Types of anorexia
- restricting = during last 3 mo no episodes of binge-eating or purging
- binge-eating/ purging type = in last 3 mo have participated in recurrent episodes of binge-eating/purging
Severity of anorexia
- mild = BMI >17 kg/m
- moderate = BMI 16-16.99 kg/m2
- severe = BMI 15-15.99 kg/m2
- extreme = BMI <15 kg/m2
Clinical features of anorexia
- Eating
- Disordered eating
- Don’t want to maintain weight - continue to lose weight (cf. bulimia who purge to stop getting fat - maintain weight)
- Excessive exercising
- Purging
- Anhedonia - reduced response to reward makes it hard to treat
- Medical
- Amenorrhoea
- Osteopaenia/porosis +/- fracture Hx
- Cold intolerance
- Constipation
- Cramps (Mg deficiency)
- Easy bleeding (Mg deficiency)
- Cardiac related symptoms
- Perfectionistic - obsessive compulsive personality disorder common
- Rigid thinking/cognitive inflexibility - makes treatment hard
- Alexithymia - inability to describe emotions or feelings within ones self
- Low self esteem
Examination of anorexia: findings
- At any time - signs of self harm
- General inspection
• Emaciation
• Psychomotor retardation
• Hypercarotinaemia (liver can’t function) - Vitals
• Autonomic dysfunction: hypothermia, hypotension, pulse
• Hyperventilation (from metabolic acidosis) - Hands
• Lanugo hair-type - fine, soft hair
• Alopecia
• Russell’s signs - callouses around hands as pts often put hands into mouth to initiate purging
• Nail changes
• Dry skin
• Bruises - Eyes
• Anaemia
• Jaundice - Mouth
• Dentition - teeth erosion, gum recession
• Tongue e.g. B12 deficiency
• Angular stomatitis e.g. B12, iron
• Dry mucous membranes
• Parotid enlargement - recurrent vomiting - CV**
• Auscultate for systolic murmur - can get MVP - Chest
• Breast atrophy - Abdo
• Palpation - more for tenderness (if vomiting, can get gastritis) - Legs
• Peripheral oedema**
• Proximal myopathy (squat)
• Peripheral neuropathy - Other
• Signs of deliberate self-harm, Fractures
What Ix might you order for anorexia?
- ECG: if hypokalaemic, widespread U waves, QTC 450
- UECs usually normal
• Hypokalaemia (2.4) if vomiting/laxatives
• HCO3 >30 mmol/L where there is vomiting or <18 in laxative misuse.
• Urea usu. low in restricting but may be increased if dehydrated
• Hypomagnesemia (0.74)
• Hyponatremia (consider if patient water loading) - Endocrine
• Hypothalamus shuts down and goes out of wack: change in LHRH, LH, FSH, oestrogen, progesterone, T3, fasting growth hormone
• Increased cortisol - LFTs: AST, ALP, GGT
- Haematological:often get a pancytopenia • Hb (normochromic, normocytic) • WCC • Plt • ESR
Medical reasons (not psychiatric) for admission in paeds
- Rapid weight loss
- HR < 50 min;
- BP < 80/50 mm;
• Proximal myopathy (how would you demonstrate this to a parent?)
• Hypoglycaemia
• Electrolyte imbalance (low K, Mg, PO4)
• Several days of no oral intake
• Petechial rash and platelet suppression
Impaired cognition
Why are CV parameters so important in anorexia?
because a) cardiogenic shock b) more easily slip into arrhythmia c) can get complications e.g. pericardial effusions d) injuries - falls
Mx principles of admission of anorexia
- Re-feeding [primary purpose ofinpatient admission]
- supplemental phosphorus
- Keep checking bloods daily esp in first week for refeeding syndrome
- agree on target body weight on admission and reassure this weight will not be surpassed
- monitor for complications of AN
Briefly explain how re-feeding syndrome occurs
- Increased CHO intake -> increased insulin for inc glyocogen, protein and fat synthesis -> PO4, K, Mg drawn into cells -> fall in serum concentration
- -> severe fluid shifts and electrolyte levels -> hypoglycaemia, hypoPO4, hyponatraemia, sometimes thiamine def
Complications of re-feeding syndrome
- Peripheral: oedema, fibrillations, rhabdomyolysis
- Respiratory, pulmonary oedema, respiratory failure
- Cardiac: cardiac failure, arrhythmias
- Neurological: delirium, seizures, muscle weakness
- Haematological: anaemia
- Sx of thiamine deficiency
General Mx options for anorexia
• Education for family and patient
• Refer to AMHS
○ Education/work path
○ Social connection
• Family therapy - best in adolescence, not CBT
• Nutritional rehabilitation and dietary changes
• Psychotherapy
• MDT: dietician, GP, eating disorders specialist
