Eating disorders Flashcards
What is the scoff questionnaire and what other screening questions can you ask for eating disorders?
S – Do you ever make yourself SICK because you are uncomfortably full?
C – Do you ever worry you’ve lost CONTROL over how much you eat?
O – Have you recently lost over ONE stone of weight in a 3-month period?
F – Do you believe yourself to be FAT when others say you are too thin?
F – Would you say that FOOD dominates your life?
- Do you think you have an eating problem?
- Do you worry excessively about your weight?
How common is anorexia nervosa?
• 1 in 250 females, 1 in 2000 males - may be higher (disguised symptoms)
What is the mortality rate in anorexia nervosa?
• Highest mortality rate of any psychiatry condition (1 in 5 deaths from AN are suicide, others mostly are cardiac arrest)
What are risk factors for anorexia?
• Sociodemographic
10:1 F:M
wealthier socioeconomic groups, models, gymnasts and dancers.
Average onset = 15-16 years, (rare after 30)
strongly related to occidental values such as individualism and the idealisation of thinness and ‘beauty’ for which reason it is sometimes considered to be a culture bound syndrome.
• Biological
16x risk if present in 1st degree relative
o ?genetic and social
• Psychological/psychiatric/medical factors
Anorexia nervosa has sometimes been considered as a struggle for control and identity as a form of escape from the emotional problems of adolescence.
What is the DSM V criteria for anorexia?
o BMI ,18.5
o Core psychopathology
Fear of fatness
Pursuit of thinness
Body dissatisfaction
Body image distortion
Self-value based on weight and shape
• Other common sx/behaviours
• Refusal to maintain weight at more than 85% of expected
• Widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis
o Amenorrhoea in women
o Sexual dysfunction & disinterest in men
• Delayed or arrested puberty (if early onset)
Important patients with AN DO NOT have suppression of appetite, if they do think organic
What CVS symptoms can you get in starvation?
- Bradycardia
- Hypotension
- Sudden death - low K+/Mg+ - prolonged QTc
- Mitral valve prolapse
What renal symptoms can you get in starvation?
- Oedema
- Electrolyte abnormalities (low)
- Renal calculi
- Renal failure
What GI symptoms can you get in starvation?
- Parotid swelling
- Delayed gastric emptying
- Nutritional hepatitis
- Constipation
What MSK symptoms can you get in starvation?
- Osteoporosis
- Pathological fractures
- Short stature
- Muscle cramps
What Endocrine symptoms can you get in starvation?
• Amenorrhoea (low oestrogen from reduced
adipose tissue)
• Infertility
• Hypothyroidism
What haematological symptoms can you get from starvation?
- Anaemia
- Leukopenia
- Thrombocytopenia
What neuro symptoms can you get in starvation?
- Generalised seizures
* Confusional states
What metabolic symptoms can you get in starvation?
- Impaired temp regulation
- Hypoglycaemia
- Impaired glucose tolerance
- Increased growth hormone and cortisol
What Dermatological symptoms can you get in starvation?
- Lanugo hair (thin soft downy unpigmented hair)
* Brittle hair and nails
What CVS features can you get in binge/purge/bulaemia?
• Arrhythmias – prolonged QTc Torsades de
pointes
• Cardiac failure
• Sudden death
What renal features can you get in binge/purge/bulaemia?
- Severe oedema
- Electrolyte abnormalities
- Renal calculi
- Renal failure
What GI features can you get in binge/purge/bulaemia?
• Parotid swelling (chipmunk face) • Constipation • Dental erosion • Oesophageal erosion/perforation • Mallory-Weiss tear • Dehydration (secondary to laxative use) • Metabolic alkalosis (vomiting leads to loss of Hydrochloric acid)
What MSK features can you get in binge/purge/bulaemia?
- Osteoporosis
* Pathological fractures
What endocrine features can you get in binge/purge/bulaemia?
• Oligomennorrhoea/amenorrhoea
What haematological features can you get in binge/purge/bulaemia?
• Leukopenia/lymphocytosis
What neuro features can you get in binge/purge/bulaemia?
- Generalised seizures
* Confusional states
What metabolic features can you get in binge/purge/bulaemia?
- Impaired temp regulation
* Hypoglycaemia
What derm features can you get in binge/purge/bulaemia?
• Calluses on dorsum of hands
Russel’s sign
What investigations should be done in eating disorders?
• BMI • Bloods FBC, U&E, phosphate, glucose, CK, LFTs • Stand up squat tests proximal myopathy • Blood pressure erect and supine • Pulse • Core body temperature • ECG if BMI < 16 or QT prolonging drugs in use o Most deaths are due to cardiac arres o Look for bradycardia (<40bpm) T wave changes (hypokalaemia) U waves (hypokalaemia) QTc prolongation
Which blood tests can come back high in eating disorders?
Most things LOW EXCEPT FOR G’s and C’s • Growth hormone • Salivary Glands • Creatine kinase • Cortisol • Cholesterol • Carotenemia (excess beta-carotene, yellow discolourisation of the skin)
What can re-feeding syndrome show as on bloods?
