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psychiatry > eating disorders > Flashcards

eating disorders Flashcards

1
Q

sd

A

ICD-10
anorexia nervosa
bulimia
atypical anorexia

DSM-V
binge eating
ARFID

Other
disordered eating
acute food refusal

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2
Q

subtypes of AN

A

restirctive

binge eating/purging type

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3
Q

how to get/stay thin

A
  • eat very little
  • ignore hunger
    compensatory behaviours
    diabetics may restict insulin
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4
Q

compensatory mechanisms

A

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

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5
Q

Bulimia nervosa define

A

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’.

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6
Q

types of BN

A
  1. 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.
  2. 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.
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7
Q

what is a binge

A

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

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8
Q

atypical AN nad BN

A

they have some features of AN or BN but the overall clinical picture does not justify that diagnosis

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9
Q

disorders which affect eating

A

vomit phobia

obsessive compulsive rituals - do not have time to eat, scared of germs

depression

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10
Q

other classified

A

avoidant restricitve food intake disorder

  • sensory based avoidance
  • distressing experience
  • ass with ASD
  • fear/anxiety
  • inability to recognise hunger

pts avoid certain foods

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11
Q

unclassified ED

A

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
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12
Q

biological RFs for AN

A

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

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13
Q

Ix for eating disorders

A

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)

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14
Q

outpatient therapy

A

guided slef-help
mantra
cbt-e
sscm

CAMHS
Family based therapy

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15
Q

medical complications of eating disorders

A

degree of weight loss and th chronicity of the illness

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16
Q

MARSIPAN

A

managemnt of really sick pts under 18 w AN

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17
Q

refeeding syndrome

A
  • 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.
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18
Q

Sx of refeeding

A 
oedema of ledgs/face/hands
SOB
N/V
muscle weakness
confusion
hypertension
rapid changes in body weight
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19
Q

characteristic features of refeeding

A

hypophosphotaemia
hypokalaemia
hypomagnaesaemia
hponatraemia

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20
Q

hypophosphotaemia

A

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

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21
Q

hpokalaemia

A

secodnary to self induced vomiting -> met alkalosis
<3 - paeds - iV correction
<2.5 - intensive monitoring - central venous access

22
Q

<3

A

lassitiude
gen weakness and miscle pain
constipation

ECG
falt t eaves
st depression
prominent u waves

23
Q

<2.5

A 
severe muscle wekaness and paralysys - lower extremities
resp failure
illeus
paraesthesia
tetany
24
Q

hyperkalaemia

A

peaked t waces
prolonged pR interval
widening of the QRS

25
Q

hypocalcaemia levels

features

A

<1.1

tetany stridor seizures weakness av

26
Q

features of anorexia nervosa

A

reduced BMI
Bradycardia
hypotension
enlarged salivary glands

27
Q

physiological abnormalities of anorexia nervosa

A

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
28
Q

definition of anorexia nervosa

A

eating disorder characterised by deliberate weight loss, intense fear of fatness, distorted body image and endocrine disturbances

29
Q

Psychological RFs of AN

A

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

30
Q

social RFs of AN

A

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
31
Q

ICD-10 criteria for anorexia nervosa

A

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
32
Q

DDx for AN

A
  • bulimia
  • eating disorder not otherwise specified
  • depression
  • OCD
  • schizophrenia
  • organic causes of low weight - diabetes, hyperthyroidism, malignancy
  • alcohol/substance misuse
33
Q

Mx of AN

A
  • 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
34
Q

how to prevent refeedign

A

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

35
Q

complication of AN

A

hypothyroidism

36
Q

Biological RFs of BN

A 
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

37
Q

Psychological RFs of BN

A 
􏰀 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

38
Q

social RFs of BN

A 
􏰀 Living in a developed
country
􏰀 Profession (e.g.
actors, dancers, models, athletes)
􏰀 Difficulty resolving
conflicts

Precipitating
􏰀 Environmental stressors
􏰀 Family dieting

Perpetuating
- environmental stressors

39
Q

Features of BN

A
  1. 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.
  2. Preoccupation with eating
    A sense of compulsion (craving) to eat which leads to bingeing. There is typically regret or shame after an episode.
  3. Fear of fatness
    Including a self-perception of being too fat.
  4. 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

40
Q

Hypokalaemia

A

􏰀 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.

41
Q

DDx for BN

A

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.

42
Q

Mx of BN

A

􏰀 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
43
Q

complications of AN

A
  1. Heart Failure
  2. Bradycardia/arrythmias
  3. mitral valve prolapse
  4. osteoporosis
  5. infertility
  6. anaemia/leucopenia
  7. 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

44
Q

Signs of AN on examination

A
  • 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.
45
Q

What aetiological/epidemiological factors can contribute to developing an eating disorder?

A
  • 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
46
Q

outcomes of bulimia nervosa

A

50% -70% recover completely
Relapsing and remitting course
Increasing recognition of long term impact on
QOL

47
Q

outcome for AN

A

• 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

48
Q

signs of BN

A

russels sign
bilateral parotid swelling
dental erosions

49
Q

endocrine causes for significant weight loss

A

type 1 diabetes mellitus
thyrotoxicosis
addison’s disease

50
Q

clinical features of AN

A 
vomiting
laxatives
diuretics
excessive exercise
extent of weight loss - <17.5 or 15%
avoidance of fattening foods
amenorrhoea

psychiatry (14 decks)

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