EDs, PDs and MUS Flashcards
What are the types of eating disorders and who do they affect? What is the aetiology of EDs?
EDs:
- Anorexia (restriction of food intake and weight loss methods) - commonest in ED clinics, 16-22yo, 0.6% incidence
- Bulimia (restriction-> binge -> voiding e.g. purging/laxatives), 1% incidence
- BED - most common ED generally
Aetiology:
- > 90% are females [usually perfectionist, high-achieving women, low self-esteem/body fixation]
- > Often have co-morbid depression, substance misuse, OCD/dysmorphia
Anorexia:
Bio -> genetics (58% heritability), FHx of obesity, depression, substance misuse
Psychosocial -> perfectionism, low-self esteem, sociocultural (especially models, athletes, dancers), previous anorexia, parental overprotection
BN:
Bio -> 5-HT dysregulation, FHx of obesity, depression, substance misuse
Psychosocial -> perfectionism, low-self esteem, sociocultural (especially models, athletes, dancers), personal history of obesity, disturbed family dynamics, parental weight concern, high parental expectation
When would you immediately admit an ED patient (what is the high risk criteria)?
Admit if: [use MHA if needed]
- -> Based on MARSIPAN guidelines for admission but this includes:
- BMI low (<70% expected but not defined by NICE)
- WL >1kg/week
- Septic looking signs (low temperature, BP<80/50, cold peripheries, purpuric rash)
- HR <40 bpm and long QT
- Suicide risk!
How is AN diagnosed? What are some RFs? How may atypical AN present?
ICD10: Diagnosis must have all 3:
- BMI <17.5 or weight is = <15% than expected
- Deliberate weight loss (excessive exercise, laxatives, vomiting, appetite suppressants, restriction)
- Morbid fear of fatness
RFs = OCD, FHx, psychosocial factors, childhood feeding difficulties
Atypical:
- Sub-diagnostic features e.g. young boys losing weight for ‘6 pack’ but currently healthy weight
How may AN present? What are some signs and symptoms? What are some other DDx?
Sx:
- > Psych - intense fear of fatness and gaining weight/food, overexercising, body image issues
- > General = cold, lethargic, lanugo hair, Russel’s sign, cytopenias so infections/anaemia
- > CVS = low HR, postural hypotension, arrhythmias secondary to low K+
- > GI = Constipation, MW tears
- > Repro = amenorrhoea, loss of libido, infertility
- > MSK = proximal myopathy (squat test +), Hx of fractures, osteoporosis
- > Neuro = peripheral neuropathy, delirium/coma
DDx:
- > Organic causes of WL such as hyperthyroidism
- > Bulimia, EDNOS, body dysmorphic disorder
What Ix would you do in a patient with suspected AN?
Ix:
- Full Psych history + MSE (assess insight e.g. AN)
- Physical examination - weight, height, lanugo hair, Russel’s sign, dental hygeine, BP
- Bloods (exclude hyperthyroidism and other medical causes; U&Es, FBC, TFTs and LFTs main; results = low T4, ESR, glucose, Hb, electrolytes; high cortisol, cholesterol, carotenaemia, GH, glands (salivary), LFTs [‘raised G&Cs]
- Urine drug screen + assess hydration status
- ECG (bradycardia, arrhythmia, long-QT in BN)
- DEXA (osteoporosis risk, >2y history)
- Rating scale (eating attitudes test)
- Other bloods
How would you manage anorexia nervosa in terms of admission and referrals? How would you counsel them at their 1st visit at the GP?
Mx: [NO w&w - immediate referral]
-> Screen for immediate ADMISSION (Mx = MARSIPAN guidelines) but mostly managed as outpatients
OR
-> Immediate referral;
–> SEVERE = urgent referral to CEDS (community ED service) e.g. if BMI <15, rapid weight loss, evidence of systems failure
–> MODERATE = routine referral to CEDS e.g. if BMI 15-17, no evidence of systems failure
–> MILD = monitor/advice/support for 8w, BEAT for support e.g. pt BMI>17, no additional comorbidity but follow moderate referral to CEDS if failed to respond)
Mx upon 1st presentation to GP:
- > Engage and educate (stop laxative/diuretic/purging as doesn’t reduce calorie intake)
- > Signpost support (BEAT, MIND, NHS)
- > Treat cormorbid psychiatric illness if present
- > Plan for future with regular f/u and review (nutrition and weight gain e.g. 0.5-1kg/week*, CBT-ED, MANTRA or SSCM or family therapy if <18yo)
What is the management of AN in adults? How does this vary to management in children?
