eating disorders Flashcards
sd
ICD-10
anorexia nervosa
bulimia
atypical anorexia
DSM-V
binge eating
ARFID
Other
disordered eating
acute food refusal
subtypes of AN
restirctive
binge eating/purging type
how to get/stay thin
- eat very little
- ignore hunger
compensatory behaviours
diabetics may restict insulin
compensatory mechanisms
purging behaviours
- self induced vomiitng
- laxative
- chewing and spitting food
standing
tensing muscles
- water loading - mask true weight, artifically infalted, do bloods look at Na level, go toilet before weighing
chewing gum
meds
- diuretics
- slimming aids
- levothyroxine
- insuln
- amphetamine like drugs
caffeine
reduced clothing. - shiver
calorie restriction
avoidance of certain foods/food groups
rules around eating
- eat less than others
never clear plate
dont eat in front of others
Bulimia nervosa define
recurrent over eating (bingeing)
preoccupation of eating at least 2 episodes per week for a period of 3 months
followed by compensatory weight loss behaviours and overvalued ideas regarding ‘ideal body shape/weight’.
types of BN
- Purging type: The patient uses self-induced vomiting and other ways of expelling food from
the body, e.g. use of laxatives, diuretics and enemas. - Non-purging type: Much less common. Patients use excessive exercise or fasting after a
binge. Purging-type bulimics may also exercise and fast but this is not the main form of
weight control for them.
what is a binge
eating within a discrete period of time within a 2 hour period an amount of food that is larger than most ppl would eat during a similar period of time
lack of control over eating during the episode - guilty, cannot stop
atypical AN nad BN
they have some features of AN or BN but the overall clinical picture does not justify that diagnosis
disorders which affect eating
vomit phobia
obsessive compulsive rituals - do not have time to eat, scared of germs
depression
other classified
avoidant restricitve food intake disorder
- sensory based avoidance
- distressing experience
- ass with ASD
- fear/anxiety
- inability to recognise hunger
pts avoid certain foods
unclassified ED
Eating Disorder - deliberately restricting food/fluid intake concerns over shape and weight
disordered eating - restrict eating/drinking
- > emotinal regualtion
- > self harming
- > communicating distress
- > acute food refusal
biological RFs for AN
predisposing
- female
- genetically inherited for both AN and/pr OCD
- early menarche
precipitating
- adolescence and puberty
perpetuating
- starvation leads to neuroendocrine changes that perpetuate anorexia
Ix for eating disorders
Bloods:
•Hormone: low LH, FSH & oestradiol
TFT – low T3, normal T4, normal TSH (low T3 syndrome)
raised cortisol and GH
•FBC:
- normocytic, normochromic anaemia.
- Potential low WCC and low platelets
•U&E’s:
- hypokalaemic (if vomiting)
- Potential hyponatraemia
- hypokalaemia (if using laxatives)
- Hypophosphataemia
- Hypomagnesemia
•Other: Hypercholesterolaemia
Potentially DEXA scan (usually organised by Eating Disorders team if necessary)
• ECG – potential for conduction defects, prolongation of QTc, consequences of electrolye abnormalities.
VBG - metabolic alkalosis (vomiting), metabolic acidosis (laxatives)
outpatient therapy
guided slef-help
mantra
cbt-e
sscm
CAMHS
Family based therapy
medical complications of eating disorders
degree of weight loss and th chronicity of the illness
MARSIPAN
managemnt of really sick pts under 18 w AN
refeeding syndrome
- Hormoral/electrolyte response on initiation of food after prolonged period of starvation.
- Insulin release is increased, leading to phosphate, potassium and magnesium being taken into cells (becoming intracellular) leading to potentially low levels of them in the circulating blood.
- U&E’s. Phosphate and Magnesium.
