Eating Disorders

Question 1

What are the risk factors for developing an eating disorder ?

Answer 1

White females
16-22 years
High achieving perfectionists with low self esteem
Assoc with depression and substance misuse
10% of cases are male

Question 2

Is there a genetic component to eating disorders ?

Answer 2

Monozygotic twin concordance 65% in AN

Unlikely to be a genetic link in BN

Question 3

What is the psychological theory regarding the aetiology of anorexia nervosa?

Answer 3

Successful weight loss gives patient sense of autonomy and achievement during times when life feels uncontrollable.
Avoiding separation from family

Question 4

What is the sociocultural theory of the aetiology of anorexia nervosa?

Answer 4

Social pressures to be thin
Promotion of dieting
High risk groups:
Models, athletes, dancers

Question 5

What elements of family life might contribute to development of anorexia nervosa?

Answer 5

Parental overprotection

Family enmeshment: over involved, poor boundaries

Question 6

What factors may contribute to development of bulimia nervosa ?

Answer 6

Perfectionism and low self esteem
Promotion of dieting, pressure to be thin
History of obesity
Previous AN
Disturbed family dynamics 
Parental weight concern
High parental expectation
Fhx: obesity, depression, substance misuse

Question 7

What is the clinical presentation of anorexia nervosa?

Answer 7

BMI

Question 8

What are physical complications of anorexia nervosa?

Answer 8

Lethargy and cold intolerance
Anaemia/ leukopenia/ thrombocytopenia 
If severe = pancytopenia
Bradycardia, hypotension, arrhythmia
Constipation, abdo pain, ulcers, oesophageal tears, gastric rupture, delayed gastric emptying, nutritional hepatitis
Amenorrhoea, infertility, loss of libido
Osteoporosis, proximal myopathy
Peripheral neuropathy
Lanugo hair

Question 9

What might swollen submandibular a parotid glands indicate?

Answer 9

Anorexia or bulimia

Bingeing

Question 10

What investigations would you undertake in suspected anorexia nervosa?

Answer 10

Height, weight, BMI
Squat test
Bloods: ESR, TFTs to rule out organic causes
FBC, U+Es, phosphate, albumin, LFT, creative kinase, glucose to evaluate nutritional state and risk
ECG: bradycardia, Arrhythmias, long QT
Possible DEXA

Question 11

What organic causes might you want to rule out in apparent anorexia nervosa?

Answer 11

Hyperthyroidism
Malignancy
GI disease
Addison's 
Chronic infection 
Inflammatory conditions
AIDS

Question 12

What is EDNOS

Answer 12

An eating disorder not otherwise specified

Atypical presentation

Question 13

What is body dysmorphic disorder?

Answer 13

BDD
Distorted body image
Deliberate weight loss unusual

Question 14

What is Russell’s sign?

Answer 14

Calluses or cuts on knuckles from self induced vomiting

Question 15

What is melanosis coli?

Answer 15

Pigmentation of colonic mucosa

Seen with laxative abuse

Question 16

How are patients with anorexia managed?

Answer 16

Engagement: with early family involvement
Psycho-education: advice on nutrition and health
Treat comorbid psychiatric illness: depression, OCD, substance misuse
Nutritional management and weight restoration: negotiate realistic weekly weight gain target 0.5-1kg target weight and eating plan
Psychotherapy: motivational interviewing, family therapy, interpersonal therapy, CBT
Medical treatment: physical complications, rapid weight loss or BMI

Question 17

When might you consider inpatient treatment for anorexia nervosa?

Answer 17

BMI

Question 18

What clinical presentation is seen in bulimia nervosa?

Answer 18

Binge eating: irresistible cravings, loss of control, sense of desperate urgency + compulsion, triggered by distress
Purging: shame + guilt, vomiting, laxatives, episodes of fasting, excessive exercise
Body image distortion
BMI> 17.5

Question 19

What complications are associated with purges in bulimia nervosa?

Answer 19

Arrhythmias: hypokalaemia
Convulsions: hyponatraemia

Question 20

How are patients with bulimia nervosa managed?

Answer 20

Community based
Treat medical complications
SSRIS can reduce bingeing and purging by enhancing impulse control
Treat comorbid psych illness: depression, self harm, substance misuse
CBT

Question 21

What are the hallmarks of nutritional decompensation?

Answer 21

BMI1kg/wk
Purpuric rash
Cold peripheries
Core body temperature

Question 22

Why is establishing adequate food intake hazardous?

Answer 22

Refeeding syndrome: cause of mortality
Electrolyte imbalance:
Low PO4 Low K Low Mg
Due switch from fat to carbohydrate metabolism and secretion of insulin causing sudden intracellular electrolyte movement

Question 23

What is the prognosis with anorexia nervosa?

Answer 23

After 10 years:
50% no eating disorder
40% ongoing problems
10% have died (1/3 due to suicide)

Features of poor prognosis:
V low weight, bulimic features, later onset, longer illness duration.

Question 24

What is the prognosis with bulimia nervosa?

Answer 24

After 10 years:
70% recovered completely
29% ongoing problems
1% have dies

Poorer prognosis associated with: severe bingeing or purging, low body weight, comorbid depression

Question 25

What is the lifetime risk of eating disorders?

Answer 25

Anorexia nervosa: 0.6%
Bulimia nervosa: 1%
Binge eating disorder/ 2.8%