Anorexia Nervosa Flashcards
(28 cards)
1
Q
Essence
A
Most commonly seen in young woman
Marked distortion of body image, pathological desire for thinness, and self-induced weight loss by variety of methods
2
Q
Epidemiology - M:F ratio
A
1:10
3
Q
Epidemiology - age of onset
A
F - 16-17 years (rarely > 30 years)
M - 12 years
4
Q
Epidemiology - incidence
A
0.5% adolescent and young woman
5
Q
Diagnostic criteria
A
- Low body weight
- 15%+ below expected or BMI 17.5 or less
- Self-induced weight loss
- Avoidance of fatty foods, vomiting, purging, excessive exercise, use of appetite suppressants
- Body image distortion
- Dread of fatness, overvalued idea, imposed low weight threshold
- Endocrine disorders
- HPA xis such as amenorrhoea, reduced sexual interest/impotence, raised GH levels, raised cortisol, altered TFTs, abnormal insulin secretion
- Delated/arrested puberty
- If onset pre-puberty
In atypical cases one or more of these key features may be absent or all but to lesser degree
6
Q
Methods of self induced weight loss
A
- Avoidance of fatty foods
- Vomiting
- Purging
- Excessive exercise
- Use of appetite suppresants
7
Q
Endocrine disorders as part of diagnostic criteria
A
- HPA axis such as
- Amenorrhoea
- Reduced libido/impotence
- Raised GH levels
- Raised cortisol
- Altered TFTs
- Abnormal insulin secretion
8
Q
Aetiology
A
- Genetic
- Adverse life events
- Psychodynamic models
- Family pathology - enmeshment, rigidity, over-protectiveness, lack of conflict resolution, weak generational boundaris
- Individual pathology - disturbed body image (due to dietary problems in early life or parents preoccupation with food)
- Analytical model - regression to childhood, fixation on oral stage, esacape from emotional problems of adolescence
- Biological
- Hypothalamic dysfunction - ? cause or consequence
- Neuropsychological deficits - reduced vigilance, attention, visuspatial abilities and associative memory
- Pseudoatrophy/sulcal widening and ventricular enlargement
- Unilateral temporal lobe hypoperfusion
9
Q
Aetiology - psychodynamic models
A
- Family pathology
- Enmeshment, rigidity, over-protectiveness, lack of confilct resolution, weak generational boundaries
- Individual pathology
- Disturbed body image due to dietary problems in early life or parents preoccupation with food
- Analytical model
- Regression to childhood, fixation on oral stage, escape from emotional problems of adolescence
10
Q
Aetiology - biological
A
- Hypothalamic dysfunction
- Neurophychological deficits
- Reduced vigilance, attention, visuospatial abilities and associated memory which improve with weight gain
- Pseudoatrophy/sulcal widening and ventricular enlargement
- Improves with weight gain
- Unilateral temporal lobe hypoperfusion
11
Q
Differential diagnosis
A
- Chronic debilitating physical disease
- Brain tumours
- GI disorders
- Crohns, malabsorption syndromes
- Loss of appetite
- Secondary to drugs
- Depression/OCD
12
Q
Complications
A
- Oral
- Dental caries
- Cardiovascular
- Hypotension, prolonged QT, arrhythmias, cardiomyopathy
- GI
- Prolonged GI transit, constipation
- Endocrine
- Hypokalaemia, hyponatraemia, hypoglycaemia, hypothermia, altered thyroid function, hypercortisolaemia, amenorrhoea, delay in puberty, arrested growth, osteoporosis
- Renal
- Renal calculi
- Reproductive
- Infertility, low birth weight infant
- Dermatological
- Dry scaly skin and brittle hair (hair loss), lanugo body hair
- Neurological
- Peripheral neuropathy, loss of brain volume, ventricular enlargement, sulcal widening, cerebral atrophy
- Haematological
- Anaemia, leukopenia, thrombocytopenia
13
Q
Most common cause of death due to anorexia nervosa
A
Cardiac complications
14
