Eating Disorders

Question 0

Insight in anorexia nervosa

Answer 0

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

Question 1

Common eating disorders

Answer 1

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

Question 2

Transtheorectical model of change in AN

Answer 2

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

Question 3

Cognitive features of anorexia nervosa

Answer 3

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

Question 4

Cognitive strategies in AN

Answer 4

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

Question 5

Progression of disease

Answer 5

Root causes - family tensions, relationship, practical issues

Honeymoon phase - initial praise, poss admiration

Late phase - illness, concerns, social isolation and hospitalisation

Question 6

Clues for engaging with an ambivalent client

Answer 6

Identify who made them come/who they are here to please

Discuss this persons concerns, then move try to move to their own concerns

Question 7

Physical complications of AN

Answer 7

Stopping periods Problems sleeping
hirsutism Loss of libido
reduced stamina and fainting Bladder dysfunction
Brain shrinkage Osteoporosis

Question 8

Psychological complications of AN

Answer 8

Low mood Poor concentration
Irritability Anxiety
Obsessions and compulsions Preoccupation with food

Question 9

Social and personal complications of AN

Answer 9

Disinterest and detachment Antisocial or criminal behaviour
Fear of public eating Stigma or alienation
Frustration Family problems

Question 10

Prevalence of psychiatric co-morbidity in AN

Answer 10

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

Question 11

Structural brain changes in AN

Answer 11

Significant Brain shrinkage during acute phase

Decreased grey matter restored after weight gain

Question 12

Osteoporosis in AN

Answer 12

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

Question 13

Reproductive problems in AN

Answer 13

Cessation of periods
Pre-pubertal AN can lead to multifollicular ovary
Intrauterine growth restriction in babies of anorexic mothers

Question 14

Senile purpura in AN

Answer 14

Large, sharply outlined purple red lesions appearing on the dorsum of the arm or backs of hands
More common in the elderly

Question 15

Skin changes in AN

Answer 15

Senile purpura
Erythema ab igne
Acrocyanosis

Question 16

Erythema ab igne

Answer 16

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

Question 17

Acrocyanosis

Answer 17

Persistent blue discolouration in the extremities
Similar to raynaud’s but constant
Due to peripheral shut down during starvation

Question 18

Medical emergencies from malnutrition in AN

Answer 18

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

Question 19

Biochemical signs of malnutrition

Answer 19

Raised or abnormal LFTs,
Low Na, K or glucose
Abnormal FBC particularly low Hb,WBC and platelets

Question 20

Procedure for investigating a query AN patient

Answer 20

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

Question 21

Investigations for a confirmed AN patient

Answer 21

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

Question 22

Risk assessment of a patient with AN

Answer 22

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

Question 23

Additional concerns with a new AN patient

Answer 23

Is there binge eating (binge-purge or restrictive)

Are there any co-morbidities, addictive or antisocial behaviours?

Question 24

Subtypes of anorexia nervosa

Answer 24

Restrictive - classical AN, with extreme and dangerous calorie restriction
Binge-purge - calorie restriction with food binges. Differs from BN in psychological basis/BMI

Question 25

Bulimic patients are

Answer 25

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

Question 26

Mental basis of BN

Answer 26

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

Question 27

Personal and environments factors leading to BN

Answer 27

Lack of intimacy in relationships worsened by secretive behaviours
Impulsive or antisocial behaviours followed by disgust and self hate

Question 28

Psychological state in BN

Answer 28

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

Question 29

Binge-purge cycle

Answer 29

Eat loads intermittently and then purge using induced vomiting, laxatives or diet pills.
Commonly this is associated with secrecy, lying or criminal behaviour

Question 30

Physical symptoms of BN

Answer 30

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

Question 31

Mental basis of binge eating disorder (BED)

Answer 31

Depressive, impulsive or compulsive and post traumatic symptoms common
Binge eating as comfort/coping mechanism and purging or fasting as a control point

Question 32

Physical symptoms of BED

Answer 32

Weight gain
Stomach pains 
Irregular periods
Poor skin
Insomnia

Question 33

Psychiatric co-morbidity in BN

Answer 33

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

Question 34

Assessment for query BN

Answer 34

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

Question 35

Physical signs of BN

Answer 35

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

Question 36

Prognosis for BN and BED

Answer 36

Treatments are effective in 50% of patients
Few die from disorder, can from psychological co-morbidity and suicide
20% develop a chronic eating disorder

Question 37

Diagnostic criteria for AN

Answer 37

BMI under 17.5 –> under 15 is high risk

Hormonal dysfunction and loss of periods in girls

Question 38

Prevalence of eating disorders

Answer 38

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

Question 39

SCOFF

Answer 39

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?

Question 40

Physiological complications of malnutrition

Answer 40

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

Question 41

Re-feeding syndrome

Answer 41

After World War Two

Sudden drop in phosphate due to sudden re-feeding after restriction.

Question 42

Thyroid tests in eating disorders

Answer 42

Important differentials
People can abuse thyroid supplements to lose weight
People can get hypo-thyroid post eating disorders

Question 43

Motivational interviewing

Answer 43

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