Module 5.1 (Eating Disorders)

Question 1

What is an eating disorder?

Answer 1

• Unlikely to develop from one single cause
• “Feeding and eating disorders are serious mental health disorders that cause impairment to physical health, growth and development, cognition and psychosocial functioning.”
• not a lifestyle choice or a diet gone wrong

Question 2

What are the classifications of eating disorders?

Answer 2

1. Pica
   * people have an appetite for non nutritious substances (ice, metal, glass, soil & faeces) can be diagnosed with another eating disorder (pica with binge eating d, with bulimia), the other 5 disorders are mutually exclusive, so you can’t be diagnosed with binge eating disorder and bulimia nervosa
2. Rumination Disorder
3. Avoidant/Restrictive Food Intake Disorder
4. Anorexia Nervosa
5. Bulimia Nervosa
6. Binge-eating disorder

Question 3

What are some social, biological and psychological factors that can lead to eating disorders?

Answer 3

Question 4

Who can get an eating disorder?

Answer 4

• Eating disorders can affect anyone.
• Across all cultural and socio-economic backgrounds
• Amongst people of all ages, from children to the elderly
• Onset before puberty and after 40 years is uncommon
• In both men and women
• Anorexia nervosa
  
  • Probably most prevalent in postindustrialised, high-income countries*
  • Differing cross-cultural presentations
• Bulimia Nervosa
  
  • Far less common in males than females

Question 5

Whats the Primary prevention of eating disorders?

Answer 5

• Interventions aim to prevent onset or development of an eating disorder
• Goals
  
  • Improve general health, nutrition and psychological wellbeing (e.g. self-esteem and positive body image)
  • Enhance media literacy: education on the unrealistic standards of beauty set in the media
  • Reduce teasing and bullying and weight-based teasing

Question 6

What is body image?

Answer 6

• The perception a person has of their physical self and thoughts and feelings that arise from that perception
• 4 aspects of body image
  
  • Perceived body image
  • Affective body image
  • Cognitive body image
  • Behavioural body image
• Positive body image occurs when a person is able to accept, appreciate and respect their body
  
  • Can make a person more resilient to developing an eating disorder

Question 7

What are some common symptoms in eating disorders?

Answer 7

• Destructive behaviours
  
  • Restrictive behavior
  • Binge eating
  • Associated features of binge eating
  • Purgative behavior
  • Excessive exercise
  • Drinking behaviours
  • Body checking
  • Body avoidance
• Psycopathology
  
  • Body image disturbance
  • Distorted thoughts about food
• physical sxs
• are they obsessive about food? is their behaviour changing? Do they have distorted beliefs about their body size? Are they often tired or struggling to concentrate? Do they disappear to the toilet after meals? Have they started exercising excessively?

Question 8

Symptom of restrictive eating hebaviours?

Answer 8

• Cutting back on the amount of food eaten
  
  • Dieting, pro-longed fasting, skipping meals, self starvation
• Strict rules about eating
  
  • Specific times of day, unbalanced eating, little variety in diet
• Ritualised behaviour associated with with the purchase, preparation and consumption of food
  
  • Avoidance of social eating, secret eating
• Social competitiveness around eating

Question 9

Symptoms of compulsive binge eating?

Answer 9

• Eating an amount of food in a discrete time that is considered excessive in view of the situational context (objective)
• Eating an amount of food that is not excessive in view of the context but is considered large by the individual because of associated feelings of loss of control over eating (subjective)
  
  • e.g. someone who eats 2 chocolate biscuits and feels extremely guilty because they don’t eat chocolate at all
• associated featutes- eating more rapidly than normal, eating until uncomfortably full, eating large amounts even when not hungry, eating alone because of embarrassment, feeling disgust, depressed, or just really guilty because of the eating that’s taken place

Question 10

What are some other destructive behaviours that may be indicative of an eating disorder?

Answer 10

• Self-induced vomiting, chew-spit
• Misuse of laxatives, diet pills, enemas, emetics, stimulants
• Steroid and creatine use
• Intense, highly driven exercising of a compulsive nature
• A drive to exercise that is associated with impaired social and/or physical function
• Either limiting fluids (1.5L/day) or excessive drinking (>1.5L/day)

Question 11

What are some examples of body obsession?

Answer 11

• Repeated weighing
• Pinching or measuring the size of body parts
• Repeated checking of the protrusion of specific bones
• Checking that specific clothes fit
• Mirror gazing
• Comparison with others bodies
• Conversely can have avoidance of all of the above e.g. avoiding mirrors, wearing baggy clothing, refusal to weigh

Question 12

Exmaples of distorted thought about food?

