Eating Disorders Flashcards
Eating Disorder
Disturbance of Eating Habits or Weight-Control Behaviour that results in
Clinically Significant Impairment of Physical Health or Psychosocial Functioning
o Highest Mortality of any psychiatric disorder, notoriously difficult to engage and treat
o Unclear whether increased presentations due to true increase or increased diagnosis
• 5 – 7% Life-time Risk for women, 2.5% for men in the developed world
Eating Disorder Presentation
Presentation frequently to other services e.g. Gastro, Gynae, A+E
Eating Disorder Classification
Classified either as Anorexia Nervosa, Bulimia Nervosa, and Atypical versions of both
o Transdiagnostic Theory – Suggests all eating disorders share same characteristic
psychopathology; Spectrum of symptoms; Majority of patients exhibit behaviours
from both at different times
Epidemiology of Anorexia
Prevalence 0.5 – 1% young females and 0.1% young males; Onset average 15 – 17yrs in women and 12 – 13 men also can present at any age
Features of Anorexia Nervosa
Characterised by Low Body Weight, Amenorrhoea, Distorted Body Image and Intense Fear of Weight Gain; Significant Heterogeneity in presentation
o Key features of Excessive Concern over Shape and Weight, with Relentless Pursuit of Thinness; Often, initial presentation is with physical symptoms of starvation
Features of Anorexia Nervosa: Food Habits
• Limited Intake, Avoidance of Carbohydrates and Fats; Food diary is best method for data
o Frequently entire diet of fruits and vegetables, and calorie free fluids
o Daily Calorie Limits, Eating Alone at particular times of the day, extremely slowly,
Elaborate Rituals pertaining to eating; Excessive gum or cigarettes as suppressants
• Most are preoccupied with thoughts of food; Some will enjoy cooking complex meals or cakes
for others but refuse to eat any themselves
o Up to half will have episodes of uncontrollable overeating (=Bingeing, Bulimia);
Followed by remorse and intensified efforts to lose weight
• Patients might develop fears that calories might enter through various everyday situations
Features of Anorexia Nervosa: Other Methods of Weight Loss
Various Methods to lose weight – Self-induced Vomiting, Laxative Abuse (E.g. Senna, Bisacodyl), Excessive Exercise, etc
Core Psychopathy of Anorexia Nervosa
Core Psychopathy – Disturbance of Body Image despite evidence of the contrary; Fear/Hatred
of Fatness, Valuation of Self-worth through Weight and Body Shape (Overvalued Idea)
o Associated also with Preoccupation/Obsession, Overchecking, Denial of Severity, Low-Esteem, Perfectionism; Low Mood (which might be a symptom of Starvation), Social Withdrawal, Deliberate Self-Harm and Suicide (most frequent mode of death); OCD
Physical Consequences of Anorexia Nervosa
Emaciation, Constipation, Dry Skin/Brittle Nails, Hypotension/Bradycardia, Lanugo hair, Eroded Teeth Enamel, Osteoporosis, Stone Disease, Peripheral Neuropathy Amenorrhea/Infertility, Reduced Libido
o Amenorrhoea occurs early in development of condition; 1/5 amenorrhoea before
obvious weight loss; Prepubertal hormonal patterns
o Hypokalaemia, Hypophosphataemia, Metabolic Alkalosis; Arrhythmia from Electrolyte
Imbalance; Hypoglycaemia, Hypercortisolaemia, Anaemia/Pancytopaenia
o Peripheral Oedema; Can progress to Pulmonary Oedema and Congestive HF
Diagnosis of Anorexia
• Refusal to maintain weight ≥ normal for age/height (BMI 17.5, or Ideal Weight 85%)
• Intense Fear of Weight Gain or Obesity; Disturbance in experience of weight/shape, Undue influence on self-evaluation or denial of seriousness
• Amenorrhoea at least 3 cycles if appropriate
• DSM defines either Restricting Type vs Bingeing or Purging Type – Self-induced vomiting,
Over-exercise, Laxative/Diuretic/Enema misuse
