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Psychiatry STG > Eating Disorders > Flashcards

Eating Disorders Flashcards

1
Q

Eating Disorder

A

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

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2
Q

Eating Disorder Presentation

A

Presentation frequently to other services e.g. Gastro, Gynae, A+E

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3
Q

Eating Disorder Classification

A

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

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4
Q

Epidemiology of Anorexia

A

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

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5
Q

Features of Anorexia Nervosa

A

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

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6
Q

Features of Anorexia Nervosa: Food Habits

A

• 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

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7
Q

Features of Anorexia Nervosa: Other Methods of Weight Loss

A

Various Methods to lose weight – Self-induced Vomiting, Laxative Abuse (E.g. Senna, Bisacodyl), Excessive Exercise, etc

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8
Q

Core Psychopathy of Anorexia Nervosa

A

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

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9
Q

Physical Consequences of Anorexia Nervosa

A

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

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10
Q

Diagnosis of Anorexia

A

• 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

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11
Q

Anorexia Comorbidities

A

Depressive Disorder, Deliberate Self-Harm in 40-60%; Also, OCD, BDD, Sleep
Disorders, Anxiety Disorders, Chronic Fatigue

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12
Q

Ddx for Anorexia

A

• 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

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13
Q

Iatrogenic Causes of Low Weight

A

E.g. SSRIs, Stimulants, Slimming medications (E.g. Orlistat, Sibutramine)

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14
Q

Organic Disorders of Low Weight

A

IBD, Coeliac, Chronic Panc, Hyperthyroid, DM,

Insulinoma, Hypothalamic Tumours, Dementia, Chronic Degenerative Conditions, Cancer

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15
Q

Klein-Levin Syndrome

A

Adolescent Males; Binge-eating and Hypersomnia

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16
Q

Aetiology of Anorexia: Complex Genetic Inheritance

A
  • 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)
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17
Q

Aetiology of Anorexia: Organic

A

Rarely might have organic causes e.g. Hypothalamic lesions; Interestingly, Widening of Sulci
and Ventricular Enlargement occurs (reversed on weight gain)

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18
Q

Aetiology of Anorexia: Serotonin Dysregulation

A

Although Meta-analysis for RCTs in SSRI for Anorexia shows not to
be of benefit in reducing core psychopathology

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19
Q

Aetiology of Anorexia: Zinc Deficiency

A

– Leads to loss of appetite; Use in management is controversial

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20
Q

Aetiology of Anorexia: Personality

A

– Obsessive-Compulsive, Perfectionism, Personal Restraint, Anxious

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21
Q

Aetiology of Anorexia: Parental

A

Extension of abnormal concern onto children; Also, dietary restriction; Abnormal
beliefs might be carried into later life

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22
Q

Aetiology of Anorexia: Previous Adverse Experience

A 
Sexual Problems (Often male; loss of libido that occurs with
weight loss) and Childhood Sexual Abuse (1/3 of patients)
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23
Q

Aetiology of Anorexia: Social

A

Overprotective/Rigid/High Expectations Parenting, Societal Pressures (Non-causal, but may help reinforce abnormal beliefs)

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24
Q

Aetiology of Anorexia: Precipitating Factors

A

Bereavement, Divorce, Change in
Environment/Circumstances, Academic Stress, Serious Physical
Illness, Bullying and Abuse etc

25
Q

Maintaining Factors in Anorexia

A

• 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

26
Q

Course of Anorexia

A
  • 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)
27
Q

Assessment of Eating Disorders: History

A

• 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

28
Q

Assessment of Eating Disorders: Physical Exam

A

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

29
Q

Assessment of Eating Disorders: Psychological Tests

A

EDE-Q, Also PHQ9, Beck Depression Scale,

Hospital Anxiety and Depression Scale etc

30
Q

Investigations in Eating Disorders

A
  • 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
31
Q

Risk in Eating Disorders

A
  • 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
32
Q

Management of Eating Disorders

A

• 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

33
Q

Nutritional Rehab

A

• 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

34
Q

Refeeding Syndrome

A

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

35
Q

Psychological Treatment of Anorexia

A

• 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

36
Q

Maudsley Anorexia Nervosa Treatment for Adults

A

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

37
Q

If Psychotherapy is ineffective

A

Eating-Disorder Focussed Focal Psychodynamic Therapy (Patient-centred Focal Hypothesis, addressing Pro-Anorexic and Ego-Syntonic Beliefs)

38
Q

When to offer dietary counselling

A

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

39
Q

Pharmacotherapy for Eating Disorders

A

• 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

40
Q

Compulsory Treatment

A

• 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

41
Q

Bulimia Nervosa Epidemiology

A

• 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)

42
Q

Bulimia Nervosa Features

A

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

43
Q

Bulimia Nervosa Psychopathology

A

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

44
Q

Physical Consequences of Bulimia Nervosa

A

• 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

45
Q

Diagnosis of Bulimia Nervosa

A
  • 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)
46
Q

Differential Diagnosis for Bulimia

A

• 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

47
Q

MANGEMENT OF BULLIMIA NERVOSA

A

• 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

48
Q

CBT for Bulimia Nervosa

A

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

49
Q

Interpersonal Psychotherapy

A

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

50
Q

Pharmacotherapy

A

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

51
Q

Obesity

A

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

52
Q

Obesity Aetiology

A

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

53
Q

Obesity Aetiology: Psychological

A

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

54
Q

Obesity Aetiology: Social

A

Lower SES in developed countries, opposite in developing; More common in
Urban areas and if malnourishment in early life

55
Q

Obesity Assessment

A

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)

56
Q

Management of Obesity

A

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

57
Q

Management of Obesity: Self Help

A

Education about causes and guiding Lifestyle and Diet modifications; Usually for
overweight (rather than obese) who are highly motivated

58
Q

Management of Obesity: Pharmacotherapy

A

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

59
Q

Management of Obesity: Surgery

A

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

Psychiatry STG (12 decks)

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