Answer 12

• Distorted thoughts about food
  
  • Preoccupation with eating and food
  • Feeling anxious around mealtimes
  • Feeling “out of control” around food
  • Rigid thoughts about food being “good” or “bad”
  • Using food as a source of comfort or as a self punishment

Question 13

Exmaples of distorted thought about body image?

Answer 13

• Body image disturbance
  
  • Preoccupation with weight shape and/or appearance
  • Over-valuation of weight/shape/appearance as measure of self-worth
  • Minimisation or denial of symptom severity
  • Disturbance in the way the body is experienced
  • Intense fear of gaining weight

Question 14

What are some physical symptoms and complications (consequences) of eating disorderS?

Answer 14

• Menstrual irregularities or amenorrhoea
• Reduced libido, less waking erections in men
• Bone marrow suppression → anaemias, infections
• GI dysfunction – nausea, reflux constipation, diarrhoea, bloating, abdominal pain, oesophageal erosions, gallstones, pancreatitis
• Endocrine abnormalities (including ↑ cortisol) hypoglycaemia, osteoporosis
• Neurological impairment – peripheral neuropathy, myopathy, headaches, seizures
• Weakness, fatigue, lethargy, fainting (dehydration)
• Brittle nails and hair (reduced beard growth)
• Dry scaly skin with fine soft hair

Question 15

Why is early identification of eating disorders important?

Answer 15

• Early intervention is critical because it improves outcomes if treatment is started early
• Patients may present with other issues
  
  • Weight concerns (even though not overweight)
  • Anxiety or depression
  • Fertility issues
• Pharmacists can play an important role
  
  • Often the first health professional to see a person with an eating disorder
  • Can identify presence of an eating disorder, provide support, advice and aid in appropriate referral

Question 16

What are Evidenced based screening questions which can help initiate disclosure may lead to earlier access to treatment?

Answer 16

• Questions specifically for detecting Bulimia Nervosa
  
  • 1. Are you satisfied with your eating patterns?
  • 2. Do you ever eat in secret?
• Best individual screening questions
  
  • 1. Does your weight ever affect the way you feel about yourself?
  • 2. Are you satisfied with your eating patterns?
• S- Do you make yourslef SICK because you feel uncomfortably full?
• C- Do you worry you have lost CONTROL over how much you eat?
• O- Have you recently lost more than 6kg in a 3 month period?
• F- Do you believe yourself to be FAT when others say you are too thin?
• F- Would you say FOOD dominates your life?

Question 17

What is anorexia nervosa characterised by?

Answer 17

• Characterised by relentless pursuit of thinness- results in weight loss, failure to gain weight during periods of growth, refusal to maintain a normal body weight, fear of gaining weight or becoming fat
• can lead to physiological manifestations of starvation= amenorrhoea, bone loss, vomiting, laxative abuse

Question 18

What is teh diagnostic criteria for anorexia nervosa? What are the 2 subtypes of AN?

Answer 18

• Restricting type
• Binge-eating/purging type

Question 19

What is partial remission for anorexia nervosa?

Answer 19

• Low body weight criteria has not been met for a sustained period but fear of weight and distorted perceptions remain

Question 20

How is severity of AN measured?

Answer 20

• Measures used to check minimum level of severity
• Adults – BMI
• Children BMI percentage § Level of severity can be increased to reflect clinical symptoms, disability and need for supervision to maintain weight
• Clinical judgement required
• Mild: BMI>17kg/m2
• Moderate: BMU 16-16.99kg/m2
• Severe: BMI 15-15.99kg/m2
• Extreme BMI <15kg/m2

Question 21

Intense fear of weight gain?

Answer 21

• Intense fear of becoming fat is usually not alleviated by weightloss
• Concern about weight may even increase as weight falls
• Extreme weight-loss that can be life threatening

Question 22

What are the treatment principles of anorexia nervosa?

Answer 22

• Must be tailored to the needs of the patient & severity of illness
• Denial can make treatment difficult
• Guiding principles of treatment
  
  • 1. Manage physical health (restoration of body weight)
  • by checking for physical complications- hypokalaemia and dehydration
  • 2. Identification and management of any contributing family and personal problems (psychological issues associated with AN)
• Other key considerations
  
  • Cormorbid depression secondary to starvation
  • Checking for physical complications can be lifesaving- high levels of mortality!

Question 23

What is the approach to treatment for anorexia nervosa?