Q
Findings of cardiac complications
A
- Significant bradycardia (30-40bpm)
- Hypotension (systolic <70mmHg)
- ECG changes
- Sinus bradycardia, ST-segment elevation, T-wave flattening, low voltage and right axis deviation
- Echocardiogram
- Decreased heart size and left ventricular mass, mitral valve prolapse
15
Q
Treatment of osteopenia due to anorexia
A
- 1000-1500mg/d of dietary calcium and 400IU of vitamin D
- Prevent further bone loss and maximise peak bone mass
- Exercise and HRT
- In adult woman
16
Q
Physical signs
A
- Loss of muscle mass
- Dry skin
- Brittle hair and nails
- Callused skin over IPJ (Russel sign)
- Anaemia
- Hypercarotinaemia (yellow skin and sclera)
- Fine, downy, lanugo body hair
- Eroded tooth enamel
- Peripheral cyanosis
- Hypotension
- Bradycardia
- Hypothermia
- Atrophy of breasts
- Swelling of parotid and submandibular glands
- Swollen tender abdomen
- Peripheral neuropathy
17
Q
Psychiatric symptoms
A
- Concentration/memory/decision making problems
- Irritability
- Depression
- Low self-esteem
- Loss of appetite
- Reduced energy
- Insomnia
- Loss of lobido
- Social withdrawal
- Obsessiveness regarding food
18
Q
Systemic enquiry symptoms
A
- Amenorrhoea
- Cold hands and feet
- Weight loss
- Constipation
- Dry skin
- Hair loss
- Headaches
- Fainting or dizziness
- Lethargy
19
Q
Investigations
A
- BMI
- Assess physical sign of starvation and vomiting
- Routine and focussed blood tests
- ECG (and echocardiogram if indicated)
20
Q
Blood test findings
A
- FBC
- Hb normal or elevated (dehydration)
- Leukopenia and thrombocytopenia
- ESR
- Normal or reduced
- U&Es
- Raised (drhydration)
- Hyponatraemia
- Hypokalaemia
- Hypochloraemia
- Hypophosphataemia
- Hypomagnesaemia
- Glucose
- Hypoglycaemia
- LFTs
- Minimal elevation
- TFTs
- Low T3/T4
- Increased rT3
- Albumin/total protein
- Usually normal
- Cholesterol
- May be dramatically elevated
- Endocrine
- Hypercortisolaemia
- Increased GH
- Decreased LNRH
- Decreased LH
- Decreased FSH
- Decreased ostrogens
- Decreased progestogens
21
Q
Management
A
-
Psychological - 1st line
- Family therapy in early onset
- CBT/behavioural therapy
- Pharmacological
- Fluoxetine - especially if clear obsessional ideas regarding food
- Education
- Nutritional education
- Hospital admission only if serious medical problem
22
Q
Criteria for admission to hospital
A
- Extremely rapid or excessive weight loss that has not responded to outpatient treatment
- Severe electrolyte imbalance
- Serious physiological complications
- Temperature < 36
- Fainting due to bradycardia or marked postural drops in BP
- Cardiac complications or other acute mental disorders
- Marked change in mental status
- Psychosis or risk of suicide
- Failure of outpatient treatment
23
Q
Risks of re-feeding
A
- Re-feeding syndrome
- Cardiac decompensation (myocardium cannot withstand stress of increased metabolic demand)
24
Q
Re-feeding symptoms
A
- Excessive bloating
- Oedema
- Congestive heart failure
25
How to limit risk of re-feeding syndrome
* Measure U&Es and correct abnormalities before re-feeding
* Recheck every 3 days for first 7 days then weekly during re-feeding period
* Attempt to increase calories slowly by 200-300 every 3-5days until sustained weight gain of 1-2lb/week achieved
* Monitor patient for development of tachycardia or oedema
26
Prognosis - mortality rate
10-15%
27
Prognosis - re-occurance
* Rule of thirds
* 1/3 full recovery, 1/3 partial recovery, 1/3 chronic problems
28
Prognosis - poor prognostic factors
* Chronic illness
* Late age of onset
* Bulimic features
* Anxiety when eating with others
* Excessive weight loss
* Poor childhood social adjustment
* Poor parental relationships
* Male sex