Mx: [Refer to CEDS]
1st line [any of below]:
- CBT-ED (1:1, 40 weekly sessions which address low self esteem, perfectionism, control issues]
- MANTRA (Maudsley anorexia treatment in adults, 20 sessions, focus on the cause of AN)
- SSCM (specialist supportive clinical management, 20 weekly sessions led by practitioner, explores problems of anorexia, education on nutrition and habits and a future beyond anorexia e..g getting back into work)
2nd line [if 1st line fails]:
- ED-focussed focal psychodynamic therapy (FTP)
- Adolescent focussed psychotherapy
- Motivational interviewing
- Family therapy (20 sessions over year, indicated in young-onset pts (<19) and short Hx of illness
- Interpersonal therapy (improves social functioning and interpersonal skills, indicated in longer Hx of illness, later onset AN)
Pharmacological management:
- Fluoxetine (especially helpful with food preoccupations and impulsivity control)
Children Mx:
1st line = Family therapy
2nd line = ED-CBT
What is refeeding syndrome? How does it present?
Important to consider in AN patients when in recovery
- Defined mainly by low phosphate
- Due to intracellular shift of already low levels of ions due to insulin release when refeeding
- Biochemistry = LOW K+ (arrhythmias)»_space; LOW PO4- (hypophosphataemic HF) and LOW Mg+
Sx - fatigue, weakness, confusion, high BP, seizures, arrhythmia, HF
What is the prognosis of anorexia and particularly bad prognostic factors? What are complications?
After 10y
- 50% recover
- 40% ongoing problems
- 10% die, 1/3 due to suicide
Complications:
- Osteoporosis
- Cardiac arrhythmia and failure
- Infertility
- Early death
Bad prognosis - very low weight, later onset, bulimic features, longer illness duration
How can you screen for EDs in your psychiatric history?
Initially screen with body image/weight perceptions e.g. negative thoughts about your body and weight?
SCOFF:
- Do you make yourself SICK because you feel uncomfortably full (+ ask laxatives/diet pills)
- Do you worry you have lost CONTROL over how much you eat?
- Have you recently lost weight (>ONE stone) recently in a 3m period?
- Do you believe yourself to be FAT when others say you are too thin?
- would you say FOOD dominates your life?
How is bulimia defined?
ICD10: must have all 3:
- Bingeing or a persistent preoccupation with eating and/or irresistible craving for food
- Purging behaviours (attempt to counteract binge) -> diuretics, laxatives, vomiting, insulin therapy, excessive exercise
- Psychopathology - morbid fear of fatness, loss of control, Hx of AN, set weight goal
How may patients with bulimia present? What are some differentials?
Sx:
- > Similar to AN but often at a normal body weight/less severe
- > Russel’s sign (rare), dental caries
- > Amenorrhoea in 50% despite a normal body weight
DDx:
- Upper GI disorder leading to vomiting
- Personality disorder
- Depressive disorder
how would you Ix bulimia?
Ix:
- Full Psych history + MSE (assess insight e.g. AN)
- Physical examination - weight, height, Russel’s sign, dental hygiene, BP
- Bloods (exclude hyperthyroidism and other medical causes; U&Es, FBC, TFTs and LFTs
- Urine drug screen + assess hydration status
- ECG (bradycardia, arrhythmia, long-QT in BN)
- DEXA (osteoporosis risk, >2y history)
- Rating scale (eating attitudes test)
- Other bloods
How would you manage bulimia? + In children?
Mx: [NO w&w - immediate referral]
-> Screen for immediate ADMISSION (Mx = MARSIPAN guidelines) but mostly managed in community
OR
-> Immediate referral;
–> SEVERE = if daily purging, significant electrolyte imbalance, comorbidity. Mx = URGENT referral to CEDS (community ED service)
–> MODERATE = frequent bingeing and purging (>2x a week, some medical consequences like chest pain). Mx = guided self-help, recommend BEAT charity support and monitor for 8w. Routine referral to CEDS if failed to respond
–> MILD = infrequent bingeing <2x/week routine. Mx = guided self-help, recommend BEAT charity support and monitor for 12w. Referral to CEDS if failed to respond
Mx upon 1st presentation to GP:
- > Engage and educate (explain Dx, stop laxative/diuretic/purging as doesn’t reduce calorie intake)
- > Signpost support (BEAT, MIND, NHS)
- > Treat medical complications e.g. dental review (had any tooth pains etc?)
- > Treat co-morbid psychiatric illness if present
- > Moderate to severe –> high dose SSRIs e.g. 60mg fluoxetine to help with impulses of bingeing and purging
- > Plan for future with regular f/u and review
Children:
1st line = BN-focussed family therapy
Adults:
1st line = Guided self help programme (Bulimia focussed)
2nd line = [if 1st line ineffective for 4w/declined] then try CBT-ED
- Also consider high dose SSRI
PACES:
- Explain Dx + causes (low self esteem, body image/relationship issues)
- Explain complications (teeth, heart, gum and GI problems)
- Education on support, guided self help and monitoring
- Referral if persistent sx - can use talking therapies (CBT-ED and family therapy if younger)
- Pharmacological options (fluoxetine)
What is the prognosis of bulimia? What are bad prognostic indicators?
After 10y:
- 70% recover
- 1% die
Bad prognostic indicators:
- V low weight
- Severe bingeing and purging
- Co-morbid depression
- Biochemical changes such as hypokalaemia from vomiting and hypocalcaemia