Answer 23

• involves a multidisciplinary approach
  
  • psychotherapy
  • nutrional management
  • pharmacotherapy
• Referral to specialist services should always be contemplated even if weight loss not yet critical!!!!!!!!!!!!!!!
• Inpatient treatment: required for patients who fail to make progress or are at physical risk (including suicide risk)
• Outpatient programs: now more common way of treating patients

Question 24

What are the indicators for INPATIENT TREATMENT?

Answer 24

Question 25

What is outpatient treatment in anorexia nervosa?

Answer 25

• Involves working with a team of health professionals in a hospital or clinic on a regular basis (e.g. daily or weekly)
• Suited to someone who needs help with their eating disorder but can continue with their everyday life and activities
• The Swan centre
• Perths Childrens hospital
• Hollywood private hospital- eating disorder day program

Question 26

What does psychotherapy in AN include?

Answer 26

• PSYCHOTHERAPY IS A KEY ELEMENT OF TREATMENT IN AN
• Individual and family therapy
• treatments include
  
  • Cognitive Behavioural therapy (CBT)
    
    • tries to change unhelpful or unhealthy habits of thinking, feeling and behaving, we have a cycle where our thoughts govern our behaviours, and our behaviours govern our emotions which therefore govern our thoughts
  • Dialectical Behavioural Therapy (DBT)
    
    • based on regulating emotions, based on the idea that eating disorder is a coping mechanism- give patients new strategies for coping, modified CBT
  • Family based Psychotherapies
    
    • Family based therapy, Maudsley Approach
    • when young adults, children suffering from eating disorder, whole family is involved during their treatments, whole family to provide appropriate care, focus on strengthening family relationships
  • Self-help approaches
    
    • involves some form of CBT, most effective when combined with other treatment approaches provided by clinicians and professionals, risk of relapse with self-help alone

Question 27

What is the maudsley approach?

Answer 27

• An intensive outpatient treatment
• Parents play an active & positive role in order to:
  
  • Restore their child’s weight to normal levels
  • Hand control of eating back to the adolescent
  • Encourage normal adolescent development
• The Maudsley Approach opposes the notion that families are pathological or should be blamed for the development of AN
• Considers the parents as a resource and essential in successful treatment
• good evidence of success in treatment of adolescents, children with anorexia nervosa of short-moderate duration (less than 3 years), no evidence to support model in adults over age of 18
• Older people- CBT, DBT most often used on outpatient basis, no evidence on best form of psychotherapy for adults aged over 18

Question 28

What else is used to manage AN?

Answer 28

• Nutritional management in AN
• Provided by a dietician, nutritionist or sometimes a GP
• Approach to nutritional management is to:
  
  • 1. Restore weight and nutritional status
  • 2. Assist in the development of normal and beneficial eating habits and behaviours

Question 29

What can a dietician do in AN?

Answer 29

• translate scientific info into practical advice surroundng food and healthy eating
• prescribe dietary treatments for people suffering from eating disorders
• teach people with eating disorders how to eat ad how to buy appropriate foods e.g. in a supermarket
• provide medical nutrition therapy services

Question 30

Priorities of treatment: includes addressing malnutrition!

Answer 30

• Acute- Need to restore them to normal weight and treat malnutrition because patients can’t respond to drugs and psychotherapy when they’re malnourished
• Refeeding reduced apathy, lethargy
• Malnutrition & the brain:
  
  • The brain “shrinks” over time with malnutrition
  • Receptors in the brain change
    
    • Relevant to responsiveness to therapies
  • Cognitive changes
  • ↑ Anxiety, depression and rumination
  • Constant pervasive thoughts of food
• treatment
  
  • Nutrition restoration core to treatment
  • Restore weight to:
    
    • Avoid physical complications
    • Improve response to therapies
• Enteral feeding via nasogastric tube maybe required (food refusal)

Question 31

Weight restoration & nutritional status

Answer 31

• Weight recovery defined as attaining 95% of the median BMI
• Weight restoration (Refeeding)
  
  • Slow and steady
  • Low calorie approach (<1200kcal/day)
  • 1-1.5kg/week (for inpatients)
  • Fast weight gain → higher relapse
  • ↓ risk refeeding syndrome
• Food choices less important than total calories
• ↓ excessive activity
• • Patients can become hypermetabolic ↑ their caloric needs
• Refeeding can be:
  
  • Food alone
  • Meal-based with highenergy liquid supplements
  • Combination of oral & NG
  • NG alone
  • Occasionally TPN
  • ensure plus, enlive plus. resource 2.0

Question 32

What is refeeding syndrome?

