*Lecture 15 - Eating Disorders 1: Anorexia Nervosa (AN) Flashcards
Do we have effective treatment for AN? and if so, what are they?
No
Is AN the consequence of the modern fashion industry?
Provide evidence to support your opinion.
No, AN has been around for centuries. It is likely that ‘green sickness’ was an early form of AN. Stephen Touyz believes Juliet (from Romeo and Juliet) had green sickness.
AN existed when it was fashionable to be overweight in fact.
However it is possible that the modern industry had some sway over the prevalence of AN.
What were the symptoms of green sickness? How do these overlap with AN?
○ paleness* ○ mood swings ○ lassitude (a state of physical or mental weariness)* ○ breathlessness ○ pica (eating non-foods) ○ palpitations* ○ raving ○ sexual promiscuity or aversion ○ suicidal tendencies*
*obvious overlap, but mood swings, breathlessness may also overlap and pica is now its own disorder.
When was the first case of AN described?
1684 - by Richard Morton
but was ignored because he wrote it in French, no one read it
Who gave AN its name?
Is it a good name?
Sir William Gull Bart
The name means nervous loss of appetite.
But this name is somewhat inappropriate as people with AN do not have a loss of appetite. They are very hungry. rather they are restricting high energy food from their diet.
Describe the 1930s treatment of AN and its flaws.
J.F. Venables 1930
- every patient can be persuaded to eat normal (not true)
- condition is hysterical and no patient should remain uncured (not true, 40% remain uncured)
- doctor must sit down with patient and fight for every mouthful of food, which may take an hour or two every meal
- never lose temper
- one must cure the anorexia before one starts on the psychology of the patient’s symptoms (well this is silly because now we know it is a psychological disorder)
- special nurses are usually needed
Who was credited with discovering AN?
When?
What did they say about the condition?
Sir William Gull Bart (Englishman)
1874
- patients are hypothermic
- restless
- must try and keep them warm (they like to shiver to burn calories)
- medical problems are caused by the psychological problem
Is AN exclusively an illness for women?
No
- In 1993 - Stephen Touyz published a paper about Anorexia Nervosa in males: 12 cases
- now about 20-25% of cases are male but tend not to go for treatment as stigma of being diagnosed with a woman’s illness
- doctors treat thin women and men differently - different set of questions
What happens to someone with AN?
- loss of weight
- loss of calcium (as less oestrogen, as underweight)
- osteoporosis - often have broken bones
- may become infertile
- ‘Lanugo’ hair on skin
- hypothermia
- bones protrude
- vomiting is hard - so scars on hands from putting them down their throat
- some get very burnt - since they’re always cold, they easily burn themselves in warm shower
- may die from heart attack
What is AN?
A Psychosomatic (relating to the interaction of mind and body) syndrome of self-induced weight-loss
It involves an excessive use of behaviours directed at bringing about weight loss.
What is AN associated with?
- obsessionally
- depression
- low self-esteem
What are 3 essential features of Anorexia Nervosa (AN)?
- persistent energy intake restriction
- intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain
- a disturbance in self-perceived weight or shape
What are 3 social effects of AN?
- Invalidism (prolonged ill health)
- Regression
- Isolation
What are 3 physical consequences of AN?
- Malnutrition
- Disturbed body chemistry
- Endocrine dysfunction
Which systems can AN medically manifest in?
*Don’t need to know too well but yeh.
- Neurological
- Metabolic
- Cardiovascular
- Haematological
- Renal
- Endocrine
- Gastronomical
- Immunological
slides 31-32
Name 5 Co-morbid Physical Conditions?
- osteoporosis
- hypothermia
- irregular heart beat (arrhythmia)
- liver damage
- anaemia
True or False?
AN can lead to pseudoatrophy.
True.
Fluid drains to ventricles, leads to shrinkage.
True or False?
AN can lead to renal failure.
True.
True or False?
AN can lead to constipation.
True.
The body empties the food very slowly in an attempt to extract all the nutrition it can.
True or False?
AN can compromise the immune system.
True.
AN patients may experience neutropenia, which means they have less white blood cells. This makes it hard to fight off bacterial infections.
What 2 drugs do AN patients often get prescribed?
What kind of drugs are these?
- Olanzapine
- Seroquel
Anti-psychotic, initially used for schizophrenia.
(smaller doses than in Schitz.)
all they do is reduce anxiety.