Anorexia Comorbidities
Depressive Disorder, Deliberate Self-Harm in 40-60%; Also, OCD, BDD, Sleep
Disorders, Anxiety Disorders, Chronic Fatigue
Ddx for Anorexia
• Bulimia – Uncontrolled Overeating, Compensatory Methods and Fear of becoming fat;
Distinct based on weight criteria (C/f Anorexia Nervosa Binge-Purge Subtype)
• Atypical Bulimia/Anorexia =EDNOS; Does not meet complete criteria
• Mood Disorder – Without specific psychopathology or weight control behaviours
• Substance Abuse – Low BMI due to neglect but no other characteristics
Iatrogenic Causes of Low Weight
E.g. SSRIs, Stimulants, Slimming medications (E.g. Orlistat, Sibutramine)
Organic Disorders of Low Weight
IBD, Coeliac, Chronic Panc, Hyperthyroid, DM,
Insulinoma, Hypothalamic Tumours, Dementia, Chronic Degenerative Conditions, Cancer
Klein-Levin Syndrome
Adolescent Males; Binge-eating and Hypersomnia
Aetiology of Anorexia: Complex Genetic Inheritance
- Complex Genetic Inheritance (8× Risk if relatives); Many have positive family history
- Rarely might have organic causes e.g. Hypothalamic lesions; Interestingly, Widening of Sulci and Ventricular Enlargement occurs (reversed on weight gain)
Aetiology of Anorexia: Organic
Rarely might have organic causes e.g. Hypothalamic lesions; Interestingly, Widening of Sulci
and Ventricular Enlargement occurs (reversed on weight gain)
Aetiology of Anorexia: Serotonin Dysregulation
Although Meta-analysis for RCTs in SSRI for Anorexia shows not to
be of benefit in reducing core psychopathology
Aetiology of Anorexia: Zinc Deficiency
– Leads to loss of appetite; Use in management is controversial
Aetiology of Anorexia: Personality
– Obsessive-Compulsive, Perfectionism, Personal Restraint, Anxious
Aetiology of Anorexia: Parental
Extension of abnormal concern onto children; Also, dietary restriction; Abnormal
beliefs might be carried into later life
Aetiology of Anorexia: Previous Adverse Experience
Sexual Problems (Often male; loss of libido that occurs with weight loss) and Childhood Sexual Abuse (1/3 of patients)
Aetiology of Anorexia: Social
Overprotective/Rigid/High Expectations Parenting, Societal Pressures (Non-causal, but may help reinforce abnormal beliefs)
Aetiology of Anorexia: Precipitating Factors
Bereavement, Divorce, Change in
Environment/Circumstances, Academic Stress, Serious Physical
Illness, Bullying and Abuse etc
Maintaining Factors in Anorexia
• Starvation – Odd Eating Behaviours, Obsession with Food,
Excessive Exercise
• Ongoing Precipitating Factors
• Denial – Impossible for illness to recede unless accepted
• Transdiagnostic Model of Eating Disorders
• Ingrained part of identity; Benefits of sick-role
Course of Anorexia
- Often fluctuant with periods of partial remission early
- Most sensitive predictor of poor outcome is long history at first presentation; Other factors include BMI<14, older age onset, Bingeing-Purging, Personality, Relationship Difficulties, Male
- 1/3 make full recovery; 1/3 severely ill; 1/3 have partial recovery (improved weight, menstrual function; But some continue with abnormal eating habits, some become overweight and some might develop Bulimia)
- Mortality 0.5% per year; Complications from Starvation account for 50% of deaths, with Suicide making majority of other half (and single biggest cause in Anorexia)
Assessment of Eating Disorders: History
• SCOFF Screening – Sick, Control, One Stone, Fat, Food
• Diet Behaviour – Restraint, Patterns, Rituals, Avoidance and Restriction, Experience of Hunger and Urge to eat, Fasting, Ability to eat in front of others
o Weight, Fluctuations, Amenorrhoea
• Thoughts – About Body, Weight, Fatness, Specific Body Parts
o What do you think would happen if you did not control your eating/weight?
