Eating Disorders

Question 1

What is anorexia nervosa?

Answer 1

-A. refusal to maintain weight above minimally normal predicted weight (i.e. weight loss leading to weight
B. Intense fear or weight gain/fat
C. Distorted body image

Question 2

What is bulimia nervosa?

Answer 2

-craving for food and uncontrolled binge eating
-morbid fear of fatness
-distorted body image
-Sense of lack of control
-Recurrent, inappropriate compensatory behaviour: purging / vomiting / laxative abuse
-Fluctuating (N or excessive) weight
Binges and compensatory behaviours occur at least 2x/week for 3/12

Question 3

Epidemiology anorexia?

Answer 3

Onset 13-20

• 1-2% schoolgirls and female students
• 3F:1M

Question 4

Epidemiology bulimia?

Answer 4

• Onset 15 - 30
• Prevalence 1-3%
• 3F:1M

Question 5

DDx anorexia?

Answer 5

-psychosis: schizophrenia (delusions about food)
-organic: diabetes (but may coexist)
-Addison’s
-malabsorption
-malignancy
Latter 3 unlikely

Question 6

DDx bulimia?

Answer 6

• Psychiatric: anorexia

- Neurological: Kleine-Levin, Kluver-Bucy (rare causes overeating)

Question 7

Management anorexia?

Answer 7

• Exclude other diagnoses and monitor physical health
• Family interventions
• Motivational counselling
• CBT
• Hospitalisation if indications

Question 8

Management bulimia?

Answer 8

• Medical stabilisation
• CBT: establish regular eating program, address abN cognitions
• SSRIs (fluoxetine best established)

Question 9

Prognosis anorexia?

Answer 9

-40% recover
-35% improve
-20% develop chronic disorder
-5% death (highest death rate any psych disorder)
Long term risk osteoporosis

Question 10

Indicators of poor prognosis bulimia?

Answer 10

Poor if:

• low BMI
• high frequency of purging
• 30-40% remission with CBT

Question 11

Aetiological factors eating disorders?

Answer 11

-GENETIC/FHx: eating disorders, parental obesity, restrictive dieting
-PERSONALITY: anxious, OCD/perfectionistic and depressive traits; alexithymia and low self esteem;
==>anorexia: constricted affect and emotional expressiveness
==> bulimia: impulsive
-BIOLOGICAL: altered brain 5HT
-CHILDHOOD
-CULTURE: value on thinness, media representations, occupation that values thinness (i.e. modelling)

Question 12

Factors supporting genetic component to eating disorder development?

Answer 12

• twin studies indicate genetic component;

- 1st degree relatives inc risk OCD, depression, obsessional personality, EtOH/substance abuse (bulimia only)

Question 13

How does 5HT interact with eating disorder pathways? i.e. effect is has leading to eating disorder?

Answer 13

Altered brain 5HT contributes to appetite dysregulation, mood and impulse control

Question 14

Childhood personal/environmental factors predisposing to eating disorders?

Answer 14

• Sexual, physical or emotional abuse
• Overprotective or overcontrolling environment; or one where food, eating, weight, body shape overvalued
• troubled interpersonal or family relationships
• being ridiculed because of size or weight (i.e. childhood obesity)
• early menarche (

Question 15

AFx anorexia?

Answer 15

• preoccupation with food (dieting, elaborate meals for others)
• self consciousness about eating in public; socially isolating behaviour
• vigorous exercise
• constipation
• cold intolerance
• depressive and OCD symptoms

Question 16

Physical signs / complications of anorexia?

Answer 16

• Vitals: hTN, brady, arrhythmia, post drop, hypervent (acidosis), systolic flow murmur
• Emaciated frame
• Psychomotor retardation
• Stupor
• Peripheral shutdown
• Carotinemia
• Russell’s sign
• Easy bruising
• Lanugo
• Cyanosis, anemia
• Parotidomegaly
• Poor dentition
• breast atrophy
• abdo tenderness (gastritis)
• Proximal myopathy
• Peripheral neuropathy
• DSH
• Fractures
• Oedema (low alb; CCF)

Question 17

What is Russell’s sign?

Answer 17

Scarring/calluses of dorsum of hand. Indicates repeated vomiting

Question 18

AFx bulimia?