NOT TREATMENTS for AN.
What are 4 indications for hospitalisation in AN?
- Physiological Instability
- Cardiac arrhythmia (abnormal heart rhythm)
- Electrolyte disturbances
- Severe malnutrition
See slide 33 for details
Discuss the use of pharmaceutical treatment in AN?
No drug treatments have been found effective.
- No RCT in children and adolescents
- antipsychotics used to reduce anxiety in adults
- no support for SSRI use in the acute or maintenance phase of AN.
Do SSRIs have any benefit in AN?
Hay and Claudino, 2012
RCTs of SSRIs in adults with AN do not support their use in the acute or maintenance phase of AN.
FIX CARD
Walsh 2008 conclusions,
- highlighted importance of early and prompt identification and intervention
- supports effects to dvlp more effective treamtent with long-standing AN
- AN and BN are 2 dif. disorders
True or False?
Putting on weight is always safer for an AN patient then not.
False - see refeeding syndrome.
What is refeeding syndrome?
• when weight gets very low - more dangerous to start to eat again than to keep losing weight
• patients died from being fed to rapidly by doctors
• because cells in body get depleted - esp imp. phosphate
• keeps heart going and helps with digestion
• phosphates totally depleted - when fed, heart stops
• so treatment is no easy - could get refeeding syndrome
need to get lots of phosphates into them
Learnt about through prisoners of war.
Outline the procedure and findings for the “Body shape perception and its disturbance in AN” study.
(Touyz et al., 1984)
Procedure:
• took pics of patients in leotard
• patients could distort image to how they look
Results:
• participants got confused - did they want it how they felt or how they looked?
• when set as they looked - they were right
• but set it as fat when told to make it how they felt
• not a perception issue!!!!
What happens to an AN brain compared to a ‘normal’ brain in an fMRI machine when presented with a stimulus of a calorie rich food?
In one study, participants were presented with a doughnut
In AN patient:
amygdala lights up
In ‘normal’ patient
pleasure centre lights up
What does it mean by having a weak central coherence?
AN patients can see all the minute details, but cannot see the bigger picture it forms. E.g. of the face, the elephants, shape within the image.
What is set-shifting?
The ability to move back and forth between multiple tasks, operations or mental sets. It is a major component of executive functioning.
(alzheimers patients also struggle with this)
FIX CARD
Why do AN ppl struggle with central coherence and set-shifting
DON’T KNOW HOW TO ANSWER
What are the 7 measures for set-shifting?
- Wisconsin Card Sorting Test
- Trail Making Test
- The Brixton Test
- The Haptic Illusion Test
- The CatBat Task
- CANTAB IDED set-shifting subtest
- Picture Set Test
- Verbal Fluency Task
Name 4 psychological co-morbitities?
Co-morbid Psychological Conditions: • Depression • Severe Anxiety • OCD • OCPD (obsessive compulsive personality disorder)
FIX CARD
DONT REALLY NEED TO KNOW
- Clinical Stage
- Issues for DSM-5
- Why stage?
What are barriers for treatment for AN patients?
- Most patients do not want to be treated
- They fear putting on weight! Which is what treatment aims to do
- If being tube fed, patients can pull out the tubes when nurse not looking. But as an x-ray must be used to make sure the tube goes into the stomach and not the lungs, which would kill them, once the tube has been pulled out it can not be put back in because too many x-rays causes cancer.
- They will fight you every step of the way
- If you are male, you may want to avoid the stigma associated with getting help for having ‘a woman’s disorder’
- Doctors treat thin women and men differently - different set of questions, as they do not expect men to have AN
- Must be careful of re-feeding syndrome
How do AN brains react when looking at themselves and others?
(Sachdev et al., 2008)
• when look at others - patients responded the normal way
• but when looked at themselves - no activation at all
thought of looking at themselves was so terrifying, the brain actually shut down
What is the average duration of AN?
7 years
True or False.
AN is transdiagnostic.
False.
Treatment doesn’t cross diagnoses, all the treatments for it are specifically for AN and won’t help their other stuff.
DONT REALLY NEED TO KNOW
True or False.
Is AN highly inheritable?
(Kaye, Fudge & Paulus, 2009)
Apparently, yes.
What % of patients do not recover from AN?
40% do not get better
What % of patients do not recover from AN?
40% do not get better
What is the mortality rate of AN?
25% (Highest mortality rate out of all the DSM)
In what decade and by whom was the distinction between 2 different types of AN made?
