Eating Disorders Flashcards
What kind of person is likely to have an eating disorder?
Perfectionist, high achieving young women with low self esteem
What age do eating disorders start at?
16-22
What are components to the aetiology of ED?
Genetic
Personality (perfectionist, low self esteem)
Personal history (obesity, child abuse, traumatic life event)
Family (overprotective, overbearing, poor boundaries)
Societal pressures
What conditions to eating disorders overlap with?
Depression
Anxiety
OCD
What are the 4 KEY clinical presentations of anorexia nervosa?
BMI <18.5 (or 15%lower than expected)
Deliberate WL
Distorted body image
Endocrine dysfunction
How do AN patients cause deliberate WL?
Restricted eating (counting calories, avoid fatty foods)
Purging (vomiting, laxatives)
Increase energy expenditure (excess exercise e.g. 10k runs every day)
Dangerous medications
What kind of dangerous medications could an ED pt take for WL?
What about diabetics?
appetite suppressant thyroxine diuretic stimulant Diabetics may SKIP insulin to prevent fat deposit
What kinds of endocrine dysfunction occur in AN?
HPA dysfunction > amenorrhoea, erectile dysfunction, loss of libido
No secondary sex characteristics if prepubertal
Low insulin
High cortisol
Altered TFT
What are systems you need to look into for symptoms of AN (starvation)
General Neuro Cardio GI Haem Endocrine MSK
What are general symptoms of starvation
Emanciation Dehydration Short stature Lethargy Cold intolerance Cold peripheries Hypothermia Infection (from weak immunity) Dry skin, brittle hair and nails Lanugo hair Peripheral oedema (LOW ALBUMIN) Hypercholesteraemia Hypercarotenaemia (yellow skin)
What are Neuro symptoms of starvation?
Peripheral neuropathy
Cognitive defects
Delirium
Coma
What are cardio sx of starvation?
Bradycardia hypotension mitral valve dysfunction cardiafc failure syncope sudden death
What are GI sx of starvation?
constipation abdo pain bloating (delayed gastric emptying) Reflux Malnutrition > deficiency diseases
What are endocrine sx of starvation?
delayed/arrested puberty
Amenorrhoea
Erectile dysfunction, loss of morning erections
ow libido
infertility (ovarian, testicular atrophy)
Hypothyroidism
What are haematological sx of starvation?
Anaemia
Leukopoenia
Thrombocytopoenia
Pancytopoenia
What are symptoms of purging?
Dehydration Russell sign (knuckle calluses/cuts from induced self vomiting) Dental caries Mallory weiss tear Gastric rupture
What are differentials for AN?
Organic:
- Endocrine - Hyperthyroidism, T1DM, Addison’s
- malignancy
- chronic infection (TB, HIV)
- GI disease (coeliac, Chron’s)
Affective (depression/BPAD)
Anxiety (GAD, OCD with food avoidance)
Psychosis (persecutory - someone is trying to steal my food)
ASD
Body Dysmorphic Disorder
What are differentials for BED?
Depression (atypical, with overeating)
Organic - Kluver Bucy (hyperrhagia, hyper sexuality), Prader WIlli
Investigations for AN
BMI SCOFF questionnaire SUSS (sit up squat stand) test Bloods (FBC, U&E, ESR, TFT, LFT, CK, K+. PO43-. Na ) ECG Dexa, pregnancy test if indicated
Why would you check CK=?
To see if patient has been exercising
Why would you check Na?
Because it is low in patients who waterload
They have raised ICP > cerebral oedema >death
How do you manage anorexia nervosa?
Psychotherapies
- Motivational interviewing
- Family therapy
- Interpersonal therapy
- CBT
Medical treatment (nutritional stabilisation on medical ward) using MARSIPAN guidelines
Treat other psych conditions
What are complications of AN?
Refeeding syndrome
What is refeeding syndrome?
Complication of establishing adequate food intake in patients who are starved
Why does refeeding syndrome occur?
During starvation, body switches from carb to fatty acid / amino acid metabolism > insulin secretion is suppressed
During refeeding, if there is sudden increase in glucose, insulin secretion resumes
There is a rapid increase in basal metabolic rate
Electrolytes (K, Mg, PO - already low) are rapidly moved from blood to IC stores
This causes severe electrolyte depletion > arrhythmia > death
What does refeeding syndrome present as?
LOW phosphate, magnesium, potassium
Thiamine deficiency
Salt and water retention
How do you know if a patient with AN needs to be admitted?
Use MARSIPAN guidelines
- BMI <13
- hypotension
- bradycardia
- hypothermic
- low muscle power (SUSS)
- blood test results (low Na, K)
- ECG with long QT
What is bulimia nervosa?
4 KEY presentations
binge eating with compensatory behaviour and overvalued ideas about ideal body shape
- BINGE EATING
- PURGING
- BODY IMAGE DISTORTION
- BMI >18.5
what is binge eating?
Repeated bouts of overeating
Irresistible cravings, lose control (eat large amount with urgency and compulsion)
How do you treat BN?
Treat medical complications
SSRI (reduces bingeing by enhancing impulse control)
Treat comorbid psych illness
What questionnaire can you do for anorexia and bulimia
SCOFF questionnaire
Explain the SCOFF questionnaire
S: Do you make yourself Sick because you feel uncomfortably full
C: Do you ever worry you have lost Control on how much you eat
O: Have you ever lost more than One stone (6kg) in 1 month
F: Do you believe yourself to be Fat when others say you are thin
F: Do you think that Food dominates your life
When doing an electolyte/blood test in anorexia, what things are low and what things are high
Most things are LOW
HIGH Cs and Gs:
- Cortisol
- Cholesterol
- Carotinaemia
- GH
- Glucose
- Salivary glands
How do you manage anorexia nervosa
- Psycho education: advise on nutrition and health
- Treat co-morbid psych illness - depression, OCD, substance misuse
- Nutritional management, weight restoration - set realistic weight gain target, set eating plan
What kind of anorexia specific psychotherapies are available for AN in adults
Offer one of 3:
CBT-ED
MANTRA: Maudsley AN Treatment in Adults
SSCM: Specialist Supportive Clinical Management
What is CBT ED
addresses control, low self esteem, perfectionsism 40 sessions (once weekly)
what is MANTRA
Maudsley AN Treatment in Adults
Helps patient understand what is causing the anorexiaa and focus on 3hat is important to the patient
20 sessions
What is SSCM
Specialist Supportive Clinical Management
- explores the main problems that cause andorexia
- educate about nutrition and how different eating habits cause symptoms
20 sessions
What are therapies for AN in children
- Family therapy
2. CBT
what other general therapies are good to consider for AN
motivational interviewing
interpersonal therapy
How does family therapy for AN work
some sessions alone
other sessions with family
In extreme cases, how can you enforce feeding?
Mental health act
What kind of referrals can you do for AN
REFER ALL PTS WITH ED TO SPECIALIST TEAM IMMEDIATELY
Severe: urgent referral to Community Eating Disorder Service
Moderate: routine referral to CEDS
Mild: support for 8 weeks, reccomend BEAT, refer to CEDS if no improvement
What charity is good for AN
BEAT
What kind of self help programme can you give for BN
BN focused guided self help programme for adults
What is the general plan for BN for adults
- self help programmee 4 weeks
- CBT-ED
- Consider trial of high dose fluoxetine for impulse control