Answer 18

• N or excess weight
• Loss of control / trance like state while binging
• intense self loathing and depression
• multi impulse bulimia: +drug/EtOH abuse, DSH, stealing, sexual disinhibition (poor impulse control pathway)

Question 19

Physical signs / complications bulimia?

Answer 19

• amenorrhoea
• hypokalemia (dysrhythmias or renal damage)
• consequences of repeated vomiting: hypokalemia, alkalosis, pitted teeth, parotid swelling, scarring of dorsum of hand (Russell’s sign) (oesophageal tears can occur)

Question 20

Anorexia subtypes?

Answer 20

• Restrictive (minimal food intake, exercise): person has not engage in self-induced vomiting / laxative abuse
• Binge eating-purging type: (episodes binge eating, laxative use, induced vomiting, enemas)

Question 21

Common co-morbid psych conditions in individuals with anorexia?

Answer 21

• Mood d/o: MDD, chronic dysthymia
• Anxiety: panic d/o, PTSD, OCD, social phobia
• Substance use d/os
• Somatoform d/o: conversion, somatisation
• Personality d/o: OCPD, BPD

Question 22

Psych indications for admission anorexia?

Answer 22

1. Active suicidal plan
2. Anorexic cognitions: continuous preoccupation, cooperative only in highly structure Rx
3. Other psych d/o req hospital
4. Eating: NGT, constant supervision
5. Exercise: supervised to restrain
6. Compulsive, uncontrolled purging
7. Severe family problems
8. Treatment availability

Question 23

Useful investigations in anorexia?

Answer 23

• ECG: if hypoK, widespread U waves, QTC 450
• UEC: usu N (look for hypoK/Mg, hyper bicarb, urea low)
• LFTs (increased)
• Haem (dec HB, WCC, PLT, ESR)

Question 24

Bicarb changes in anorexia?

Answer 24

->30mmol/L when vomiting

-

Question 25

Endocrine Ix in anorexia?

Answer 25

- Dec: LHR, LH, FSH - Dec oestrogen, progesterone - Dec: T3 - Inc cortisol - Inc fasting GH

Question 26

What is refeeding syndrome?

Answer 26

- Starvation: low CHO = low insulin secretion - body stores K, Mg, PO4 deplete (although serum level maintained) - Refeeding -> CHO metabolism --> inc insulin --> PO4, K, Mg uptake into cells --> fall in serum concentration

Question 27

When does refeeding syndrome occur?

Answer 27

3-4 days of refeeding

Question 28

What is refeeding syndrome associated with?

Answer 28

- hypoK, hypoMg - Sodium and fluid retention - Thiamine deficiency - Hyperglycemia

Question 29

Serious sequelae refeeding syndrome?

Answer 29

- Acute cardiac failure - Resp failure - Wernicke's encephalopathy - Sepsis - Acute renal failure

Question 30

Alexithymia

Answer 30

Inability to articulate one's emotional state

Question 31

What is a binge eating episode classified as?

Answer 31

Eating in a discrete period of time an amount of food definitely lager than most people would eat in a similar period. Sense of lack of control during the episode.

Question 32

General indicators (adult and child) for admission?

Answer 32

- Proximal myopathy - Hypoglycemia - Electrolyte imbalance (low K, Mg, PO4) - Petechial rash and platelet suppression

Question 33

What are issues surrounding patients with anorexia nervosa?

Answer 33

- lack of shared illness model - high risk situations - dysfunctional/reinforcing family dynamics - health systems not designed to support - often past traumatic experiences - strong counter transference issues

Question 34

What are the severe sequelae of refeeding syndrome?

Answer 34

- Acute cardiac failure - Respiratory failure - Wernicke's encephalopathy - Sespis - Acute renal failure

Question 35

What are the criteria for discharge in anorexia?

Answer 35

- 1. Medically stable - 2. Sufficient nutrition to reverse any cognitive effects of starvation so can benefit from outpatient therapy - 3. Trials of leave to demonstrate can eat outside hospital - 4. Direct link with appropriate outpatient monitoring, support and treatment

Question 36

Physical criteria for admission adult anorexia?

Answer 36

- Bradycardia ( below 50 bpm) - Postural hypotension (fall in systolic BP lying to standing 20 mmHg +) - Dehydration - Hypothermia (temp. under 35o C oral) - Electrolyte abnormalities (eg. hypokalaemia, hypernatraemia) - Severe weight loss (30%+ of pre-morbid weight)