Eating Disorders Flashcards
Insight in anorexia nervosa
When patients are acutely ill they lack insight
Don’t believe they are ill, are pro-anorexia
Very resistant to treatment
Treatment prompted by family, often forcefully treated
Common eating disorders
Anorexia nervosa (AN) - BMI physical complications of starvation Bulimia nervosa (BN) - binge and purge, with preoccupation and craving Binge eating disorder (BED) - binge and preoccupation only
Transtheorectical model of change in AN
Pre-contemplation–> does not see a problem
Contemplation–> ambivalent, part wants to change, part resistant
Preparation–> ready to make plans, leading to decision
Action–> made a start
Maintenance–> resisting relapse
Cognitive features of anorexia nervosa
Body image distortion is not essential, absent in 20% of patients
Overvaluing of emancipated state/ obsession with fatness.
Occasionally strict rules/rituals or compensatory behaviours
Depressive compulsive and PTSD symptoms
Cognitive strategies in AN
Distractions - rituals applied to food to distract from eating
Magical thinking/detail obsessions - calories from smells etc
Implementations - if I eat more, then I must run more etc
Progression of disease
Root causes - family tensions, relationship, practical issues
Honeymoon phase - initial praise, poss admiration
Late phase - illness, concerns, social isolation and hospitalisation
Clues for engaging with an ambivalent client
Identify who made them come/who they are here to please
Discuss this persons concerns, then move try to move to their own concerns
Physical complications of AN
Stopping periods Problems sleeping
hirsutism Loss of libido
reduced stamina and fainting Bladder dysfunction
Brain shrinkage Osteoporosis
Psychological complications of AN
Low mood Poor concentration
Irritability Anxiety
Obsessions and compulsions Preoccupation with food
Social and personal complications of AN
Disinterest and detachment Antisocial or criminal behaviour
Fear of public eating Stigma or alienation
Frustration Family problems
Prevalence of psychiatric co-morbidity in AN
80% have a H/O depression, and 50% a major affective disorder
1/4 obsessive compulsive disorder and 1/3 social phobia
25% of restrictive AN are cluster C, while 40% of binge-purge subtype are cluster B personality types
10-20% of B-P AN have co-morbid alcohol or drug problems
Structural brain changes in AN
Significant Brain shrinkage during acute phase
Decreased grey matter restored after weight gain
Osteoporosis in AN
Related to duration and severity of weight loss
Return to normal weight with regular periods can increase bone mineral density by 10%, and adolescents have a better prognosis
Oestrogen is ineffective but IGF produces short term improvement but long term benefit unclear
Reproductive problems in AN
Cessation of periods
Pre-pubertal AN can lead to multifollicular ovary
Intrauterine growth restriction in babies of anorexic mothers
Senile purpura in AN
Large, sharply outlined purple red lesions appearing on the dorsum of the arm or backs of hands
More common in the elderly
Skin changes in AN
Senile purpura
Erythema ab igne
Acrocyanosis
Erythema ab igne
Patches of reticulated, hyper pigmented, and scaly skin
Commonly caused by prolonged,high heat exposure to the skin (hot water bottle rash)
Found due to cold intolerance in AN patients
Acrocyanosis
Persistent blue discolouration in the extremities
Similar to raynaud’s but constant
Due to peripheral shut down during starvation
Medical emergencies from malnutrition in AN
Fits, coma or cardiac arrhythmias
Become worried if hypotensive or significant postural drop, difficulty standing up unaided
Look for petechial rash,ulcers or abnormal muscle tone
Biochemical signs of malnutrition
Raised or abnormal LFTs,
Low Na, K or glucose
Abnormal FBC particularly low Hb,WBC and platelets
Procedure for investigating a query AN patient
Detailed eating and weight history with collateral account
Bloods–> low WBC and Hb is common
Low K and HCO3 suggests binge-purge subtype, low urea suggests low protein intake, likely restrictive
Once diagnosis confirmed perform further tests
Investigations for a confirmed AN patient
Bone scan–> osteoporosis is common and severe
ECG–> QT prolongation and u waves are common
ESR–> useful to rule out other problems if diagnosis not certain
Risk assessment of a patient with AN
Moderate risk –> BMI0.5kg/week, BP 10mmHg postural drop, HR 110, temp BMI1.0kg/week, BP 20mmHg postural drop, HR 120, temp <34.5 degrees
Additional concerns with a new AN patient
Is there binge eating (binge-purge or restrictive)
Are there any co-morbidities, addictive or antisocial behaviours?
