Eating Disorders

Question 1

Environmental factors that increase the risk of developing an eating disorder?

Answer 1

• Childhood maltreatment
• More common with higher socioeconomic status
• Adoption
• Immigration
• Living conditions (urban/rural area, alone or with others)

Question 2

Definitions of anorexia nervosa?

Answer 2

There are many

1. Weight loss, or in children a lack of weight gain, leading to a body weight of at least 15% below norm / expected weight for their age and height
2. Weight loss is self-induced by avoidance of fattening foods
3. Self-perception of being too fat, with an intrusive dread of fatness, leading to a self-imposed low weight threshold
4. Widespread endocrine disorder, inv. the HPG axis; manifests in the female as amenorrhoea and, in the male, as a loss of sexual interest and potency

Question 3

Exception to the fact that females with anorexia nervosa have amenorrhoea?

Answer 3

Persistence of vaginal bleeds in anorexic women who are on replacement hormonal therapy (most commonly taken as a contraceptive pill)

Question 4

Developmental signs of anorexia nervosa if onset is pre-pubertal?

Answer 4

Sequence of pubertal events is delayed or even arrested:
• In girls - breasts do not develop and there is primary amenorrhoea
• In boys - genital remain juvenile

NOTE - with recovery, puberty is often completed normally but menarche is late

Question 5

According to DSM V, what is anorexia nervosa?

Answer 5

Characterised by distorted body image and excessive dieting that leads to severe weight loss with a pathological fear of becoming fat

Persistent restriction of energy intake leading to significantly low body weight

Either an intense fear of gaining weight, or of becoming fat, OR persistent behaviour that interferes with weight gain, despite having a low weight already

Disturbance in the way one’s weight / shape is experienced OR a persistent lack of recognition of the seriousness of current low body weight

Question 6

Sub-types of anorexia nervosa according to DSM-5?

Answer 6

• Restricting

* Binge-eating / purging

Question 7

According to ICD-10, what is bulimia nervosa?

Answer 7

Recurrent episodes of over-eating (at least twice a week over a period of 3 months), in which large amounts of food are consumed in short periods of time

Persistent preoccupation with eating and a strong desire or sense of compulsions to eat

Patient attempts to counteract fattening effects by 1 / more of:
• Self-induced vomiting
• Self-induced purging
• Alternating periods of starvations

Self-perception of being too fat, with an intrusive dread to fatness; typically leads to person being underweight

Question 8

How can drugs be abused in a patients with anorexia nervosa?

Answer 8

E.g: appetite suppressants, thyroid preparations or diuretics

When bulimia occurs in diabetic patients, may choose to neglect insulin treatment

Question 9

According to DSM V, what is bulimia nervosa?

Answer 9

1. Recurrent episodes of binge eating, characterised by
2. Recurrent inappropriate compensatory behaviour:
   • Self-induced vomiting
   • Misuse of laxatives, diuretics or others
   • Fasting
   • Excessive exercise

NOTE - binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months

3. Self-evaluation is unduly influenced by body shape and weight

NOTE - disturbance does not occur exclusively during episodes of anorexia nervosa

Question 10

Characteristics of binge eating episodes?

Answer 10

1. Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances
2. Sense of lack of control over eating during the episode

NOTE - marked distress regarding binge eating is present

Question 11

Features assoc. with binge eating episodes?

Answer 11

3 or more of the following:
• Eating more rapidly than normal
• Eating until uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone due to embarrassment
• Disgust with oneself, depression or guilt

Question 12

Signs of bulimia nervosa?

Answer 12

Caries

Russel’s sign (callouses of knuckles due to abrasions from teeth)

Question 13

Occurrence of anorexia nervosa?

Answer 13

Typically has pubertal onset (7-15 years of age) with the most common age of presentation being 18 years old

Question 14

Occurrence of bulimia nervosa?

Answer 14

Average age of onset is 20 years old

Question 15

Evolution of anorexia nervosa?

Answer 15

1. High risk:
   • Behavioural features - feeding issues, low BMI, social difficulties
   • Psychobiological features - decreased reward and increased threat sensitivity, social cognition issues and cognitive rigidity
2. Prodromal:
   • Behavioural - coping with avoidance and perfectionist tendencies
   • Psychobiological - compulsivity and anxiety
3. Full syndrome:
   • Beavioural - increased eating control, weight control behaviour
   • Psychobiological - cognitive control over drives, emotional avoidance and ability to delay reward
4. Severe enduring:
   • Behavioural - social isolation, impaired physical and mental QoL
   • Psychobiological - habits have formed, threat sensitivity, decreased social cognition

Question 16

Evolution of binge eating disorders and bulimia nervosa?

Answer 16

1. High risk:
   • Behavioural - robust feeding, increased BMI
   • Psychobiological - increased reward sensitivity, decreased response inhibition to food
2. Prodromal:
   • Behavioural - poor problem solving, increased attention to food
   • Psychobiological - emotional suppression
3. Full syndrome:
   • Behavioural - loss of control of eating
   • Psychobiological - decreased cognitive control over-drives, decreased ability to delay reward
4. Severe enduring:
   • Behavioural - impaired physical and mental QoL
   • Psychobiological - habits have formed, addiction prone

Question 17

Genetics of eating disorders?

Answer 17

50-75% heritability and a 10x increased risk in affected families

Question 18

Biological effects of eating disorders?

Answer 18

On puberty, weight loss, starvation effects

Question 19

Psychological effects of eating disorders?

Answer 19

Low self-esteem

Perfectionism / obsessional

Black and white thinking

Issues in adolescence and childhood sexual abuse

Question 20

Social issues than influence development of eating disorders?

Answer 20

Culture and expectations

Family environment

School bullying and academic pressure

Question 21

Mortality rate in anorexia nervosa?

Answer 21

1 in 5 patients

Question 22

Co-morbidities assoc. with anorexia nervosa?

Answer 22

Depression
OCD
Substance misuse
Diabetes

Question 23

Effects of starvation on the brain?

Answer 23

Loss of grey and white matter (brain shrinks)

Increased compulsive behaviour and focus on food

Reduced social skills

Enhanced response to hedonic and nutrostate signals

Poor conc. and decision-making and new learning is stunted

Question 24

What is refeeding syndrome?

Answer 24

Caused by depletion of already inadequate stored of nutrients, e.g: Mg2+, K+, phosphate, which are quickly used up as the body starts to repair itself

Question 25

Prevention of refeeding syndrome?

Answer 25

Frequent blood monitoring Initial refeeding at a slow pace

Question 26

Metabolic complications of eating disorders?

Answer 26

Hypothermia Dehydration Electrolyte disturbances (low K+, Mg2+, Ca2+ and phosphate) Hypoglycaemia Raised LFTs

Question 27

Risk assoc. with eating disorder, with relation to BMI?

Answer 27

Low-moderate: 17.5 – 16 Moderate: 16 – 15 High: 14.9 – 13 Very high: <13

Question 28

Ix to assess risk of eating disorder?

Answer 28

* Rate of weight loss * Blood results * Circulation * Muscle strength * Temp * ECG