Sx of refeeding
oedema of ledgs/face/hands SOB N/V muscle weakness confusion hypertension rapid changes in body weight
characteristic features of refeeding
hypophosphotaemia
hypokalaemia
hypomagnaesaemia
hponatraemia
hypophosphotaemia
0.7-1.4mmol/L
clinical symptoms seen when conc fall below 0.3mmol/L
sx
weakness, anorexia, malaise, tremor, paraesthesia, seizures, acute respiratory failure, arrhythmia, altered mental status, hypotension
moderate - phosphate supplements
sever - sodium glycerophosphate
hpokalaemia
secodnary to self induced vomiting -> met alkalosis
<3 - paeds - iV correction
<2.5 - intensive monitoring - central venous access
<3
lassitiude
gen weakness and miscle pain
constipation
ECG
falt t eaves
st depression
prominent u waves
<2.5
severe muscle wekaness and paralysys - lower extremities resp failure illeus paraesthesia tetany
hyperkalaemia
peaked t waces
prolonged pR interval
widening of the QRS
hypocalcaemia levels
features
<1.1
tetany stridor seizures weakness av
features of anorexia nervosa
reduced BMI
Bradycardia
hypotension
enlarged salivary glands
physiological abnormalities of anorexia nervosa
G’s and C’s raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotinaemia
hypokalaemia low FSH, LH, oestrogens and testosterone raised cortisol and growth hormone impaired glucose tolerance hypercholesterolaemia hypercarotinaemia low T3
definition of anorexia nervosa
eating disorder characterised by deliberate weight loss, intense fear of fatness, distorted body image and endocrine disturbances
Psychological RFs of AN
predisposing
- sexual abuse
- preoccupation with slimness
- dieting behaviours starting in adolescence
- low self-esteem
- premorbid anxiety or depressive disorder
- perfectionism, obsessional/anankastic personality
precipitating
- criticism regarding eating, body shape or weight
perpetuating
-perfectionism, obsessional/anankastic personality
social RFs of AN
predisposing
- western society - pressure to diet
- bullying at skl revolving around weight
- stressful life events
precipitating
- occupational or recreational pressure to be slim ie ballet dancers, models
perpetuating
- occupation
- western society
ICD-10 criteria for anorexia nervosa
FEED
1. Fear of weight loss
2. Endocrine disturbances resulting in amenorrhoea in females and loss of sexual interest and potency in males
3. Emaciated (abnormally low body weight): >15% below expected weight or BMI <17.5
4. Deliberate weight loss with reduced food intake or increased exercise
Distorted body image
must be present for at least 3 MONTHS and must be the ABSENCE of recurrent episodes of binge eating or preoccupation with eating/craving to eat
other features that are not included in ICD-10
- physical: fatigue, hypothermia, brady, arrhythmias, peripheral oedema, headaches, lanugo hair
- preoccupation with food - dieting, preparing elaborate meals for other
socially isolated, sexuality feared
Sx of depression and obsessions
- lanugo hair
DDx for AN
- bulimia
- eating disorder not otherwise specified
- depression
- OCD
- schizophrenia
- organic causes of low weight - diabetes, hyperthyroidism, malignancy
- alcohol/substance misuse
Mx of AN
- Monitoring of weight & dietary counselling
- Vitamin and mineral supplementation
- Admission to hospital if physical health severely compromised.
Biological
- treatment of medical complications
- SSRIs for co-morbid depression/OCD
- aim as inpatient to gain 0.5-1kg/week and as an outpatient 0.5g/week
Psychological - for at least 6 months ADULTS
• individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
• specialist supportive clinical management (SSCM).
children and YOUNG PPL
- Anorexia focused family therapy FIRST LINE
CBT
- Psychoeducation about nutrition
- CBT
- cognitive analytic therapy
- interpersonaly therapy
- family therapy
Social
- voluntary organisations
- self help groups
how to prevent refeedign
measure serum electrolytes prior to feeding and monitor refeeding bloods daily, start at 1200kcal/day
- gradually increase every 5 days, monitor for signs such as tachycardia and oedema
complication of AN
hypothyroidism
Biological RFs of BN
predisposing Female sex Family history of eating disorder, mood disorder, substance misuse or alcohol abuse Early onset of puberty Type 1 diabetes Childhood obesity
precipitating
- early onset of puberty/menarche
perpetuating
- Co-morbid mental health problems
Psychological RFs of BN
Physical or sexual abuse as a child Childhood bullying Parental obesity Pre-morbid mental health disorder Preoccupation with slimness Parents with high expectations Low self-esteem
precipitating
Perceived pressure to be thin may come from culture (e.g. Western society, media and profession)
Criticism regarding body weight or shape
perpetuating
Low self-esteem, perfectionism
Obsessional personality
social RFs of BN
Living in a developed country Profession (e.g. actors, dancers, models, athletes) Difficulty resolving conflicts
Precipitating
Environmental stressors
Family dieting
Perpetuating
- environmental stressors
Features of BN
- Behaviours to prevent
weight gain (compensatory)
- self-induced vomiting, alternating periods of starvation
- drugs (laxatives, diuretics
- appetite suppressants, amphetamines, and thyroxine)
excessive exercise. NOTE: diabetics may omit or reduce insulin dose. - Preoccupation with eating
A sense of compulsion (craving) to eat which leads to bingeing. There is typically regret or shame after an episode. - Fear of fatness
Including a self-perception of being too fat. - Overeating
normal weight
depression and low self-esteem
irregualr periods
Signs of dehydration: blood pressure, dry mucous membranes, capillary refill time, skin turgor, sunken eyes.