Answer 32

• when food is introduced too quickly after a period of malnourishment
• due to shifts in electrolyte levels that can cause serious complications such as seizures, heart failure, and even coma- be careful how to re initiate re feeding
• most likely in the 1st week and can be fatal
• main pathophysiologic features of refeeding syndrome?
  
  • abnormalties of fluid balance
  • abnormalties of glucose metabolism
  • vitman deficiency (B1, thiamine)
  • hypophosphatemia
  • hypomagnesaemia
  • hypokalaemia

Question 33

Who is at risk of refeeding syndrome?

Answer 33

Question 34

What do you do if a patient is at risk of refeeding syndrome?

Answer 34

• Give thiamine before starting
• Give a multivitamin
• monitor: vital signs and cardiac rhythm signs of oedema, heart failure and deteriorating mental state

Question 35

Can we use pharmacotherapy in anorrexia nervosa?p

Answer 35

• No strong evidence for drug treatment of Anorexia Nervosa
  
  • Either in acute or maintenance phase of illness
• Drugs that are sometimes used in specific circumstances
  
  • Antidepressants
  • Antipsychotics
  • Hormone replacement therapy
  • Bisphosphonates
  • Gastrointestinal drugs
  • Vitamin D therapy,
  • Calcium supplementation
  • Other supplements
• Also need to asses cardiac risk! People with AN may have ECG changes (prolonged QT interval) some antidepressants and antipsychotics can have this effect

Question 36

Possible indications for medications such as depression or extreme agitation?

Answer 36

• depression
  
  • Differentiate - depression associated with malnutrition and comordid major depressive illness
  • Patients with persistently depressed mood, insomnia, diurnal mood variation, anhedonia and depressive ideations such as guilt hopelessness and worthlessness
  • half usual dose due to POTENTIAL CARDIAC ISSUES
  • Avoid antidepressants that cause QT-interval prolongation—patients with anorexia nervosa are at increased risk of cardiovascular sequelae because of possible electrolyte disturbances. Of the antidepressants, fluvoxamine, paroxetine and sertraline have a lower risk of QT-interval prolongation. For patients with a body mass index (BMI) less than 14 kg/m2, start antidepressant treatment at half the usual starting dose; the dose adjustment schedule and maximum dose do not need to be reduced.
• extreme agitation
  
  • Low dose antipsychotics including olanzapine quietiapine and amisulpride
  • May ↓ anorexic ruminations, psychological distress and improve weight gain

Question 37

Possible indications for medications such as osteopenia and gastrointestinal symptoms?

Answer 37

• osteopenia
  
  • HRT & bisphosphonates may be used for continued ostepoenia – role uncertain
  • Vitamin D and dietary calcium supplementation recommended but not demonstrated to reverse bone loss
• gastrointestinal symptoms
  
  • GI symptoms common during refeeding and often persist
  • Metoclopramide (5-10mg one hour before meals and at bedtime) can help with bloating
  • PPIs can help with reflux symptoms

Question 38

Possible indications for medications for replacement of essential nutrients and managing hypokalaemia?

Answer 38

• Potassium chloride sustained release 1200 to 3600mg daily in divided doses
• Initial dose based on estimated potassium deficit
• Effervescent formulation used for patients unable to swallow

Question 39

What is the diagnostic criteria for bulimia nervosa?

Answer 39

Question 40

How is the severity of bulimia nervosa assessed?

Answer 40

• The level of severity may be increased to reflect other symptoms and the degree of functional disability
• Mild: average of 1-3 episodes of inapropriate compensatory behaviours per week
• Moderate: average of 4-7 episodes of inapropriate compensatory behaviours per week
• Severe: average of 8-13 episodes of inapropriate compensatory behaviours per week
• Extreme: average of 14 or more episodes of inapropriate compensatory behaviours per week
• Compensatory behaviours include:
  
  • Self-induced vomiting
  • Misuse of laxatives, diuretics, other medications
  • Fasting
  • Excessive exercise

Question 41

How do we recognise the patient?

Answer 41

• More newly recognised disorder
• Patients typically in the normal weight range
  
  • BMI ≧ 18.5 and < 30 in adults
  • Weight can fluctuate
• Patients will often go to great lengths to conceal their behaviours – sense of shame

1. Tension and cravings
2. Binge eating
3. Purging to avoid gaining weight
4. Shame and disgust
5. Strict dieting

Question 42

What are some physical signs and effects?

