Psychiatry- Eating Disorders Flashcards
What is anorexia nervosa
Eating disorder characterised by restriction of caloric intake, resulting in low body weight and intense fear of gaining weight
What is ICD-10 diagnostic criteria for anorexia nervosa
◦ 1) BMI <17.5kg/m^2
◦ Deliberate weight loss:
◦ Use of laxatives
◦ Vomiting
◦ Excessive exercise
◦ Appetite suppressants or diuretics
◦ Fear of gaining weight:
◦ Think they are fat, despite being thin
◦ Distortion of body image
◦ Low self-esteem and drive for perfection
General symptoms of anorexia nervosa
• Low BMI (<17.5kg/m^2):
‣ Key differentiator between anorexia and bulimia (would have normal or increased BMI)
General:
• Lethargy
• Cold intolerance
• Lanugo hair: fine downy hair growth in response to loss of body fat
• Russel’s sign: Callous/cut knuckles from self-induced vomiting
Cardiovascular symptoms of anorexia nervosa
Cardiovascular:
• Bradycardia
• Hypotension (postural)
• Arrhythmias: secondary to Hypokalaemia
GI symptoms of anorexia nervosa
Gastrointestinal:
• Constipation
• Mallory-Weiss tear: from vomiting
Reproductive symptoms of anorexia nervosa
Reproductive:
• Amenorrhoea
• Infertility
• Loss of libido
• Failure of secondary sexual characteristics
MSK symptoms of anorexia nervosa
MSK:
• Osteoporosis
• Proximal myopathy: +ve squat test
General investigations for anorexia nervosa (not bloods)
• BMI
• BP
• Sit-up-squat-stand (SUSS) test: assesses muscle wasting (proximal myopathy), red flag if positive
What bloods are LOW in anorexia nervosa
• LOW:
◦ Hypokalaemia
◦ Hb
◦ Na
◦ Po
◦ ESR
◦ T4
◦ Glucose
◦ Oestrogen, testosterone
◦ FSH, LH
What is RAISED in anorexia nervosa
• RAISED (4C’s + 2G’s):
‣ Cortisol
‣ Hypercholesterolaemia
‣ Carotenaemia
‣ Creatine Kinase
‣ Growth hormone
‣ Glands (salivary)
Signs of anorexia nervosa indicating immediate admission
• BMI <13kg/m^2, weight loss >1kg/week, septic signs (cold peripheries), HR <40bpm or suicide risk
Signs of severe anorexia nervosa and referral pathway
‣ Urgent referral to Community Eating Disorder Service (CEDS)
‣ If BMI <15, rapid weight loss, system failure, HR <40bpm, muscle wasting on SUS test
Signs of moderate anorexia nervosa and referral pathway
‣ Routine referral to CEDS
‣ If BMI 15-17, no evidence of system failure
Signs of mild anorexia nervosa and referral pathway
◦ Monitor/advice/support for 8 weeks
◦ ‘BEAT’ charity support
◦ If BMI >17, no additional co-morbidities
◦ Then routine referral to CEDS if failure to respond
Primary care management of anorexia nervosa
• Appropriate referral pathway
• Educate about laxative/diuretic use as it does not reduce caloric intake
• Signpost to BEAT charity, MIND etc
• Plan going forward:
◦ Nutrition and weight restoration (set target weight + aim to gain 0.5-1kg/week)
1) Individual eating-disorder-focused CBT (CBT-ED): 40 weekly sessions
• Maudsley Anorexia Nervosa Treatment for Adults (MANTRA):
◦ Focus on cause of anorexia
• Specialist Supportive Clinical Management (SSCM)
Management of anorexia nervosa in <18yo
1) Anorexia Nervosa Focussed Family Therapy (FT-AN):
Pharmacological management of anorexia nervosa
1) Fluoxetine:
‣ Especially if OCD with food
Complications of anorexia nervosa
-Refeeding syndrome
-Loss of cardiac muscle: mitral valve prolapse leading to pan-systolic murmur
What is refeeding syndrome
◦ Occurs when there is sudden reversal of prolonged starvation
◦ Leads to large intracellular shift of (already low) ions due to insulin release upon feeding
◦ Causes extremely low levels in blood
◦ Defined by LOW PHOSPHATE mainly
◦ Low potassium
◦ Low magnesium
Symptoms of refeeding syndrome
◦ Fatigue
◦ Weakness
◦ Confusion
◦ Hypertension
◦ Seizures
◦ Arrhythmias
◦ Heart failure
Management of Refeeding syndrome
slow refeeding, Pabrinex
What is bulimia nervosa
Eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours (such as laxatives, diuretics or excessive exercise)
Diagnostic criteria of bulimia nervosa
◦ Binging/overeating: lack of control during episode, MAIN SYMPTOM
◦ Purging behaviours: Vomiting, excessive exercise, laxatives, diuretics ◦ Psychopathology: feeling of loss of control, body image distortion, dread of fatness
Presentation of bulimia nervosa
• NOT underweight:
◦ Normal/excessive weight/BMI
◦ Unlike anorexia nervosa
• Recurrent vomiting:
◦ Erosion of the teeth
◦ Russell’s sign: calluses on the knuckles or back of the hand
• Amenorrhoea
• Lethargy
• Swollen salivary glands
• Gastroesophageal reflux
• Fear of gaining weight
• Persistent preoccupation and craving for food + feelings of guilt/shame about eating
Bulimia nervosa investigations
• ECG:
◦ Hypokalaemic changes (due to loss of HCl from vomiting)
◦ First-degree heart block, tall p-waves, flattened t-waves
• Metabolic Alkalosis:
◦ Caused by low Cl from vomiting
Bulimia nervosa signs for immediate admission
• Screen for IMMEDIATE admission (low HR, septic signs, hypoglycaemia, low BMI, suicidal ideations, arrhythmias, muscle weakness)
Signs of severe bulimia nervosa and referral pathway
◦ Urgent referral to CEDS
◦ Daily purging, significant electrolyte imbalance, comorbidities
Signs of moderate bulimia nervosa and referral pathway
‣ Guided self-help, monitor for 8 weeks
‣ If unresponsive, then routine referral to CEDS
‣ Frequent binging and purging >2/week
Signs of mild bulimia nervosa and referral pathway
◦ Bulimia focused self-help, monitor for 12 weeks
◦ If unresponsive, then routine referral to CEDS
◦ Infrequent binging and purging <2/week
General management of bulimia nervosa
1) Bulimia focused guided self-help:
◦ 4 weeks
2) CBT-ED:
‣ If self-help ineffective after 4 week
• Consider high dose fluoxetine if moderate-to-severe
• Regular dental review for erosion
Management of bulimia nervosa in <18yo
1) Bulimia focused family therapy
Most common diagnosed eating disorder
Eating Disorder Not Otherwise Specified (EDNOS): • Diagnosed when many but not all of the criteria for anorexia or bulimia is met
What is binge-eating disorder
• Consume excessive amount of food in relatively short-period of time
• BUT,
◦ No compensatory behaviours (e.g. vomiting, excessive exercise, laxatives, diuretics) unlike bulimia
Frequency of binge-eating disorder
• Must occur at least once per week for at least 6 months