↓ Phosphate ↓ Magnesium ↓ Calcium ↑ LFTs ↓ K+
What is PREDIX and what does it show?
asseses physical risk in eating disorders
What is the biological management of anorexia?
• Little evidence for drugs, none licensed - food is best medication
• Establish good relationship for refeeding
o Gradual safe increase working with dietician
o Aim for 3000 balance calories a day
o Small meals and snacks
• Monitor for refeeding syndrome
o Risk of sudden death - arrhythmia, confusion, convulsions, cardiac arrest
- Treat any associated medical or psychiatric conditions
- Feeding against will with NG tube = LAST RESORT
describe how refeeding syndrome works
During fasting body switches fuel source from carbs to fatty acids/ketones
o When carbs reintroduced insulin levels rapidly rise and carb metabolism resumes which requires phosphates, magnesium and potassium
o Those with little intake will have low phosphates, magnesium and potassium
o Therefore gets rapidly used up - acutely low electrolyte state
o So if very little intake there is high risk of refeeding syndrome
What is the psychological management of anorexia?
• Patient and family education o Carers must be firm but supportive o CBT, CAT, IPT, family therapy New therapy called MANTRA which is specific for AN has everything Social - family therapy
What are your differential diagnoses for anorexia?
• Other psychiatric disorders
o EDNOS, bulimia nervosa, body dysmorphic disorder, depressive disorder, OCD, social phobia, conversion disorder, schizophrenia and personality
• Secondary to medical disorders
o endocrine disorders such as diabetes mellitus, diabetic ketoacidosis, hyperthyroidism, Graves disease and Addison’s disease; from gastrointestinal disorders such as gastroenteritis, IBD, malabsoption and intestinal obstruction; chronic renal failure, chronic anaemia, chronic infections, neoplasm and pregnancy.
What is the prognosis in anorexia?
- Prognosis is very variable and a younger age of onset and a short history are important positive prognostic factors.
- One fifth of sufferers recover completely but another fifth experience chronic, severe illness.
- The remainder make a recovery of sorts but retain abnormal eating habits and sometimes become bulimic.
- The long term mortality from suicide and from the complications of starvation is about 15% (higher than any other mental disorder)
- Prognosis worse if fast weight loss (>1kg a week)
What is bulimia nervosa?
Bulimia nervosa is a syndrome characterized by repeated bouts of overeating and an excessive preoccupation with the control of
body weight, leading the patient to adopt extreme measures so as to mitigate the “fattening” effects of ingested food.
what is the epidemiology of bulimia?
• 10:1 F:M
• more common than anorexia nervosa
o 1 in 50 females
o 1 in 500 males
• It is also commoner in models, gymnasts, dancers and male homosexuals.
• Typical onset = teens/early 20s
• More common in occidental or occidentalised societies that promote individuality and idealise thinness and beauty.
• Many bulimia suffers also have a history of anorexia nervosa
o Interval between 2 disorders ranges from few months to several years
• Premorbid obesity is common
o Also history of affective disorders, personality disorders, anxiety, substance misuse and Hx of abuse
o Or FH of obesity
What are tge ICD criteria for bulimia?
- Recurrent episodes of overeating (at least 2x/week over a period of 3 months) in which large amounts of foods consumed over short periods of time
a. Binge can be thousands of calories - There is a persistent preoccupation with eating, and an irresistible craving for food
- The patient attempts to counteract the ‘fattening’ effects of food by one or more of the following
a. self-induced vomiting
b. purging
c. alternating periods of starvation
d. use of drugs e.g. appetite suppressants, thyroid preparations or diuretics or other strategies.
i. may see drug S/E or OD - N.B. diabetic patients may neglect their insulin treatment (diabteitcs particulary at risk with hypoglycaemia)
- The psychopathology consists of a self-perception of being too fat and a morbid dread of fatness.
What are binges?
loss of control followed by intense guilt, NB only small amount of food is not a true binge eg 5 grapes more likely restrictive AN
What is the core psychopathology in bulimia?
- Fear of fatness
- Pursuit of thinness
- Body dissatisfaction
- Body image distortion
- Self-value based on weight and shape
What symptoms do patients describe before the onset of bulimia?
- The onset of bulimia is typically preceded by a period of dietary restriction.
- The patient often complains of fatigue, bloating, flatulence, constipation, abdominal pain and menstrual irregularities.
- Depressive symptoms are more prominent than in anorexia.
What is the Management for bulimia?
• Education and psychological therapies as for AN
o Support the patient and alter disturbed perceptions of the self.
o BN: Family therapy is the best for children/ adolescents, CBT for adults
- SSRIs have been demonstrated to have a specific antibulimic effect at higher doses, so consider prescribing an SSRI such as fluoxetine 60mg daily.
- Monitor and treat assoc physical and mental disorders.
What is the prognosis in bulimia?
better than in anorexia nervosa, not least because bulimia sufferers are keener to seek and accept help (egodystonic)
What is EDNOS?
- Subthreshold disorders that don’t meet diagnostic criteria for AN/BD
- Or, Binge Eating Disorder
Do you do anything differently in EDNOS than in anorexia/bulimia?
no