Answer 42

• tooth erosion and decay
• Russells sign- repeated contact of the fingers with teeth during self-induced vomiting episodes can lead to characteristic abrasions, small lacerations, and calluses on the back of the hand overlying the knuckles
• feeling faint
• throat swelling from excessive vomitting
• bloody vomit
• hemorrhoids- excessive use of laxatives- damaging digestive tract
• dry skin
• low sex drive
• irregular heartbeat
• facial swelling
• red eyes
• mood swings- frequent bing eating can heighten feelings of depression, anxiety and irritability

Question 43

How is bulimia nervosa treated?

Answer 43

• psychotherapy
• pharmacotherapy
• patients are rarely admitted to the hospital but indications for admission to hospital include:
  
  • risk of suicide
  • medically unwell
  • 1st trimester of pregnancy
  • symptoms refractory to outpatient care
  • hollywood clinic- private hospital has a BN program

Question 44

What form of psychotherapy is used in BN?

What techniques are used in manual-based CBT?

Answer 44

• CBT cognitive behavioural therapy (psychologist) is 1st line treatment, evidence is strong to help the patient have a positive relationship with food and eating
• focuses on good psychosocial function and mental wellbeing
• aims to change eating habits, weight-control behaviours and also preoccupation with shape and weight
• has good acceptability
• Recovery rates: 50% full recovery, 30% partial recovery
• Techniques used in manual-based CBT
  
  • Psychoeducation about nutrition, shape and weight issues, and eating disorders
  • (including important complications, such as hypokalaemia)
  • Daily self-monitoring of relevant thoughts and behaviours
  • The prescription of a normal eating pattern and proscription of restrictive dieting
  • The gradual introduction of avoided foods into the patient’s diet
  • Cognitive restructuring procedures to identify and challenge problematic thoughts and attitudes
  • Problem-solving
  • Relapse prevention strategies

Question 45

What are some other forms of psychotherapy?

Answer 45

• For some patients CBT is unnecessarily intensive
• For others it is insufficient
• Recent research has focussed on other forms of therapy
• Interpersonal Therapy (IPT)
• Emphasizes the interpersonal context of symptoms
• Family therapy
• Dialectical Behaviour Therapy (DBT)
  
  • Focus on emotional regulation

Question 46

Are medicines used in bulimia nervosa?

Answer 46

• recommended if psychotherapy is unavailable or unacceptable
• Generally efficacious in acute stage with short term treatment (~ 8 weeks)
  
  • Lack of evidence for long term use
  • Lack of evidence in children
  • Uncertain whether drugs can prevent relapse
• Drugs used in Bulimia Nervosa
  
  • SSRIs
  • Topiramate

Question 47

Which drugs are used in bulimia nervosa and why?

Answer 47

• SSRIs
  
  • particularly fluoxetine, have the strongest evidence for use in patients with bulimia nervosa; there is some evidence for citalopram, fluvoxamine and sertraline
• SSRIs modify eating behaviours through serotonin-mediated effects on satiety, and have a beneficial effect on mood :)
• Fluvoxamine and sertraline have a lower risk of QT-interval prolongation than fluoxetine and citalopram, they may be preferred in patients at risk of hypokalaemia and cardiac arrythmias
• the long-term efficacy has not been established and the optimal duration of therapy is unknown—regular review of pharmacological treatment every 3 to 6 months is recommended
• 1st line= fluoxetine 20-60mg mane
  
  • assess the patient’s response to therapy every 1 to 2 weeks to determine whether dose adjustment is needed
  • f it is, increase the daily dose by 20 mg no more often than weekly until an acceptable response is achieved or a daily dose of 60 mg is reached
  • Continue at the same dose for at least 6 months, then consider deprescribing
• others: citalopram, fluvoxamine, sertraline

Question 48

What about topiramate as per the lecture and etg?

Answer 48

• Can be effective in ↓ bulimic and purging symptoms
• safety profile needs to be established for this indication
• Dose: Topiramate 250mg daily
• small evidence base for the use of topiramate for bulimia nervosa
• may be used by specialists for patients who have not responded to treatment with other agents
• should not be used in patients who are underweight because it is associated with weight loss

Question 49

Comparison of drug treatments for AN and BN! (table)

Answer 49

Question 50

Summary for AN and BN

Answer 50

• Eating disorders are not lifestyle choices they are serious mental health disorders
• They are caused by a complex combination of biological and environmental factors
• Both Anorexia Nervosa and Bulimia Nervosa can be life threatening
• The disorders can be successfully treated
• There is insufficient evidence to suggest the best form of psychotherapy in AN but CBT is useful in adults and the Maudsley Approach can be helpful in adolescents
• The psychotherapy with the best evidence for BN is CBT
• Pharmacotherapy is not recommended to directly treat AN but there is good evidence for short term use of SSRIs (fluoxetine) in BN