Eating disorders

Question 1

Describe anorexia nervosa

Answer 1

Anorexia nervosa (AN) is an eating disorder characterised by low body weight, intense fear of gaining weight, and a body image disturbance.

Question 2

What is the diagnostic criteria for anorexia nervosa?

Answer 2

1. Weight loss, or in children a lack of weight gain, leading to a body weight of at least 15% below the normal
2. The weight loss is self-induced by avoidance of “fattening foods”.
3. A self-perception of being too fat, with an intrusive dread of fatness
4. A widespread endocrine disorder involving the hypothalamic-pituitarygonadal axis, manifest in the female as amenorrhoea, and in the male as a loss of sexual interest and potency (an apparent exception is the persistence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill).

There is also a persistent lack of recognition of the seriousness of current low body weight

Question 3

Who is most commonly affected by anorexia nervosa ?

Answer 3

Females - typically mid-adolesnece (from puberty to adulthood)

Question 4

If anorexia nervosa occurs before puberty has occurred how does it affect pubertal development in girls and boys?

Answer 4

• If onset is pre-pubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea
• In boys the genitals remain juvenile).
• With recovery, puberty is often completed normally, but the menarche is late.

Question 5

What 2 conditions is anorexia nervosa (this is simply anorexia) linked too and why ?

Answer 5

• Linked to autism and OCD
• Anorexia is about maintaining control so associated with these conditions

Question 6

Along with the diagnostic criteria for anorexia nervosa what symptoms might a patient also experience ?

Answer 6

• Fatigue and weakness
• Poor concentration
• Fainting
• Constipation
• Orthostatic hypotension
• Bradycardia
• Arrhythmias due electrolyte imbalances or decreased heart size
• Dehyration
• Hair loss
• Fractures

Question 7

What are the 2 subtypes of anorexia nervosa and describe them ?

Answer 7

1. restrictive subtype - no episodes of binge eating or purging, weight loss achieved by dieting, fasting &/or excessive exercise
2. Binge-eating/purging type - recurrent episodes of binge eating or purging behaviour i.e. self induced vomiting or the misuse of laxatives, diuretics, or enemas

When underweight individuals with anorexia nervosa also engage in bingeing and purging behavior the diagnosis of anorexia nervosa supercedes that of bulimia.

Question 8

How is the level of severity of anorexia nervosa assessed?

Answer 8

BMI

Question 9

Do having a family member who is affected by anorexia nervosa increase the risk of having anorexia nervosa ?

Answer 9

Yes - 50-75% heritability, 10 x risk in affected families

Question 10

What are some of the ways in which people with anorexia nervosa try to control their weight ?

Answer 10

• Decrease the amount of food being eaten, skipping meals
• Over-excercising
• Induced vomiting (this is in reference to someone eating a normal or reduced amount and then vomiting)
• Abuse of laxatives, diuretics or diet pills
• Sometimes can have episodes of binge-eating followed by remorse and vomiting

Question 11

What is a good a mnemonic for remember questions to ask a patient with suspected anorexia nervosa ?

Answer 11

SCOFF

1. Do you ever make yourself sick because you feel too full ?
2. Do you worry that you’ve lost control over eating ?
3. Have you recently lost more than one stone in 3 months ?
4. Do you believe you are fat even though others tell you, you are thin ?
5. Does food dominant your life ?

Question 12

What is the treatment of anorexia nervosa ?

Answer 12

Structured eating plan and dietary advice and support (unless severe i.e. BMI <15 with evidence of system failure where you would then admit and refeed) + psychotherapy

May have co-morbid conditions e.g. depression or OCD which require their own treatment

Psychotherapy for adults:

• 1st line = individual eating disorder CBT (CBT-ED)
• other options include MANTRA and SSCM

Psychotherapy for children and young people:

• 1st line = anorexia nervosa focused therapy for children and yuong people (FT-AN)
• 2nd line = CBT-ED or adolescent focused psychotherapy for anorexia nervosa (AFP-AN)

Question 13

What is refeeding syndrome and when do you have to be wary about it ?

Answer 13

This is potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial feeding (enterally or parenterally), hallmark of this condition is hypophosphataemia but need to also monitor glucose, K+ and Mg2+ levels

Be wary of it in someone with anorexia nervosa

Question 14

What are the signs and symptoms of refeeding syndrome ?

Answer 14

• Renale failure
• Respiratory failure
• Cardiac failure
• Decreased BP
• Arrhythmias
• seizures
• coma
• sudden death

Give away would be if someone develops any of these who was malnourished and then received refeeding treatment

Question 15

How is refeeding syndrome risk reduced ?

Answer 15

Question 16

What are some of the risk factors for eating disorders in general ?

Answer 16

• Perfectionistic
• eager to please others
• sensitive to criticism
• self-doubting/ low self esteem
• Lack of close friends/bullying
• Academic pressure
• adverse life events

Question 17

What is the main 4 criteria for bulimia ?

Answer 17

Recurrent episodes of over-eatng (at least two times per week over a period of three months) in which large amounts of food (larger than what most people would eat) are consumed in short periods of time.

Persistent preoccupation with eating and a strong desire or a sense of compulsion to eat (craving)

The patient attempts to counteract the fattening effects of food by one or more of the following:

1. self-induced vomiting;
2. self-induced purging; laxatives, over exercise
3. Alternating periods of starvation; use of drugs such as appettite suppressants, thyroid preparations or diuretics.

A self-perception of being too fat, with an intrusive dread of fatness (usually leading to underweight - but this distrubance of symptoms does not occur exclusively during episodes of anorexia nervosa so can be normal weight with these symptoms good for differentiating the 2)

Question 18

What are some of the specific risk factors for bulimia ?

Answer 18

• Being female and esp Asians
• Homosexuality, bisexual
• Linked to ADHD and substance misuse

Question 19

What 2 signs is strongly linked to bulimia ?

Answer 19

1. Dental carries (erosion of enamel)
2. Calluses on backs of hands (Russells sign)

Question 20

What is the treatment of bulimia nervosa ?

Answer 20

• CBT
• Nutritional and meal support
• Anti-depresants - SSRI e.g. fluoxetine (reduce binging and purging)
• Treat other co-morbidities if necessary

Question 21

What is the criteria for binge-eating disorders?

Answer 21

Recurrent episodes of binge eating.

An episode of binge eating is characterised by both of the following: –

1. Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
2. A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop eating or control what or how much one is eating).

The binge eating episodes are associated with three or more of the following:

1. eating much more rapidly than normal
2. eating until feeling uncomfortably full
3. eating large amounts of food when not feeling physically hungry
4. eating alone because of feeling embarrassed by how much one is eating
5. feeling disgusted with oneself, depressed or very guilty afterward
6. Marked distress regarding binge eating is present
7. Binge eating occurs, on average, at least once a week for three months

Not associated with the compensatory methods to compensate for overeating, such as selfinduced vomiting.

Question 22

What is the key difference between bulimia and binge eating disorders?

Answer 22

Binge-eating disorders are not associated with the recurrent use of inappropriate compensation behaviours e.g. vomiting, purging, periods of starvation, diuretics etc

Question 23

What is the treatment of binge-eating disorders ?

Answer 23

• CBT
• Nutritional and meal support
• Treat co-morbidities if necessary e.g. depression