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Flashcards in Eating disorders Deck (51):
1

ICD-10 diagnostic criteria for anorexia nervosa

  1. Low weight: BMI<17.5 (weight loss or lack of weight gain in children, <5thcentile)
  2. Weight loss is self-induced by avoidance of "fattening foods"
  3. Self-perception of being "too fat" leading to low weight threshold, even when thin
  4. Irrational fear of fatness
  5. Amennorhoea 

2

Definition of atypical anorexia nervosa

Fulfills some but not all features of AN (e.g. may have weight loss behaviours in absence of endocrine changes/dread of being fat)

3

ICD-10 criteria for bulimia nervosa

  1.  Recurrent episodes of overeating: 1000-4000 kcal, loss of control
  2. Compensatory behaviours e.g. purging, starvation, exercise, drugs
  3. Preoccupation with eating
  4. Perception of being too fat/dread of fatness

4

Time criterion for bulimia nervosa

>=2 episodes of overeating per week, for 3 months

5

Criteria for binge-eating disorder (DSM-V)

  1.  Recurrent episodes of binge-eating: characterised by lack of control
  2. Distress: regarding binge-eating (depression frequently co-morbid)
  3. No compensatory behaviour: BMI >25

6

Time criteria for binge-eating disorder

>=1 per week for 3 months

7

Features of binge eating episodes in binge-eating disorder

>=3 of:

  1. Eating until uncomfortably full
  2. Eating when not physically hungry
  3. Eating alone due to shame/embarrasment
  4. Eating more rapidly than normal
  5. Feelings of disgust, guilt, depression afterwards

8

Biological predisposing factors for eating disorder

  1. Female
  2. Genetics (56% AN, up to 80% BN)
  3. Early menarche (BN)
  4. Obesity (BN)
  5. +ve FHx (?biological)

9

Psychological predisposing factors for ED

  1. Perfectionism (AN)
  2. Low self-esteem
  3. Sexual abuse (less common in ED, little evidence)
  4. Anxiety
  5. Impulsivity (BN)
  6. FHx of obesity (BN)
  7. PPH of eating disorder (AN --> BN)

10

Social predisposing factors for ED

  1. Adverse parenting (arguments, expectations, contact)
  2. Western society
  3. Specific groups (e.g. models)

11

Biological precipitating factors for ED

  1. Dieting/lent
  2. Illness/infection
  3. Puberty

12

Psychological precipitating factors for ED

  1. Emotional stress
  2. Bullying/critical comments

13

Social precipitating factors for ED

  1. Family dieting
  2. Peer group/lifecycle transition

14

Biological perpetuating factors for ED

Neuroendocrine dysregulation 

e.g. 5-HT disturbance makes psychopathology worse

15

Psychological perpetuating factors for ED

  1. Over-valued intrusive ideas re: weight
  2. Abnormal weight perception
  3. Co-morbid mood disorder (esp depression)

16

Social perpetuating factors for ED

+ve reinforcement from friends/family

17

Average age of onset for EDs

AN: 15-16 years old

BN:20

BED: 23

18

F:M prevalence ratio for eating disorders

6:1 in community, 10:1 in clinical samples

19

Prevalence of ED

AN: 1%

BN: 1%

BED: 1-2%

20

Physical symptoms in anorexia nervosa

  1. Sensitivity to cold
  2. Amennorhoea/delayed onset of puberty
  3. Reduced sex drive
  4. Dizziness, fatigue
  5. Poor concentration
  6. Poor sleep
  7. GI symptoms: constipation, bloating

21

Physical signs of anorexia nervosa

  1. Cold extremities
  2. Sarcopenia
  3. Bradycardia, postural hypotension, arrhythmia
  4. Dry skin, sometimes orange (hypercarotinaemia)
  5. Brittle hair/nails
  6. Lanugo on back, forearms, cheeks
  7. Peripheral oedema
  8. Proximal myopathy
  9. Osteoporosis/osteopaenia
  10. Poorly developed 2ry sexual characteristics

22

Endocrine abnormalities in anorexia nervosa

Low: LH, FSH, T3, estradiol

High: Cortisol, GH

23

Metabolic abnormalities in anorexia nervosa

Hypoglycaemia

Hypercholesterolaemia

24

Electrolyte abnormalities in anorexia nervosa

Hyponatraemia, hypokalaemia, metabolic alkalosis

MAY PRESENT AS ASYMPTOMATIC HYPOGLYCAEMIA DUE TO RESERVE

25

ECG abnormality in anorexia nervosa

Prolonged Q-T interval, arrhythmias, bradycardia

26

Physical signs in bulmia nervosa

  1. Pitted teeth
  2. Calluses on knuckles (Russell's sign)
  3. Enlarged salivary glands
  4. Hoarse voice

27

Blood abnormalities in bulimia nervosa

Renal dysfunction, electrolyte abnormalities from diuretics

Metabolic alkalosis from vomiting

Colonic hypomotolity from laxatives

28

Psychiatric differential for anorexia

  1. Depressive disorder
  2. OCD
  3. Body-dysmorphic disorder
  4. Substance misuse

29

Physical differential for anorexia

  1. IBD, IBS
  2. Diabetes insipidus/mellitus
  3. Hypopituitarism
  4. Pituitary brain tumour (headache + non-induced vomiting)
  5. Cancer
  6. Malabsorption syndromes
  7. Amphetamine use