• Bulimic Behaviour – Bingeing (Planning, Frequency, Starting and Ending) and Purging
(Method, Haematemesis, Washing out)
• Use of Adjuncts – Laxatives, Diuretics, Emetics, Appetite Suppressants
• Exercise – Ask about typical weekly schedule and motivation
• Psychiatric History – Focussed onto problems at Home, Work, School, Depressive symptoms,
Obsessive-Compulsive symptoms, Previous Diagnosis,Treatments, Hospitalisations, Complications from Eating
Disorders, Medications, Personality, Pre-morbid Personality,
Family History and Social Situation
Assessment of Eating Disorders: Physical Exam
Weighing in underclothes after having used toilet
(Consider dipstick for Specific Gravity); Calculate BMI, Perform Stand-squat test, Signs of regular vomiting – Swollen Parotids,
Dentition, Callouses on Dorsal Knuckles
Assessment of Eating Disorders: Psychological Tests
EDE-Q, Also PHQ9, Beck Depression Scale,
Hospital Anxiety and Depression Scale etc
Investigations in Eating Disorders
- FBC, U/Es (Hypokal, Hypophos, HypoMg, Hypochlor), TFTs (Hyper or Hypo), LFTs (Bili, Enzymes), Lipids (Increased Cholesterol), Cortisol (Increased), Sex Hormones (Decreased)
- ABG – Metabolic Alkalosis in Vomiting, Metabolic Acidosis in Laxatives
- ECG – Prolonged QT; Flattened T waves in Hypokalaemia
- Urinalysis – Reduced Specific Gravity in Water loading; Blood Glucose – Low
- DEXA – Osteopaenia or Osteoporosis
Risk in Eating Disorders
- Main risks are Starvation, Deliberate Self-Harm and Suicide; Psychosis, change in mental state
- Risk when Driving if very low BMI, Poor Concentration or Episodes of Hypoglycaemia
- BMI<14, Rapid Loss, Arrhythmia, Hypotension, Electrolyte Disturbance, Anaemia and GI Bleeding (Mallory-Weiss); Admit also if refusal to engage or failure of outpatient
Management of Eating Disorders
• Lack of good evidence about treatment and
management; Mainly clinical experience; Success
depends on good relationship between patient and
healthcare team
• Key Goal to reach healthy body weight/BMI, and
weight gain is key to supporting other
Psychological, Physical and QOL changes
• Choice of Setting – Majority effectively as
Outpatients; Admission If High Physical Risk, High
Risk of Suicide or Deliberate Self-Harm; Significant
change while on outpatient treatment or failure of
outpatient management
o Day patient programme as an alternative
to inpatient care – Supported meals,
Individual and Group Psychotherapy,
Physical Monitoring, Dietary Advice,
Medication management, Family Therapy
Nutritional Rehab
• Refeeding and Target Weight (0.7 – 1kg per week
inpatient, 0.5kg per week outpatients; 1200 –
1500kcal per day and titrated to 3000
• Supplements to increase caloric intake once normal diet re-established; Eating should be supervised; Reassurance that eating will not risk losing control of weight, to be firm about
agreed targets, and ensure patient does not hide food, or have bulimic behaviours
• Exercise – Short walks whilst underweight; Gradually increased once target weight is achieved
Refeeding Syndrome
Carbohydrate suddenly provided; Shift from Fat to Carbohydrate Metabolism; Insulin increases leading to Phosphate uptake and Electrolytes
o Main features are Hypophosphataemia, Hypokalaemia, Hypomagnesaemia,
Hypoglycaemia and Thiamine Deficiency
o Low Phosphate can lead to Confusion, Coma, Fits and Sudden Death
o Sudden Fluid Shift can lead to increased work of the heart, causing Acute HF; Oedema should be monitored daily
o Electrolytes checked regularly; Supplementation include Vitamins as appropriate
Psychological Treatment of Anorexia
• Psychoeducation for all patients, Self-Help
• Individual CBT-ED – 40 weekly sessions with twice weekly initially; Aims to reduce risk to
physical health and encourage healthy eating; Covers nutrition, cognition, mood regulation,
body image and self-esteem, Relapse prevention; Includes Homework and Self-monitoring
o Examine and Tackling Behaviours that Patients have used to reduce weight;
Correction of incorrect or abnormal beliefs about Weight, Shape, Food etc
