Eating Disorders Flashcards by Rachel Eggleton

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)

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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)

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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)

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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

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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

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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?

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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

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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

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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

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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

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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

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What is the impact on the endocrine system of:

1) Starvation
2) Bingeing / purging

1) Starvation
- Amenorrhoea
- Infertility
- Hypothyroidism

2) Bingeing / purging
- Oligomenorrhoea / amenorrhoea

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What is the impact on the haem system of:

1) Starvation
2) Bingeing / purging

1) Starvation
- Anaemia
- Leukopenia
- Thrombocytopenia

2) Bingeing / purging
- Leukopenia / lymphocytosis

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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

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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

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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

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What questionnaire is used as a screening tool for AN?

SCOFF

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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

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What should be included in a history of someone presenting with an eating disorder?

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 ```