Consequences of repeated vomiting and hypokalaemia
Hypokalaemia
A potentially life-threatening complication of excessive vomiting.
Low potassium (<3.5 mmol/L) can result in muscle weakness, cardiac arrhythmias and renal
damage.
Mild hypokalaemia requires oral replacement with potassium-rich foods (e.g. bananas)
and/or oral supplements (Sando-K).
Severe hypokalaemia requires hospitalization and intravenous potassium replacement.
DDx for BN
anorexia nervosa – with bulimic symptoms.
EDNOS (Eating Disorder Not Otherwise Specified).
Kleine–Levin syndrome: Sleep disorder in adolescent males characterized by
recurrent episodes of binge eating and hypersomnia.
Depression.
Obsessive–compulsive disorder.
Organic causes of vomiting, e.g. gastric outlet obstruction.
Mx of BN
Biological: A trial of antidepressant should be offered and can frequency of binge eating/ purging. - Fluoxetine (usually at high dose, 60 mg) is the SSRI of choice. Treat medical complications of repeated vomiting, e.g. potassium replacement. Treat co-morbid conditions
Psychological: Psychoeducation about nutrition, CBT for bulimia nervosa (CBT-BN is a specifically adapted form of CBT). Interpersonal psychotherapy is an alternative.
Social: Food diary to monitor eating/purging patterns, techniques to avoid bingeing (eating in company, distractions), small, regular meals, self-help programmes.
Risk Assessment for suicide
inpatient
- cases of suicide risk
- severe electrolyte imbalances
complications of AN
- Heart Failure
- Bradycardia/arrythmias
- mitral valve prolapse
- osteoporosis
- infertility
- anaemia/leucopenia
- wernicke encephalopathy/korsakoff
CVS - bradycardia, failure, hypotension, heart thinning
Skeletal - osteopenia/oesteoporosis
fractures
low electrolytes
GI
- mallory weiss tear
- constipation
liver failure
endocrine - amennorhoea
sick euthyroid syndrome
Signs of AN on examination
- Emaciation
- Lanugo hair
- Bradycardia (around 40bpm common)
- Postural hypotension
- Dependent oedema
- Weak proximal muscles – could do the sit up, squad stand test (see MARSIPAN guidelines)
- If inducing vomiting: Russell’s sign (calloused knuckles), swelling of parotid glands, erosion of inner surface of front teeth.
What aetiological/epidemiological factors can contribute to developing an eating disorder?
- Genetic – higher heritability in MZ twins
- Personality traits – perfectionism, cluster C traits
- Societal – social media, advertising, pursuit of size 0 culture.
- Family environment – Familiar pressure to succeed, conflict in family home, overprotectiveness.
- Social class – higher rates in middle to high income families
outcomes of bulimia nervosa
50% -70% recover completely
Relapsing and remitting course
Increasing recognition of long term impact on
QOL
outcome for AN
• Improvement is slow
• 30%-75% recover completely (best chance in
first 3 years, outcome poor post 10 years))
• up to 25% still anorectic
• 40-80% partially recover
• Mortality rate around 6% overall and 0.5%
per year 50% DEATHS DUE TO SUICIDE
signs of BN
russels sign
bilateral parotid swelling
dental erosions
endocrine causes for significant weight loss
type 1 diabetes mellitus
thyrotoxicosis
addison’s disease
clinical features of AN
vomiting laxatives diuretics excessive exercise extent of weight loss - <17.5 or 15% avoidance of fattening foods amenorrhoea