o Replace negative, unrealistic thoughts with positive, realistic ones
o Motivational Interviewing might motivate patient and identify any existing
perpetuating factors in pro-anorexia
o Considers Psychological problems e.g. Low Self-Esteem, Perfectionism, Interpersonal
Relationships and Family Issues
Maudsley Anorexia Nervosa Treatment for Adults
o Family based therapy; Only treatment to have definite effectiveness; Children and
Adolescents; Helpful adjunct in adults as well
o Phase 1 – Parents urged to take control; Patient has no input and is expected to
consume all food without eating disordered behaviours
o Phase 2 – Child starts to take more control over eating again; General Family issues
and Relationship problems dealt with
o Phase 3 – Treatment focussed on developing normal relationship with body; Working
on issues such as Perfectionism and Low Body weight; Adjusting to normalcy
If Psychotherapy is ineffective
Eating-Disorder Focussed Focal Psychodynamic Therapy (Patient-centred Focal Hypothesis, addressing Pro-Anorexic and Ego-Syntonic Beliefs)
When to offer dietary counselling
Only offer dietary counselling as part of MDT – Encourage Multivitamin supplementation,
include family in education/meal planning for younger people
Consider Family Therapy for younger people
Pharmacotherapy for Eating Disorders
• Majority do not require medications and no evidence for use of any specific drugs
• Treatment of Comorbid Depression, OCD, Anxiety disorders, starting with SSRIs
• Low dose Olanzapine, Quetiapine in severe depressed patients who continue to resist food
although no convincing evidence
• Insomnia – Avoid Benzodiazepines or Z drugs other than few days; Consider Sedating
Antidepressant (e.g. Mirtazapine) instead
Compulsory Treatment
• Section 3 of MHA (2007) – Up to 6 months of Treatment; Many initially admitted convert to
voluntary status as mental state improves
• Typically – Severe Emaciation, Long standing Illness, Outright rejection of treatment
• Majority of Anorexia death occur in patients treated involuntarily at some point
Bulimia Nervosa Epidemiology
• 1 – 2% of women 15-40yrs; Recurrent Episodes of Excessive Eating, Compensatory Methods
of Weight Control and Fear of Becoming Fat; NB: BMI >17.5 (otherwise =Anorexia Nervosa)
Bulimia Nervosa Features
o Diet-Binge-Purge cycle; Binges might be triggered or unprovoked; Binges tend to
occur when patient is at home and alone (due to embarrassment and disgust)
o Self-induced Vomiting is the most common method; Can progress to inducing
vomiting after normal meals rather than just after Bingeing
o Other methods e.g. Laxatives, Diuretics, Excessive Exercise
Bulimia Nervosa Psychopathology
Overconcern over Weight and Shape; Fear and Avoid Fatness; Low Self
Esteem and similar perfectionist traits as Anorexia; Depressive symptoms in nearly all;
Negative Cognitions, Shame, Embarrassment; Insight into consequences (C/f Anorexia)
o Suicide and Deliberate Self-Harm, ETOH and Drug Abuse
o Might meet Diagnostic Criteria for Emotionally Unstable (Borderline) PD
Physical Consequences of Bulimia Nervosa
• Bodyweight is Normal in most Bulimics
• Repeated purging – Hypokalaemia leading to weakness, Arrhythmia, Renal Damage; Metabolic Alkalosis and Hypochloraemia can occur
o Also causes Parotid Swelling, Dental Enamel Erosion, Russell’s sign, Mallory-Weiss
• Use of Laxatives and Diuretics – Fluid shifts, Hyponatraemia, Metabolic Acidosis
Diagnosis of Bulimia Nervosa
- Recurrent Episodes of Binge Eating (Larger amount of food than most in a fixed period of time; Lack of control over eating during episode)
- Recurrent Inappropriate Compensatory Behaviour (Self-Induced Vomiting, Misuse of Laxatives, Diuretics, Medications, Fasting, Excessive Exercise)
- Self-evaluation unduly influenced by Shape and Weight
- Symptoms at least averaging twice weekly for at least 3 months
- Purging vs Non-purging type (6 – 8% who use Exercise or Fasting instead)
Differential Diagnosis for Bulimia
