sepsis
- Acute renal failure
Alexithymia
Inability to articulate one’s emotional state
What is a binge eating episode classified as?
Eating in a discrete period of time an amount of food definitely lager than most people would eat in a similar period. Sense of lack of control during the episode.
General indicators (adult and child) for admission?
- Proximal myopathy
- Hypoglycemia
- Electrolyte imbalance (low K, Mg, PO4)
- Petechial rash and platelet suppression
What are issues surrounding patients with anorexia nervosa?
- lack of shared illness model
- high risk situations
- dysfunctional/reinforcing family dynamics
- health systems not designed to support
- often past traumatic experiences
- strong counter transference issues
What are the severe sequelae of refeeding syndrome?
- Acute cardiac failure
- Respiratory failure
- Wernicke’s encephalopathy
- Sespis
- Acute renal failure
What are the criteria for discharge in anorexia?
- Medically stable
- Sufficient nutrition to reverse any cognitive effects of starvation so can benefit from outpatient therapy
- Trials of leave to demonstrate can eat outside hospital
- Direct link with appropriate outpatient monitoring, support and treatment
Physical criteria for admission adult anorexia?
- Bradycardia ( below 50 bpm)
- Postural hypotension (fall in systolic BP lying to standing 20 mmHg +)
- Dehydration
- Hypothermia (temp. under 35o C oral)
- Electrolyte abnormalities (eg. hypokalaemia, hypernatraemia)
- Severe weight loss (30%+ of pre-morbid weight)
