Anorexia Nervosa Flashcards
Define eating disorders
Eating disorders: mental health disorders - persistent disturbance of eating behaviour or behaviour intended to control weight which significantly impairs physical or psychosocial functioning driven by fear of fatness or extreme distress about eating behaviour
Define anorexia nervosa
ICD-10 diagnostic criteria (must have all 3): [ICD-11, DSM-V = no endocrine dysfunction]
- BMI <17.5 (or weight is ≥15% less than expected)
- Deliberate weight loss (i.e. laxatives, vomiting, excessive exercise, appetite suppressants, etc.)
- “Fear of the fat” / distorted body image (i.e. overvalued ideas they are fat, despite being thin)
- Endocrine dysfunction (amenorrhoea (F) or impotence (M), loss of libido, delayed puberty)
Atypical Anorexia Nervosa:
- Sub-diagnostic features of anorexia nervosa
- E.G. young boys that are losing weight to have a ‘six-pack’ but are currently at a healthy weight
Epidemiology
Most commonly in adolescent girls and young women (> 90% of patients are female)
High risk is between 13-17 years
Young men, children approaching puberty and older women put to the menopause may be affected
Higher mortality than any other mental health disorders
Aetiology
Combination of genetic, neurobiological and sociocultural factors:
Genetic
* Neurobiological factors
* Abnormal neurotransmitter activity (including serotonin and dopamine) and satiety-related hormones- unclear if this is involved with or a result of malnutrition
Psychological factors
- Anxiety, depression, perfectionism, low self-esteem, body dissatisfaction and overestimation of body size
- Successful weight loss enhances the patient’s sense of achievement, autonomy and perfectionism
- When life is uncontrollable, anorexia nervosa comforts by providing the ability to control something (weight)
Sociocultural
- Social pressure of being thin and promotion of dieting
- High risk groups include occupations where emphasis on weight or body image e.g. models, athletes, dancers
Family history
Risk factors
OCD, childhood feeding difficulties, FHx
Symptoms
Unusually low BMI for their age
Rapid weight loss
Intense fear of gaining weight
* Change in eating behaviour, including restricted dietary choices
Behaviours interfering with weight gain
* Excessive exercise
* Induced vomiting and purgation
* Use of appetite suppressants and diuretics
Psychological disturbance
* Disproportionate concern about body weight or shape
* Low self esteem and a drive for perfection
* Over-evaluation of self-worth in terms of weight and shape
* Atypical presentation, faltering growth, delayed puberty in children and adolescents
IMPORTANT: some medically unstable people with eating disorders can appear deceptively well
System Findings
General
- Lethargy, cold intolerance, cytopenia (i.e. anaemia), infections, cold extremities, dry skin / brittle hair and nails, lanugo hair, oedema (face and hands/feet), Russell’s sign (callous/cut knuckles from self-induced vomiting), fatigue
CVS
- Bradycardia, postural hypotension, peripheral oedema, arrhythmias (2nd to hypokalaemia), dizziness
GI
- Constipation, pain (ulcers), Mallory-Weiss tears, nutritional hepatitis (low protein, raised BR, LDH, ALP), tender abdo
Reproductive
- Amenorrhoea, infertility, loss of libido (no morning erections)
MSK
- Osteoporosis, proximal myopathy (squat test +ve), hx of fractures, short stature
Neurological
- Peripheral neuropathy, delirium, coma, intense fear of gaining weight (change in eating behaviour), convulsions
DDx
- Medical causes of WL, depression, bulimia nervosa, psychosis
- Eating Disorder Not Otherwise Specified (EDNOS), Body Dysmorphic Disorder (BDD)
Investigations
SCOFF Questionnaire- ≥ 2 is suggestive of Anorexia Nervosa or Bulimia Nervosa
- ‘Do you ever make yourself sick because you feel uncomfortably full?’
- ‘Do you worry that you have lost control over how much you eat?’
- ‘Have you recently lost more than one stone in a 3-month period?’
- ‘Do you believe yourself to be fat when others say you are too thin?’
- ‘Would you say that food dominates your life?’
Basic observations
- CALCULATE BMI
- Physical examination
- Squat test - proximal myopathy
- Scores of 2 or less are a red flag
- Lanugo hair, Russel’s sign (dentition)
- Bloods- FBC, U&Es, LFTs, blood glucose, TFTs, calcium, B12, FSH, LH, E2, prolactin
- Hypokalaemia
- Low FSH, LH, oestrogen, testosterone
- Raised cortisol and GH
- IGT
- Hypercholesterolaemia
- Hypercarotinaemia
- Low T3
- Anorexia nervosa can precipitate hypothyroidism in some individuals.
