Eating disorders

Question 1

define russells sign

*-what elser can also be present

Answer 1

characterisitc abrasion, small lacerations and calluses on back of hand overlying the knuckles

-caused by repeated contact of the fingers with teeth during self-induced vomiting episodes
-common in bulimia

*-discolouration of the teeth

Question 2

criteria for bulimia nervosa diagnosis 4

Answer 2

recurrent episodes of overeating
-twice a week for three months

self perception of being too fat and intrusive dread of fatness

persistent preoccupation with food

attempts to counteract fattening aspect of food by:
-self induced vomiting
-purgative abuse
-alternating periods of starvation
-use of drugs

Question 3

mainstay of management of bulimia nervosa for adults 1

Answer 3

bulimia nervosa focused guided self help programmes
-CBT self help materials for eating disorders
-if unefffective consider eating disorder focused CBT (CBT-ED)

Question 4

what should eating disorder CBT (CBT-ED) consist of 4

Answer 4

20 sessions over 20 weeks

first phase
-engagement and education
-establish regular eating and provide encouragement advice and support

follow by psychopathology

towards end of treatment spread out appointments and focus on maintaining risk of relapse

if appropriate involve significant others to help

Question 5

mainstay of management of bulimia nervosa in children and young people 1

Answer 5

bulimia nervosa focuse faimily therapy

Question 6

describe bulimia nervosa focused family therapy 4

Answer 6

18-20 sessions over 6 months

establish good tehrpeytic relationship w person and family

support and encourage family to help person recover

include info about regulating body weight etc

support developing a level of independence and relapse prevention

*_if unacceptable, CI or ineffective consider CBT-ED

Question 7

aspects of CBT 5

Answer 7

[32]

Question 8

what category does binge eating disorder fall under

Answer 8

ICD 10 other eating disorder

Question 9

define binge eating disorders 5

Answer 9

regular binge eating

3/5 of:
-eating much more quickly than usual
-eating until uncomfortably full
-eating a lot when not hungry
-eating alone because of embarrassment
-feeling very bad or guilty after eating

Question 10

management of bing eating disorder 2

Answer 10

CBT self help material

focus on adherence to self help programme
-supplement self help programme w brief supportive sessions

if guided self help unacceptable, CI or ineffective after 4 weeks- offer group CBT-ED

Question 11

criteria for anorexia diagnosis 4

Answer 11

weight loss (or in children lack of weight gain)
-leading to body weight AT LEAST 25% BELOW NORMAL OR EXPECTED FOR AGE AND HEIGHT

weight loss self induced by avoidance of fattening foods

self perception of being too fat
-leads to self imposed low weight threshold

widespread endocrine disorder involving hypothalamic-pituitary-gonadal axis
-manfests as amenorrhea
-in men as loss of sexual interest and potency

Question 12

gender bias for anorexia and prognosis

Answer 12

M:F 1:10

5% mortailty rate

50% recover with treatment

Question 13

define atypical eating disorders

Answer 13

also known as eating disorder not otherwise specified
-affects approx half of all people with an eating disorder

called atypical if they do not fit exactly into diagnostic categories
-for example person may have but syx of anorexia or bulimia but not all
-may have syx of both conditions
-may move from one condition to another

Question 14

management of atypical eating disorders

Answer 14

recommened that the clinican considers following the guidance on treatment of eating problem that most closely resembles individual patients eating disorder

Question 15

main physical complciatoins of anorexia nervosa 6

Answer 15

bradycardia

amenorrhea

constipation

<eGFR

anaemia, hair loss

refeeding syndrome

Question 16

what are risks of refeeding syndrome and who gets it 6

Answer 16

if have more than 20 consecutive days of negligible nutrient intake

occurs within 10 days of starting to feed

patients can develop:
-fluid and electrolyte disorders (esp hypophosphatemia)
-hypocalcamiea and hypomagnaeisa can also occur
-cardiac arrhythmia most common cause of death
-confusion
-coma
-convulsions
-cardiac failure

