Eating Disorders Flashcards
Outline four types of eating disorder
1) Anorexia nervosa
2) Bulimia nervosa
3) Eating disorder not otherwise specified (ED-NOS)
4) Binge eating disorder (newly added to DSM-5)
Outline the diagnostic criteria of anorexia nervosa (AN) (3)
1) BMI equal to / <17.5 or <85% expected
2) Intense fear of gaining weight, or becoming fat, with persistent behaviour that interferes with weight gain
3) Feeling fat when thin
(Endocrine change such as reduced libido and amenorrhoea have been removed from DSM-5)
How common is AN in females and males?
What is the mean age of onset of AN in F and M?
F = 1/250 M = 1/2,000
F = 16-17yrs M = 12yrs
(Rare >30yr)
What is the aetiology of AN?
Genetics - first degree relative 16x risk
Cultural
Family pathology - overprotectiveness, lack of conflict resolution
Individual pathology - disturbed body image due to dietary problems in childhood / parental preoccupation with food
Outline some core psychopathology involved in AN
Fear of fatness
Pursuit of thinness
Body dissatisfaction
Body image distortion - the way they see themselves in the mirror is not representative
Self evaluation based on weight and shape - all beliefs about them being a good person come from body shape
What other psychiatric problems are related with AN? What is the relationship?
Depression
Anxiety and social phobia
Suicidal ideation
OCD symptoms / rigidity
Do these cause starvation or does starvation cause these?
What are some common behaviours in people with eating disorders?
Dieting Fasting Calorie counting Excessive exercise Water loading - to fill the stomach and try and ease the symptoms of hunger Ingesting - diet pills, water pills, thyroxine, appetite suppressants, laxatives Excessive weighing Body checking Culinary behaviours - often obsessed with good, planning meals, hrs looking at cook books or pictures of food Avoidance Isolation Binging / purging Misuse of insulin DSH / substance misuse
What is the impact on the CVS of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Bradycardia
- Hypotension
- QT prolongation
- Sudden death
2) Bingeing / purging
- Arrhythmias
- QT prolongation
- Cardiac failure
- Sudden death
What is the impact on the kidneys of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Oedema
- Electrolyte abnormalities
- Renal calculi
- Renal failure
2) Bingeing / purging
- Severe oedema
- Electrolyte abnormalities
- Renal calculi
- Renal failure
What is the impact on the GI system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Parotid swelling
- Delayed gastric emptying
- Nutritional hepatitis
- Constipation
2) Bingeing / purging
- Parotid swelling
- Dental erosion
- Oesophageal erosion / perforation
- Constipation
What is the impact on the skeletal system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Osteoporosis
- Pathological fractures
- Short stature
2) Bingeing / purging
- Osteoporosis
- Pathological fractures
What is the impact on the endocrine system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Amenorrhoea
- Infertility
- Hypothyroidism
2) Bingeing / purging
- Oligomenorrhoea / amenorrhoea
What is the impact on the haem system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Anaemia
- Leukopenia
- Thrombocytopenia
2) Bingeing / purging
- Leukopenia / lymphocytosis
What is the impact on the neuro system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Generalised seizures
- Confusional states
2) Bingeing / purging
- Generalised seizures
- Confusional states
What is the impact on the metabolic system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Impaired temperature regulation
- Hypoglycaemia
2) Bingeing / purging
- Impaired temperature regulation
- Hypoglycaemia
What is the impact on the derm system of:
1) Starvation
2) Bingeing / purging
1) Starvation
- Lanugo
- Brittle hair and nails
2) Bingeing / purging
- Calluses on dorsum of hand = Russell’s sign
What questionnaire is used as a screening tool for AN?
SCOFF
Outline the SCOFF questionnaire
1) Do you ever make yourself SICK because you feel uncomfortably full?
2) Do you ever worry you have lost CONTROL over how much you eat?
3) Have you recently lost more than ONE stone in a 3 month period?
4) Do you believe yourself to be FAT when others say you are too thin?
5) Would you say that FOOD dominates your life?
2 or more = likely to be AN or BN
What should be included in a history of someone presenting with an eating disorder?
Hx
- Ask about rapid weight loss (>1kg in a week)
- Ask about physical comorbitities
- Ask about CVS symptoms = chest pain, postural dizziness, palpitations, black outs
- Excessive exercise?
- Water loading?
- Haematemesis
- Pregnancy?
- Medication?