Peter Beaumont 1970s realised two ANs
- diet/exercise
- binge/purging vomit, laxatives etc.
if we look at these two groups, we will find one does better than the other
and that one is more disturbed than the other
What are the 2 two types of AN?
- Restrictive
2. Binge-eating/purging type
Which type of AN is more obsessive?
Restrictive
What is criterion A of AN?
Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
What is criterion B of AN?
Intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain, even though at a significantly low weight.
What is criterion C of AN?
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
What is criterion D of AN?
TRICK! There is none.
What are the 3 types of specifiers for AN?
- Type
- Remission Status
- Severity
How is the severity of AN classified?
The minimum level of severity is based, for adults, on current body mass index (BMI) (see below) or, for children and adolescents, on BMI percentile. The ranges below are derived from World Health Organization categories for thinness in adults; for children and adolescents, corresponding BMI percentiles should be used. The level of severity may be increased to reflect clinical symptoms, the degree of functional disability, and the need for supervision.
Mild: BMI ≥ 17 kg/m2
Moderate: BMI 16–16.99 kg/m2
Severe: BMI 15–15.99 kg/m2
Extreme: BMI < 15 kg/m2
How does one specify the remission status?
Specify if:
In partial remission: After full criteria for anorexia nervosa were previously met, Criterion A (low body weight) has not been met for a sustained period, but either Criterion B (intense fear of gaining weight or becoming fat or behaviour that interferes with weight gain) or Criterion C (disturbances in self-perception of weight and shape) is still met.
In full remission: After full criteria for anorexia nervosa were previously met, none of the criteria have been met for a sustained period of time.
True or False?
Crossover between the subtypes over the course of the disorder is not uncommon.
True; therefore, subtype description should be used to describe current symptoms rather than longitudinal course.
Which of the two types of AN are more neurotic?
The binge/purging type
What is the restricting type of AN?
During the last 3 months, the individual has not engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). This subtype describes presentations in which weight loss is accomplished primarily through dieting, fasting, and/or excessive exercise.
More rigid and and obsessive.
What is the binge/purging type of AN?
During the last 3 months, the individual has engaged in recurrent episodes of binge eating or purging behaviour (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).
More neurotic.
True or False?
There are more malignant and more benign forms of AN.
Debatable. Stephen Touyz believes it, but has not got substantial evidence for this theory as of yet.
Why are AN patients often hypothermic?
The brain needs 500 calories per day just to keep neurones going, heart and breathing continues, but everything else stops, including temperature regulation.
What % of AN cases are males?
~20-25%
If a healthy person normally loses calcium from their bones every day, why is calcium deficiency a problem in AN?
In a healthy body, the foods we eat put the calcium we lose back.
However, in AN patients, female hormones get suppressed when underweight.
The oestrogen falls - that is the taxi that gets calcium into your bones.
So even if consume dairy, still do not have the means to get that into ur bones.
What kind of person (age and gender wise) does AN usually occur in?
Adolescent girls and young women
How does the abuse of laxatives kill you?
AN patients may take 50-100 laxatives a day.
This reduces the bodies potassium, which is needed to keep a heart beat.
How many AN patients go through full remission?
Walsh 2008
as low as 20%
(although 60% do reasonably well)
Criticised for having too harsh a remission criteria. Too idealistic. Higher set the standard, the lower the rates are.
What are the outcomes for patients in terms of % of recovery?
Full remission: 20%
Partial remission: 40%
Never recover: 40%
What % of patients partially recover?
40%
Name two factors that may mitigate the outcome of AN?
Treating AN when patient is young leads to better outcomes.
Also catching it EARLY.
True or False?
As a teenager with AN, you are risking your brain becoming permanently damaged?
True
Adolescent brain looks like a bad hedge.
Brain prunes rough edges as growing.
But not if have AN.
What are 4 things that refeeding syndrome lead to?
1 cardiac or respiratory failure
2 gastronomical problems
3 delirium
4 death
Why may AN brains react differently to a healthy brain when looking at a picture of themselves?
Scientists believe it may be due to the under-activity of the insula - the part that helps you understand the way you look
What is the treatment of choice for an adolescent AN patient?
Systemic treatment (with family)
What psychiatric illness is AN closest to?
Schizophrenia
What is the treatment of choice for an adult with AN?
CBT - although it is not always effective, we don’t really have any better option