REMEMBER: MOST THINGS ARE LOW BUT G’s and C’s are raised: growth hormone, glucose, salivary glands, cortisol, cholesterol, carotaemia
Pregnancy test- consider if amenorrhoea
ECG
DEXA scan - osteoporosis
NOTE: MARSIPAN guidelines goes through investigations that can help to establish severity (helps screen for immediate admission)
Differential Diagnoses
Medical causes of weight loss, e.g. hyperthyroidism, malignancy, gastrointestinal disease, Addison’s disease, chronic infection, inflammatory conditions, and AIDS.
Depression
BN
OCD
ARFID - Avoidant restrictive food intake disorder (ARFID) involve intense restrictions on the amount of food and types of foods you eat, but unlike anorexia, people with ARFID aren’t worried about their body image, shape, or size.
Eating disorder not otherwise specified (EDNOS): the term for atypical presentations.
Body dysmorphic disorder (BDD): BDD is a condition characterized by body image distortion (e.g. belief that the nose is misshapen). Deliberate weight loss in BDD would be unusual.
Psychosis
Management Plan
Referral
Severe -> urgent referral to CEDS (community eating disorder service)
- Features: BMI <15, rapid weight loss, evidence of system failure
Moderate -> routine referral to CEDS
- Features: BMI 15-17, no evidence of system failure
Mild -> monitor/advice/support for 8 weeks, Beat charity support
- Features: BMI >17 (<17.5 or ≥15% less than expected), no additional co-morbidity
- Routine referral to CEDS if failure to respond
- RISK ASSESSMENT!
The following suggest severe anorexia > 18 year olds and may need immediate referral:
- BMI < 13 or below 2nd centile (or < BMI 15, rapid weight loss + evidence of system failure, serious physical complications, high suicide risk)
- Rate of weight loss: > 1kg/ week
- Pulse rate: < 40bpm
- BP: 90/70 (80/50)mmHg
- Squat test: unable to get up from squatting or lying down without using arms for balance or leverage
- Core temperature < 34.5-35oC
- Blood tests:
- ↓ K+ Mg, PO4, albumin, glucose
- ↑ urea, creatinine, transaminases
- ECG: prolonged QT interval, T wave changes, bradycardia
- SUICIDE RISK
Refer immediately to an age appropriate Eating Disorder Service for specialist assessment and management. This may be to either:
- Community Mental Health Team (CMHT)
- CAMHS
- Specialist Eating Disorder Unit
Consider emergency admission if at risk of serious physical or psychological complications:
- Severely compromised physical health e.g.,
- BMI below safe range
- Cardiac instability
- Hypothermia
- Reduced muscle power on Sit up-Squat-Stand test
- Concurrent infection
- Overall ill health
- Abnormal blood tests
- Septic looking signs
- Risk of refeeding syndrome
- Risk is increased by rapid weight loss, fasting over 5 days, BMI < 16kg/m2, compensatory behaviours etc.