30

Differential for bulimia

  1. Binge-eating disorder
  2. Atypical depression (psychogenic overeating)
  3. Anorexia nervosa
  4. Medical causes of vomiting

31

Short-term management of anorexia nervosa

  1. Physical + psychosocial assessment --> assess immediate risk to consider admission to hospital
  2. If moderate anorexia --> secondary care referral
  3. Slowly begin refeeding --> monitor electrolytes prior to refeeding and regularly to avoid refeeding syndrome
    1. Use Pabrinex, multivitamin supplements
  4. Agree on goals/need for treatment to work towards
    1. aim for 0.5-1kg weight gain per week
  5. Psychoeducation + self-help resources

32

Long-term management of eating disorders

CBT

Family therapy (esp in adolescents)

Regular physical monitoring (electrolytes, height, weight, dental review)

Use of nutritional supplements (e.g. multivitamins)

Monitor drugs (esp for prolonged Q-T)

Weight gain 0.5-1kg per week) --> improves psychopathology

Consider SSRI (for BN/BED, or comorbidity)

33

Risk factors for refeeding syndrome

Low initial electrolytes

BMI <13

Significant comorbidity (intercurrent infection, alcoholism, uncontrolled diabetes, cardiac failure)

34

Criteria for considering admission to hospital for AN

  1. Risk of suicide/severe self-harm
  2. Home environment impedes recovery
  3. Rapid weight loss, BMI <15
  4. Bradycardia, hypoglycaemia, severe intercurrent infeciton, pronounced oedema, electrolyte abnormalities

35

Components of hospital management of severe eating disorder

  1. Medical: life-saving treatment, refeeding + avoid refeeding syndrome, manage complications
  2. Psychological: intensive individual, family, and group therapy

36

Treatment of bulimia nervosa

  1. Self-help programmes
  2. CBT: Break vicious cycle between bingeing, purging + preoccupation with weight + shape
  3. interpersonal therapy (emphasises the role of relationships, takes longer)
  4. Trial of fluoxetine (high doses needed, 60mg)

37

Success rate of CBT in bulimia

60-70% disease-free at 5 years

38

Prognosis for BN

30% residual symptoms at 10y

Evidence unclear

39

Poor prognostic factors for bulimia

Low self-esteem

premorbid hildhood obesity

Co-morbid personality disturbance

long duration prior to prersentation

40

Poor prognostic factors in anorexia

Long duration prior to presentation

Adult onset (20-29)

Severe weight loss (ost prognostic)

Vomiting/purging subtype 

41

10-year mortality of anorexia nervosa

10-20%

60% due to starvation (mainly cardiac failure due to dilation/thin walls, reversible with weight gain)

27% due to suicide

42

Anorexia red flags that raise risk

  1. BMI <13
  2. ECG: Long Q-T or flattened T-waves
  3. Skin: purpura
  4. Vascular: BP <80/50, pulse <40, Sats <92%
  5. Temperature <34.5
  6. Wt loss >1kg/week
  7. Electrolyte abnormalities
  8. Proximal myopathy (not using arms for leverage unable to get up

43

Signs of refeeding syndrome

  1. Falling PO4, K+, Mg2+
  2. Falling BP
  3. Rhabdomyolysis
  4. Cardiac/respiratory failure
  5. Arrhythmias
  6. Seizures

44

Prognosis for anorexia nervosa

1/3 complete recovery

1/3 partial recovery

1/3 chronic illness

0.5% mortality per year

45

Psychosocial assessment in suspected eating disorder

  1. Motivation to change eating habits
  2. Causes of eating habits
  3. Views on consequences of eating habits
  4. Suicide risk
  5. Psychiatric comorbidities: Depression, OCD, anxiety

46

Physical assessment in suspected eating disorder

  1. Height + weight
  2. Core body temperature
  3. Cardiovascular incl. postural drop
  4. Muscle power
  5. Skin signs

47

Questions to ask about weight control behaviours

  1. Typical day's dietary intake
  2. Exercise: type and frequency
  3. Induced vomiting
  4. Laxatives, diuretics (incl. coffee), amphetamines
  5. Binges: loss of control + feelings afterwards

48

Questions to ask about attitude to weight + shape

  1. Current weight + frequency of weighing behaviour
  2. How do you feel about your body shape/weight?
  3. How would you feel if you were a size bigger?
  4. Do you think you're fat?
  5. Have other people said you're thin? Do you believe them

49

Screening questions for eating disorder

SCOFF (>2=further assessment)

  • Do make yourself SICK?
  • Do you feel like you've lost CONTROL of your eating?
  • Have you lost more than ONE stone (6-7kg) in the last 3 months?
  • Do you think you're FAT even when others tell you you're thin?
  • Do you often think about FOOD?

50

Anorexia nervosa subtype with worse mortality

Binge-purging

51

Co-morbidity in AN

40-60% depression

Also anxiety, OCD, PD