What should be included in a physical examination of someone presenting with an eating disorder?
BMI Pulse - irregular / bradycardia? BP - hypotension? Temp - hypothermia? Proximal myopathy ECG Bloods
Why is it important to do an ECG in someone presenting with AN? What changes might be seen?
80% of deaths in pt with AN are due to cardiac arrest
T wave changes due to hypokalaemia
Bradycardia
QTc prolongation
What electrolyte abnormalities are seen in starvation?
Hypoglycaemia
What electrolyte abnormalities are seen in vomiting?
Hypokalaemia
What electrolyte abnormalities are seen in water-loading?
Hyponatraemia
What electrolyte abnormalities are seen in laxative misuse?
Hyperkalaemia
Hyponatraemia
What electrolyte abnormalities are seen in diuretics misuse?
Hypokalaemia
Hyponatraemia
What electrolyte abnormalities are seen in thyroxine misuse?
Raised T3 / T4
Decreased TSH
What electrolyte abnormalities are seen in bone marrow hypoplasia?
Normocytic anaemia
Leucopenia
What electrolyte abnormalities are seen in refeeding syndrome?
Hypophopshpataemia
Hypomagnesaemia
Hypocalcaemia
Hypokalaemia
What electrolyte abnormalities are seen in proximal myopathy?
Raised CK
Raised LFTs
How is diseases severity classified in AN?
BMI:
<17.5 = AN
<15 = moderate risk
<13 = high risk
How is AN managed?
Usually as an outpatient but can be inpatient if severe
Aim to gain 0.5kg/week in community
Multivitamin supplementation
Nutritional rehabilitation and psychological intervention
- Guided self help via CBT = 1st line
Also IPT, psychotherapies and family support
Motivational enhancement
What does CBT focused on AN involve?
Increases awareness and responsibility of the condition
- Keep food diary
Structured eating
Identify and challenge beliefs
= Self guided (does not need to be managed by an eating disorder specialist)
What are the stages of changes used in motivational enhancement?
1) Pre-contemplation - unwilling to change
2) Contemplation - considering change
3) Determination - preparing to change
4) Action - implementing change
5) Maintenance - maintaining change
Either permanent exit or relaps
What motivational enhancement changes are offered in AN?
Usually 4-6 sessions
Find out what matters most to how the person feels about themselves and use this to motivate them to make a change
When counselling a pt with AN about diet and structured eating, what information may be given about carbohydrates?
Required at each meal with a view to stabilise blood sugars
When counselling a pt with AN about diet and structured eating, what information may be given about fats?
Dairy required 2x3 x daily to ensure appropriate calcium, vit D and phosphate
When counselling a pt with AN about diet and structured eating, what information may be given about protein?
Required with 2-3 meals in order for growth and repair to be appropriate eg immune system, skin integrity and tissue restoration
When counselling a pt with AN about diet and structured eating, what information may be given about fluid?
6-8 glasses / day
(30-35ml / kg) to ensure appropriate hydration levels
How sensitive and specific is the SCOFF questionnaire?
100% sensitive
87.5% specific (AN or BN)
What is the prognosis of AN?
Most common cause of death due to psychiatric disorder (approx 20%)
50% recover
30% improve
20 % chronic illness
risk of suicide = 10%
What is the average duration of illness of AN?
8yrs
What is bulimia nervosa (BN)?
1) Recurrent episodes of bingeing
- 2 / more / week for 3 months
2) Strong desire or compulsion to eat (craving)
3) Attempts to counteract the ‘fattening’ effects of food by one or more of:
- Self induced vomiting
- Self induced purging
- Alternating periods of starvation
- Use of drugs such as appetite suppressants, diuretics or thyroid preparations
4) Self-perception of being too fat, with feat of fatness
NB can be normal or overweight (unlike AN)
How common is BN?
1 / 50 F
1 / 500 M
Which wards may someone admitted with an eating disorder attend?
Specialist eating disorder unit
Gastro-enterology ward
Acute medical ward
General psych (do poorly here)
What pharmological management may be given in BN?
Fluoxetine (SSRI) 6-mg daily
AN hospital admission criteria
Low weight (≤85% and / or less than 3rd percentile BMI) Lack of any weight gain Significant oedema Physiological decompensation - Severe electrolyte imbalances - Cardiac disturbances - Altered mental status - Orthostatic differential great than 30 / min Temp <36 Pulse <45 Psychosis / high risk suicide Symptoms refractory to outpatient
