Eating disorders

Question 1

Definition of anorexia nervosa?

Answer 1

Defined by the ICD-10 as an eating disorder where there is deliberate weight loss that is induced and sustained by the patient.

Question 2

Epidemiology of anorexia nervosa?

Answer 2

The incidence of anorexia nervosa is 6/100,000, with the highest incidence occurring between age 15-19.

Question 3

Causes of anorexia nervosa?

Answer 3

Biological factors include the presence of family history and genetic influence

Psychological: Presence of co-morbid mental health disorders, such as anxiety, depression, obsessive-compulsive disorders or obsessive/perfectionist personalities

Social: Maternal encouragement of weight loss or at risk professions such as models, dancers or sportspeople

Question 4

Typical history of patient with anorexia nervosa?

Answer 4

Preoccupation with food and calories
Starvation via restricting intake, purging (through induced emesis, diuretic or laxative abuse) or excessive exercise

Poor insight

Overvalued, intrusive obsession with weight, shape and fear of becoming fat

Weight/calorie goals in mind regardless of their impact on physical health

Question 5

Clinical characteristics of anorexia nervosa?

Answer 5

BMI <17.5 kg/m2 (contrast with bulimia nervosa, where there may be many similar features, but the BMI is normal, a key distinguishing feature)

Hypotension

Bradycardia

Enlarged salivary glands

Lanugo hair (fine hair covering the skin)

Amenorrhoea (hypogonadotropic hypogonadism)

Question 6

Treatment (psychological) for anorexia nervosa?

Answer 6

Treatment involves aiming to return to a healthy weight and using psychological therapies, such as eating disorder-focused cognitive behavioural therapy (CBT)/CBT for eating disorders (CBT-ED), to treat the underlying thought processes

Question 7

Treatment (medicinal) for anorexia nervosa?

Answer 7

SSRI’s (selective serotonin re-uptake inhibitors) i.e. fluoxetine is not effective for directly treating the anorexia but it can be effective for the co-morbid health issues associated i.e. depression and anxiety.

Question 8

Some complications of anorexia nervosa?

Answer 8

Cardiac arrhythmias:
These patients are at higher risk of arrhythmias and an ECG should be performed periodically, especially if they are complaining of cardiac symptoms (eg. palpitations, fainting episodes or dizzy/light-headed spells)
Bradycardia and prolonged QTc are often seen

Osteoporosis – a long-term complication

Question 9

Definition of bulimia nervosa?

Answer 9

Bulimia nervosa is a psychiatric disorder characterized by recurrent episodes of binge eating (eating a large amount of food in a short period of time with a sense of loss of control) followed by inappropriate compensatory behaviours to prevent weight gain.

Question 10

Examples of inappropriate compensatory behaviours for weight gain in bulimia?

Answer 10

Self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.

Question 11

What is a difference between anorexia nervosa and bulimia nervosa?

Answer 11

In bulimia nervosa, patients still may maintain a BMI of above 17.5. .

Question 12

Who does bulimia nervosa typically affect?

Answer 12

Bulimia nervosa predominantly affects adolescents and young adults, with onset commonly in late adolescence or early adulthood.

It is significantly more prevalent in females, with female to male ratio estimated to be approximately 10:1.

Question 13

Bulimia nervosa presents with both physical and psychological symptoms. True/false?

Answer 13

True

Question 14

Psychological symptoms of bulimia nervosa?

Answer 14

Binge eating: Characterized by a loss of control, consumption of enormous amounts of food with high caloric content, often with a sense of urgency and compulsion

Purging: Binge episodes often lead to feelings of shame and guilt, leading to attempts to ‘undo the damage’ through behaviours such as induced vomiting, misuse of laxatives or diuretics, and excessive exercise

Body image distortion: Patients may have a distorted perception of their body, often perceiving themselves as overweight despite maintaining a normal or slightly above average weight.

Question 15

Physical symptoms of bulimia nervosa?

Answer 15

Dental erosion: Resulting from recurrent self-induced vomiting

Parotid gland swelling: Resulting from recurrent self-induced vomiting

Russell’s sign: Scarring on the back of the hand or knuckles caused by repeated self-induced vomiting and scraping of teeth

Question 16

What investigations can be done for bulimia nervosa?

Answer 16

A detailed medical history: To evaluate for recurrent episodes of binge eating and compensatory behaviours

A comprehensive physical examination: To identify potential physical signs of bulimia, including dental erosion, parotid gland swelling, or Russell’s sign

Psychological assessments: To evaluate for associated psychological conditions and body image distortion

Question 17

What is first line treatment for bulimia nervosa?

Answer 17

CBT (cognitive behavioural therapy)

Question 18

What is binge eating disorder?

Answer 18

Characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress.

This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.

Question 19

What may binges involve?

Answer 19

• A planned binge involving “binge foods”
• Eating very quickly
• Unrelated to whether they are hungry or not
• Becoming uncomfortably full
• Eating in a “dazed state”

Question 20

Management of binge eating disorders?

Answer 20

• Self help resources
• Counselling
• Cognitive behavioural therapy (CBT)
• Addressing other areas of life, such as relationships and past experiences

SSRI’s can be used by a specialist in child and adolescent mental health.

Question 21

What is refeeding syndrome?

Answer 21

Occurs in people that have been in a severe nutritional deficit for an extended period, when they start to eat again. Patients are at higher risk if they have a BMI below 20 and have had little to eat for the past 5 days.

The lower the BMI and the longer the period of malnutrition, the higher the risk.

Question 22

Underlying mechanism of refeeding syndrome?

Answer 22

Metabolism in the cells and organs dramatically slows during prolonged periods of malnutrition.

As the starved cells start to process glucose, protein and fats again they use up magnesium, potassium and phosphorus. This leads to:

Hypomagnesaemia
Hypokalaemia
Hypophosphataemia

These patients are also at risk of cardiac arrhythmias, heart failure and fluid overload.

Question 23

Treatment for refeeding syndrome?

Answer 23

Management will be according to the local protocol under specialist supervision:

Slowly reintroducing food with restricted calories
Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods
Fluid balance monitoring
ECG monitoring may be required in severe cases
Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

Question 24

Assessments for refeeding syndrome?

Answer 24

General history (concurrent disease)
Physical examination:
BMI (weight-loss trajectory)
Bradycardia
Hypothermia
Sit-up and Squat Tests

Question 25

Electrolyte and energy issues in refeeding syndrome?

Answer 25

Reduced intake of carbohydrate
Reduced secretion of insulin
Main sources of energy are fat and protein
Reduced intracellular phosphate
Extracellular phosphate may be normal
Low expenditure of energy due to lethargy/lack of physical activity
Atrophic gut, heart, muscles
Low micronutrient reserves

Question 26

What is the SCOFF questionnaire?

Answer 26

a five-question screening tool designed to clarify suspicion that an eating disorder might exist rather than to make a diagnosis.

Question 27

Questions in the SCOFF questionnaire?

Answer 27

Do you make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than one stone in a three-month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?

Question 28

Assessment for disordered eating should be part of the routine review of patients with Type 1 Diabetes . true/false?

Answer 28

True

Question 29

There is a specific BMI associated with fitness to drive. true/false?

Answer 29

False

There is no BMI associated with fitness to drive

Question 30

what eating disorder symptoms cause an impairment in driving?

Answer 30

Lack of muscle tone and strength (sit-up and squat tests)
Osteopenia/Osteoporosis
Hypoglycaemia
Hypokalaemia
Hypothermia