- Re-feeding is considered ‘treatment’ under MHA/ Children Act- may be needed if insight is lacking
- Acute mental health risk (suicide or serious self-harm)
- Lack of support at home
- Treat comorbid psychiatric illness
- E.g. depression, OCD and substance misuse- which are common
- Nutritional management and weight restoration
- Realistic weekly weight gain target (usually 0.5-1kg/ week)
- Set eating plan
Psychological Therapies
- 1st Line Options (FOR ADULTS): CBT-ED, MANTRA, SSCM
- Individual eating-disorder-focused CBT (CBT-ED)
- Addresses control, low self-esteem and perfectionism
- Usually up to 40 sessions over 40 weeks -long journey
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- Helps the patient understand the cause of their anorexia (focuses on what is important to the patient)
- Offer 20 sessions with a practitioner
- Specialist Supportive Clinical Management (SSCM)
- Explore the main problems that cause anorexia
- Educate about nutrition and how eating habits cause symptoms
- Explore other aspects of management (e.g. improving relationships, getting back to work)
- Offer 20 or more weekly sessions
If any of the above are unacceptable, offer a different one of the three or consider Eating Disorder-Focused Focal Psychodynamic Therapy (FPT), Motivational interviewing, Interpersonal therapy
Social Interventions
- Educate on nutrition and health
- Further Information: Beat Eating Disorders, Mind Ed, NHS
Biological Treatment
- Medical therapy is important if there are physical symptoms, rapid weight loss or BMI < 13.5 –> Fluoxetine
FOR CHILDREN and YOUNG PEOPLE
NOTE: Children should be monitored at least weekly until seen by CAMHS or paediatric services
- Avoid telling them their weight as part if program
- 1st Line: Anorexia Nervosa Focused Family therapy (FT-AN)
- Some sessions should be for the whole family and others should be separate
- Usually 18-20 sessions over 1 year
- Review 4 weeks after treatment, then every 3 months
If FT-AN is not acceptable, contraindicated, or ineffective, offer:
- CBT-ED or
- Adolescent Focused Psychotherapy for Anorexia Nervosa (AFP-AN)
- AFP-AN includes family therapy sessions as part of the regime
Other Aspects
- Motivational interviewing
- Tries to engage ambivalent patients who lack insight into their disorders (or think that their illness is a good thing)
- Interpersonal therapy
- Aims at improving social functioning and interpersonal skills
- Better for patients with later onset or longer duration of illness
WARNING: Refeeding syndrome
- Caused by an intracellular shift of ions due to switching from fat to carbohydrate metabolism and associated increased secretion of insulin
- Biochemical features: Low PO4, Mg, K, and thiamine, salt and water retention
- Clinical features: fatigue, weakness, confusion, high blood pressure, seizures, arrhythmia, heart failure
Complications
Refeeding syndrome
- Due to rapid initiation of food after > 10 days of undernutrition
- Occurs from ↓ PO4, K, Mg
- Characterised by electrolyte imbalance caused by their sudden intracellular movement due to switch from fat to CHO metabolism and associated increased insulin secretion
- Signs: rhabdomyolysis, respiratory or cardiac failure, low BP, arrhythmia, seizures, sudden death
- Treatment: consult dietician to develop plan of slow-refeeding with careful increase in calories, monitor PO4 (stop re-feeding if falling), ↑ glucose, ↓K and ↓ Mg. Correct metabolic imbalances (PO). Prescribe thiamine, vitamin B complex and multivitamin. Over 4-7 days, increase dietary intake
Physical
- General- lethargy, cold intolerance, pancytopaenia, infections, impacts growth and development
- Cardiovascular- brady, hypotensive, arrhythmia, mitral valve dysfunction etc.
- Gastrointestinal- constipation, abdominal pain, ulcers, oesophageal tears
- Reproductive- amenorrhoea, infertility, loss of libido, loss of morning erections
- Musculoskeletal- osteoporosis, proximal myopathy
- Neurological- peripheral neuropathy, delirium, convulsion, coma
- Metabolic - hypoK
- Hypothyroidism can occur as a result
- Social difficulties
- Anxiety and mood disorders
- Death
Prognosis
Up to 10-15% will die because of anorexia nervosa
50% of patients make a full recovery in 20 years
Mortality is higher if:
- Aged 20-29 years
- Delayed access to treatment
- Bingeing
- Vomiting
Poor prognosis predicted by long duration of illness prior to presentation, need for hospitalisation and onset in adulthood
PACES
Anorexia nervosa is a condition characterised by restriction of energy intake leading to low body weight, an intense fear of gaining weight and a disturbance in the way an individual perceives their body shape/weight. Have you heard of this before?
This can lead to several physical health problems which is why we’d like to treat your daughter and help her achieve a healthy weight. The symptoms you describe may be a sign of this.
To treat this, we can provide talking therapies such as CBT which can help to address the cognitive distortions which lead to unhelpful eating behaviours.
This can also include attending sessions of anorexia-focused family therapy – this involves showing you how you can support your daughter in developing a healthier attitude towards food and body image.
Amenorrhoea is likely to be due to the very low weight and this will likely resolve once she has regained weight.
I’d like to catch up in 4 weeks’ time to see how therapy is going. In the meantime, the organisation BEAT has a great website and runs virtual get-togethers for people with bulimia to share their experiences and get support.
OR
We’d like to admit your daughter because her weight is severely affecting her health. In hospital she’ll be seen by the eating disorder service and be placed on a feeding plan- being in hospital allows us to monitor her closely as the body can react negatively to food after being restricted for a while.
She will still receive family therapy if she is hospitalised, but the priority is reducing the risk of immediate complications.