Subtypes of anorexia nervosa
Restrictive - classical AN, with extreme and dangerous calorie restriction
Binge-purge - calorie restriction with food binges. Differs from BN in psychological basis/BMI
Bulimic patients are
Generally easier to treat when they present as more motivated with greater insight.
Harder to identify because of less clear physical signs and secretive behaviours
Risk at risk medically, but significant self harm risk
Mental basis of BN
Overvalued ideas of weight and body shape with compulsive checking and ritualisation of eating
Cycles of purges as safety behaviours to correct for binging
Depressive or post-traumatic symptoms are common
Personal and environments factors leading to BN
Lack of intimacy in relationships worsened by secretive behaviours
Impulsive or antisocial behaviours followed by disgust and self hate
Psychological state in BN
Feeling out of control due to compulsive behaviours, obsessed with food and weight
Emotional and depressed
Frequent mood swings
Intense cravings for food, or substitutes
Binge-purge cycle
Eat loads intermittently and then purge using induced vomiting, laxatives or diet pills.
Commonly this is associated with secrecy, lying or criminal behaviour
Physical symptoms of BN
Sore throat, bad breath and teeth and stomach pain due to vomiting
Irregular periods, poor skin, dehydration or fainting and kidney or bowel problems
Insomnia
Mental basis of binge eating disorder (BED)
Depressive, impulsive or compulsive and post traumatic symptoms common
Binge eating as comfort/coping mechanism and purging or fasting as a control point
Physical symptoms of BED
Weight gain Stomach pains Irregular periods Poor skin Insomnia
Psychiatric co-morbidity in BN
Lifetime rates of depression/anxiety 35-70%
20-30% alcohol and substance misuse in clinical, but not community samples
37% post traumatic stress
Borderline personality disorder common
Assessment for query BN
Detailed history, identifying the presence, frequency, severity and consequences of bulimic behaviours
Examine the oral cavity, vital signs, weight and height
Blood sample for FBC, urea & electrolyte
Physical signs of BN
Parotid or submandibular salivary gland enlargement
Eroded teeth
“Russell’s sign” - callus on back hand from inducing vomiting
Cold blue hands, nose and feet (acrocyanosis)
Lanugo (downy) hair
Prognosis for BN and BED
Treatments are effective in 50% of patients
Few die from disorder, can from psychological co-morbidity and suicide
20% develop a chronic eating disorder
Diagnostic criteria for AN
BMI under 17.5 –> under 15 is high risk
Hormonal dysfunction and loss of periods in girls
Prevalence of eating disorders
35% of boys and 45% of girls display sub-clinical eating disorder trait
1% AN, more culturally constant
2-3% BN, 1 to 10 girls to boys, more culturally dependant
SCOFF
S - sick - do you ever make yourself sick cause you feel too full?
C - control - do you think you lack control over your eating?
O - Have you ever lost more than 1st on 1 month?
F - Do you feel that food dominates your thoughts?
F - Do you feel your fat, even if people think you are not?
Physiological complications of malnutrition
Hypotensive
Bradycardia –> tachycardia can often come on before a crisis
Pancytopenia (bone marrow shut-down)
B12 and thiamine can drop causing sensation changes
Potassium changes are common and dangerous, don’t replace too fast –> start with oral replacement
Re-feeding syndrome
After World War Two
Sudden drop in phosphate due to sudden re-feeding after restriction.
Thyroid tests in eating disorders
Important differentials
People can abuse thyroid supplements to lose weight
People can get hypo-thyroid post eating disorders
Motivational interviewing
First Used in addiction
Assumes that patient wants to get better –> based on the
Aims to help patient move through stages towards recovery
OARS -> open questions, affirmation, reflection, recovery
