Eating disorders

Question 1

3 major types of ED in ICD10

Answer 1

1. Anorexia
2. Bulimia nervosa
3. EDNOS- eating disorder not otherwise specified

Question 2

Binge eating disorder

Answer 2

-currently falls under EDNOS

Question 3

Diagnosis stability

Answer 3

• patients migrate from one to other very often

- 1/4-1/3 of those with bulimia have a past history of anorexia

Question 4

Amenorrhoea

Answer 4

• DSM-5 have eliminated the requirement for amenorrhoea
• most people with BMI of 17.5 are amenorrhoeic with body image disturbance. Those with periods still have the same clinical features and outcome

Question 5

Bulimia binges

Answer 5

• DSM5 criteria is for once weekly frequency of binge eating and inappropriate compensatory behaviour
• amount of food intake during a binge is 1000 to 2000 kcals
• patients with bulimia engage in treatment better as they feel they have lost control

Question 6

Epidemiology of anorexia

Answer 6

• onset mostly in adolescents
• excess in higher social class
• 0.5-1% prevalence in teenage girls
• 19/100000 females per year

Question 7

Epidemiology of bulimia

Answer 7

• onset mostly in young adults- later onset than anorexia
• even class distribution
• 1-2% prevalence I n16-35 age group
• 29/100,000 females a year

Question 8

Comorbidity

Answer 8

• 65% patients with anorexia have depression
• 34% have social phobia
• 26% have OCD

Question 9

Aetiology

Answer 9

• shared family liability
• personality traits
• substance missuse is increased in the families in bulimic patients
• obsessive and perfectionist traits are increased in families of anorexic probands

Question 10

Anorexia heritability

Answer 10

• MZ twins 55%

- DZ twins 5%

Question 11

Bulimia heritability

Answer 11

• MZ 35%

- DZ 30%

Question 12

Risk factors for ED

Answer 12

• female sex, adolescence and early adulthood
• western cultural adaptation
• family history of ED, depression, substance missuse, alcohol and obesity
• adverse parenting
• childhood sexual abuse
• critical comments about eating, shape or weight from family
• occupational and recreational pressure to be slim
• low self-esteem and perfectionism
• past history of obesity (BN)
• early menarche (BN)

Question 13

Binge eating disorder

Answer 13

• recurrent episodes of binge eating in the absence of extreme weight control behaviour
• associated with obesity- 5-10% of obese patients
• present in 40s ,more males than in other EDs (25%)
• high degree of spontaneous remission is seen
• stress associated overeating is common
• CBT and self help can help

Question 14

Physical symptoms of EDs

Answer 14

• increased sensitivity to cold
• GI symptoms
• dizziness and syncope
• amenorrhoea, low sexual appetite, infertility
• poor sleep with early morning wakening

Question 15

Physical signs of EDs

Answer 15

• emaciation: stunted growth and failure of breast development (if prepubertal onset)
• dry skin, lanugo hair, hypercarotenaemia
• Russel’s sign- calluses on knuckles due to vomit
• swelling of parotid and submandibular glands (BN)
• erosion of inner surface of front teeth (perimylolysis)
• cold hands and feet; hypothermia
• bradycardia (HR of40 is common)
• orthostatic hypotension, cardiac arrhythmias
• hypotension
• dependent oedema
• weak proximal muscles- difficulty rising from squatting position

Question 16

Endocrine abnormalities

Answer 16

• low concentrations of LH, FSH and oestradiol
• low T3, normal T4, normal TSH
• mild increase in cortisol
• raised GH
• severe hypoglycaemia
• low leptin

Question 17

Cardiovascular abnormalities

Answer 17

• ECG abnormalities
• conduction defects
• prolonged QT
• Ipecac (emetic substance) contains emetine an alkaloid that can cause myopathy and fatal cardiomyopathy which may be reversible in early stages

Question 18

GI abnormalities

Answer 18

• delayed gastric emptying
• decreased colonic motility (secondary to chronic laxative missuse)
• acute gastric dilatation (rare, secondary to refeeding or binge eating)

Question 19

Haematological abnormalities

Answer 19

• moderate normocytic normochromic anaemia
• mild leucopenia with relative lymphocytosis
• thrombocytopenia

Question 20

Other metabolic abnormalities

Answer 20

• hypercholesterolaemia
• raised serum carotene
• hypophosphataemia (exaggerated during refeeding)
• dehydration
• electrolyte disturbance
• metabolic alkalosis and hypokalaemia due to vomiting
• metabolic acidosis, hyponatraemia and hypokalaemia in laxative missuse

Question 21

Other abnormalities in ED

Answer 21

• osteopenia and osteoporosis

- enlarged cerebral ventricles with external cerebrospinal fluid spaces (pseudoatrophy)

Question 22

Effect of ED on pregnancy

Answer 22

• decreased fertility- can be regained
• may have more abortions
• higher rates of hyperemesis gravidarum, anaemia and impaired weight gain
• compromised intrauterine foetal growth
• premature delivery is more likely
• rates of caesarians are higher
• post-natal complications and post-partum depression are higher
• associated with low birth weigh, microcephaly and low APGAR scores
• in actively anorexic mother, the neonate may have hypoglycemia

Question 23

Managing bulimia

Answer 23

• most effective treatment is CBT (needs 20 sessions over 5 months)
• 33-50% make complete recovery
• antidepressant drugs have an antibulimic effect, improve mood and decrease binge eating, but effect is often not sustained

Question 24

Managing anorexia

Answer 24

• cognitive analytic or CBT, interpersonal psychotherapy, focal dynamic therapy or family interventions
• requires engagemen
• weight restoration

Question 25

Chance of recovery in AN

Answer 25

• best chance of recovery if
  1. illness is present for less than 6 months
  2. no bingeing or vomiting
  3. have parents who cooperate and are willing to participate in family therapy