Eating disorders Flashcards
What is the aetiology of anorexia nervosa?
Biological:
Monozygotic twin concordance significantly higher than dizygotic twin
Neuro/endocrine changes (disturbance of hypothalamic function, increased serotonin levels, brain atrophy
Changes in brain normalise when weight is restored through regular intake of balanced diet
Psychological:
Perfectionism
Low self-esteem (weight loss as a sense of achievement)
Sexual development (early development)
History of abuse (sexual, physical, psychological, neglect)
Personality disorder
Social:
Theories include parental overprotection and family enmeshment. The young person with anorexia nervosa may be avoiding separation from family or becoming an independent sexual being.
What is the aetiology of bulimia nervosa?
Biological:
Changes in levels of serotonin
Monozygotic twin and dizygotic twin concordance rates broadly similar
Psychological:
Low self esteem
History of abuse (sexual, physical, psychological, neglect)
history of self harm
impulsive personality traits
personality disorder
High value placed on food and eating behaviour (either personally or within the family culture)
History of being over-weight (factual or perceived)
Social:
Exposure to culture of dieting
Family/ social culture of categorizing food as good or bad, healthy or naughty treat
What are the symptoms of anorexia nervosa?
Dry, brittle, thin hair and skin
Lanugo hair can grow over the skin on face and body to to aid warmth
Poor concentration, obsessions, interest entered around food, flattened effect, irritated, difficult decision making
BP drops, pulse declines, risk of heart arrhythmias, risk of heart failure
Osteopenia/osteoporosis
Lack of sex drive, amenorrhoea, low testosterone
Muscle wastage, cramp
Oedema feet and ankles, cold extremities, broken skin
What are other complications of anorexia nervosa?
hypothermia
infections
metabolic disturbance (hypoglycaemia, hyponatraemia, hypokalemia, vitamin deficiency, hypercholesterolaemia, deranged liver function)
haematological (iron deficiency anaemia, leucopenia and thrombocytopenia)
What are the symptoms of bulimia nervosa?
Poor concentration, irritability, seizures secondary to electrolyte imbalance
Tooth decay, horse voice, bleeding from mouth, swollen parotid glands
Hypokalaemia leads to cardiac arrhythmia
Constipation, delayed gastric emptying, oesophageal tears, rectal prolapse, renal failure, UTI
What are the other complications of bulimia nervosa?
dehydration
electrolytes imbalance
muscle paralysis
What is the DSM-5 criteria for anorexia nervosa?
BMI <17.5
Persistent restriction of energy intake leading to significantly low body weight
Either an intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain
Disturbance in the way one’s body weight or shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
What is the DSM-5 criteria for bulimia nervosa?
Recurrent episodes of binge eating, characterised by eating more than most would in a certain amount of time e.g. 2 hours or a sense of lack of control during an eating episode, unable to stop or to switch behaviour
Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting or excessive exercise
Binge eating and compensatory behaviours occur, on average, at least one a week for 3 months
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during episodes of anorexia nervosa
What is the biological management of anorexia nervosa?
Weight restoration
Input from Specialist Dietician
BMI >16: FBC, U&E, LFT & glucose
BMI <15: above and also phosphate, magnesium, calcium, creatinine kinase, zinc, B12 and folate
Dexa bone density scan if indicated
ECG, looking for QTc prolongation, rate<50, heart block or other arrhythmias
What is the psychological management of anorexia nervosa?
Motivational Interviewing, Cognitive Behavioural Therapy, Interpersonal therapy, Compassion Focused Therapy, Mindfulness, Arts Psychotherapy such as Dance Movement, Art and Drama and Cognitive Analytical Therapy Family Therapy (Systemic) is commonly used if the patient is under 18 years of age Evidence suggests therapeutic relationship being the most important factor in recovery Formal psychological therapy unlikely to be effective if below BMI 13 (inpatient admission for specialist treatment should be considered)
What is the biological management for bulimia nervosa?
SSRI (fluoxetine)
Advise cessation of laxative use
Advise cessation of excessive alcohol, planned and controlled reduction if physical dependence has occurred
Regular weight monitoring, frequency depends on severity
Regular blood monitoring, frequency depends on severity.
Most essential blood test is U&E, particularly to check for hypokalaemia, which can lead to severe effects on the heart, nerves and muscles
What is the psychological management of bulimia nervosa?
Psycho-education regarding coping mechanisms
Specialist services providing psychological therapy, 20 sessions of Cognitive Behavioural Therapy recommended by NICE.
Interpersonal Therapy, Compassion Focused Therapy, Mindfulness, Arts Psychotherapy such as Dance Movement, Art and Drama and Cognitive Analytical Therapy
Evidence suggests therapeutic relationship being the most important factor in recovery
Input from Specialist Dietician to give psycho-education on balanced eating
What is the social management of bulimia nervosa?
Advise to inform a loved one for extra support
Carer support
Focus on encouraging regular intake, cessation of restrict, binge, purge cycle
Increased involvement with social plans and lifestyle goals such as hobbies or vocation related goals
What is the prognosis for anorexia nervosa?
1/3 up to 3 years
another 1/3 3-6 years
recovery less likely after 15 years
After 10 years, 50% recovered, 10% mortality (1/3 due to suicide), 40% with ongoing eating problem (many cross-over to BN)
What are the poor prognostic factors for anorexia nervosa?
very low weight bulimic features family difficulties personality difficulties longer illness duration