• Anorexia Nervosa – While binges might also be present in Anorexia (Needs to be for Bulimia),
Low body-weight of BMI<17.5
• Similar Differential to Anorexia Nervosa
• Iatrogenic Drugs that increase appetite/weight gain – Antipsychotics, Lithium, Steroids
• Organic Disorders that cause vomiting – E.g. Upper GI disorders, Brain Tumours
MANGEMENT OF BULLIMIA NERVOSA
• 98% Outpatient; Primary care based monitoring
• Admission considered for High Suicide and Self-Harm risk, Physical Complications, Pregnancy
(High risk of Miscarriage if actively purging), Refractory cases
• Psychoeducation similar to Anorexia Nervosa; Self-Help available; If does not respond to Self-
Help in 6 – 8 weeks, referred for formal CBT
CBT for Bulimia Nervosa
80% improvement in frequency of binges but 20% drop out; Better
evidence base and results compared to Pharmacotherapy and treatment of Anorexia
o Stage 1: Education about treatment and condition, Engagement of patient, Establish
regular eating and weekly weights; Self-Monitoring of Intake, Compensatory
Behaviour, Emotions
o Stage 2: Review and Identification of main problems that need to be addressed
o Stage 3: Identify and correcting maintain factors, Plan for further work at home,
problem solving skills for setbacks and problems
Interpersonal Psychotherapy
Helps patients overcome current interpersonal problems; Not
focussed for eating disorders
o Found to be as effective as CBT, but takes several months to produce effect
Pharmacotherapy
SSRIs, TCAs, MAOI equally effective; First-line Fluoxetine at higher doses
(e.g. 60mg) although effect is not dose dependent
o 50% reduction in Bingeing and Purging, 20% stop altogether
o No evidence for multiagent pharmacotherapy; Switch agent instead
Obesity
Accumulation or presence of excess body fat to the extent that it may impair health; While not a psychiatric disorder, treatment with Behavioural Approach similar to other eating
disorders and adding Cognitive dimension to therapy improves outcomes
Obesity Aetiology
20% of the UK; F>M; Most can be attributed to Genetic factors exacerbated by social factors;
Dietary, Sedentary Lifestyle, Medical, Iatrogenic and Psychiatric Causes
Obesity Aetiology: Psychological
Obesity is more common if significant levels of Anxiety, Depression and Low Self Esteem; Might have distorted body image in few although core psychopathology different from eating disorders
Obesity Aetiology: Social
Lower SES in developed countries, opposite in developing; More common in
Urban areas and if malnourishment in early life
Obesity Assessment
Assessment focuses on identifying physical
and psychological causes, Adverse consequences of Obesity, and Motivation,
Lifestyle, Personal History and Preferences
o FBC, U/Es, LFTs, ECG and
Diabetes/IHD Screen (Fasting Glucose, HbA1c, Lipids)
Management of Obesity
Low Calorie, Low Fat, Low Carbohydrate and
High Protein Diets all lead to 2 – 4kg loss over 3-6 months; Aim 600kcal below maintenance energy needs to achieve sustained loss of 0.5kg/week; Advised to not go beyond <1000kcal for more than 12 weeks
o 5% body weight quite easily through dieting, and another 5% if determined
o Exercise is good adjunct but usually not enough to enhance loss by much
Management of Obesity: Self Help
Education about causes and guiding Lifestyle and Diet modifications; Usually for
overweight (rather than obese) who are highly motivated
Management of Obesity: Pharmacotherapy
Orlistat (Lipase Inhibitor); BMI >28 with co-morb or >30, and only continued for >3/12 if weight loss of at least 5% body weight
o Recommended only considered after Dietary, Exercise and Behavioural Approaches tried, or failed to reach target weight
Management of Obesity: Surgery
Only for severely obese who have not lost weight through Behavioural or Pharmacotherapy; Issues with Anaesthetic and Fitness for Surgery
o E.g. Gastric Banding, Gastric Bypass; Weight loss usually rapid, with large amounts lost in 2 years following surgery
o Often Nausea and Vomiting, and need to take multivitamin supplementation