Question 17

basic pathophys of refeeding syndrome

Answer 17

shifting of electorlytes and fluid balance increases cardiac workload and heart rate

O2 consumption also decreased with strains the respiratory system and can make weaning from ventilation more difficult

Question 18

management of anorexia nervosa for adults 2

Answer 18

CBT-ED

-Maudsley anorexia nervosa treatment for adults (MANTRA)

if unacceptable
-try one of the others or eating disorders focused focal psychodynamic therapy

Question 19

aspects of indivudal CBT-ED for anorexia

Answer 19

Consist of up to 40 sessions over 40 weeks with twice weekly sessions in the first 2-3 weeks
Aim to reduce the risk to physical health and any other symptoms of eating disorder
Encourage healthy eating and reach a healthy body weight
Consider nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self esteem and relapse prevention, create a personalised treatment plan, explain risks of malnutrition, enhance self efficacy, self monitoring of intake and thoughts and feelings, homework

Question 20

management of anorexia nervosa in children and young people 1

Answer 20

anorexia nervosa focused family therapy

Question 21

aspects of anorexia nervosa focused family therapy 6

Answer 21

18-20 sessions

emphasis role of family in helping them recover

psychoeducaiton about nutrition and malnutrition

establish good therapeutic alliance with the person

latterly support the person to establish a level of independence

relapse prevention

Question 22

describe MARSIPAN for anorexia

Answer 22

: Management of Really Sick Patients with Anorexia Nervosa

Concerns that a number of patients with severe anorexia nervosa were being admitted to general medical units and sometimes deteriorating and dying
Focus on patients with BMI<15
Contains guidance for clinicians looking after MARSIPAN patients on acute medical wards and psychiatric wards, but also includes service recommendations e.g. most MARSIPAN patients should be admitted to a SEDU, treated by local expert physician with interest in nutrition/ nutrition team

Question 23

physical risk assessment in patients with eating disorders 6

Answer 23

BMI and rate of weight loss

CV risk- BP, pulse, ECG

Glucose level/ albumen level

electrolyte abrnomalites

liver function abnormlaites

bone marrow abnormalites

Question 24

what electrolytte abnormalities could be caused by eating disorders 3

Answer 24

low sodium

low potassium

altered eGFR

Question 25

what bone marrow abnormlaites can be found in eating disorders 3

Answer 25

low WCC

low Hb

low platelets

Question 26

what particular concern can happen in patients with eating disorders after discharge and how is the address

Answer 26

can often have a low potassium

this can recucr after discharge with sometimes fatal results

if patient had IV replacement
-bloods should be checked frequently thereafter including post discharge

Question 27

overview of refeeding syndrome

Answer 27

[33]

Question 28

criteria for patients athigh risk of developing refeeding problems 6

Answer 28

BMI <16

weight loss >15% in last 3-6mnths

little or no nutritional intake for more than 10 days

low K, phosphate or Mg prior to feeding

Hx of alcohol abuse or drugs

presecn of purging behaviours

Question 29

management of refeeding

Answer 29

oral thiamine, vit B and balance multivitamim
-before and during first 10 days of feeding

start at 20kcal/kg/day then gradulay increase caloric intake dependent on daily bloods

Question 30

monitoring of refeeding 6

Answer 30

daily regular bloods
-close monitor Mg, K and phosphate

ECG

fluid balance

bowels

monitor for oedema, BP, pulse, sats

Question 31

other consideratinos for inpatient care of patients with eating disorders

Answer 31

Consider bed rest (BMI<13) and DVT prophylaxis, partial bed rest (BMI 13-15)
Supervised washes only (BMI<13), supervised showers (BMI 13-15)
Tissue viability risk assessment, airflow mattress
Fluid input/ output charts
Access to toilets/ taps
Meal and snack supervision and post meal and snack supervision
Leave
Frequency of physical observations
Frequency of BMs
ALERT on Kardex regarding low BMI: For dose reductions for symptomatic relief and cautious use of sedative medication