Eating Disorders

Question 1

What kind of person is likely to have an eating disorder?

Answer 1

Perfectionist, high achieving young women with low self esteem

Question 2

What age do eating disorders start at?

Answer 2

16-22

Question 3

What are components to the aetiology of ED?

Answer 3

Genetic
Personality (perfectionist, low self esteem)
Personal history (obesity, child abuse, traumatic life event)
Family (overprotective, overbearing, poor boundaries)
Societal pressures

Question 4

What conditions to eating disorders overlap with?

Answer 4

Depression
Anxiety
OCD

Question 5

What are the 4 KEY clinical presentations of anorexia nervosa?

Answer 5

BMI <18.5 (or 15%lower than expected)
Deliberate WL
Distorted body image
Endocrine dysfunction

Question 6

How do AN patients cause deliberate WL?

Answer 6

Restricted eating (counting calories, avoid fatty foods)
Purging (vomiting, laxatives)
Increase energy expenditure (excess exercise e.g. 10k runs every day)
Dangerous medications

Question 7

What kind of dangerous medications could an ED pt take for WL?
What about diabetics?

Answer 7

appetite suppressant 
thyroxine
diuretic
stimulant
Diabetics may SKIP insulin to prevent fat deposit

Question 8

What kinds of endocrine dysfunction occur in AN?

Answer 8

HPA dysfunction > amenorrhoea, erectile dysfunction, loss of libido
No secondary sex characteristics if prepubertal

Low insulin

High cortisol

Altered TFT

Question 9

What are systems you need to look into for symptoms of AN (starvation)

Answer 9

General 
Neuro 
Cardio 
GI 
Haem 
Endocrine 
MSK

Question 10

What are general symptoms of starvation

Answer 10

Emanciation 
Dehydration 
Short stature 
Lethargy 
Cold intolerance 
Cold peripheries 
Hypothermia 
Infection (from weak immunity) 
Dry skin, brittle hair and nails 
Lanugo hair
Peripheral oedema (LOW ALBUMIN) 
Hypercholesteraemia 
Hypercarotenaemia (yellow skin)

Question 11

What are Neuro symptoms of starvation?

Answer 11

Peripheral neuropathy
Cognitive defects
Delirium
Coma

Question 12

What are cardio sx of starvation?

Answer 12

Bradycardia 
hypotension 
mitral valve dysfunction 
cardiafc failure 
syncope 
sudden death

Question 13

What are GI sx of starvation?

Answer 13

constipation 
abdo pain 
bloating (delayed gastric emptying) 
Reflux 
Malnutrition > deficiency diseases

Question 14

What are endocrine sx of starvation?

Answer 14

delayed/arrested puberty
Amenorrhoea
Erectile dysfunction, loss of morning erections
ow libido
infertility (ovarian, testicular atrophy)
Hypothyroidism

Question 15

What are haematological sx of starvation?

Answer 15

Anaemia
Leukopoenia
Thrombocytopoenia
Pancytopoenia

Question 16

What are symptoms of purging?

Answer 16

Dehydration 
Russell sign (knuckle calluses/cuts from induced self vomiting)
Dental caries 
Mallory weiss tear 
Gastric rupture

Question 17

What are differentials for AN?

Answer 17

Organic:

• Endocrine - Hyperthyroidism, T1DM, Addison’s
• malignancy
• chronic infection (TB, HIV)
• GI disease (coeliac, Chron’s)

Affective (depression/BPAD)

Anxiety (GAD, OCD with food avoidance)

Psychosis (persecutory - someone is trying to steal my food)

ASD

Body Dysmorphic Disorder

Question 18

What are differentials for BED?

Answer 18

Depression (atypical, with overeating)

Organic - Kluver Bucy (hyperrhagia, hyper sexuality), Prader WIlli

Question 19

Investigations for AN

Answer 19

BMI 
SCOFF questionnaire 
SUSS (sit up squat stand) test
Bloods (FBC, U&E, ESR, TFT, LFT, CK, K+. PO43-. Na )
ECG
Dexa, pregnancy test if indicated

Question 20

Why would you check CK=?

Answer 20

To see if patient has been exercising

Question 21

Why would you check Na?

Answer 21

Because it is low in patients who waterload

They have raised ICP > cerebral oedema >death

Question 22

How do you manage anorexia nervosa?

Answer 22

Psychotherapies

• Motivational interviewing
• Family therapy
• Interpersonal therapy
• CBT

Medical treatment (nutritional stabilisation on medical ward) using MARSIPAN guidelines

Treat other psych conditions

Question 23

What are complications of AN?

Answer 23

Refeeding syndrome

Question 24

What is refeeding syndrome?

Answer 24

Complication of establishing adequate food intake in patients who are starved

Question 25

Why does refeeding syndrome occur?

Answer 25

During starvation, body switches from carb to fatty acid / amino acid metabolism > insulin secretion is suppressed During refeeding, if there is sudden increase in glucose, insulin secretion resumes There is a rapid increase in basal metabolic rate Electrolytes (K, Mg, PO - already low) are rapidly moved from blood to IC stores This causes severe electrolyte depletion > arrhythmia > death

Question 26

What does refeeding syndrome present as?

Answer 26

LOW phosphate, magnesium, potassium Thiamine deficiency Salt and water retention

Question 27

How do you know if a patient with AN needs to be admitted?

Answer 27

Use MARSIPAN guidelines - BMI <13 - hypotension - bradycardia - hypothermic - low muscle power (SUSS) - blood test results (low Na, K) - ECG with long QT

Question 28

What is bulimia nervosa? | 4 KEY presentations

Answer 28

binge eating with compensatory behaviour and overvalued ideas about ideal body shape 1. BINGE EATING 2. PURGING 3. BODY IMAGE DISTORTION 4. BMI >18.5

Question 29

what is binge eating?

Answer 29

Repeated bouts of overeating | Irresistible cravings, lose control (eat large amount with urgency and compulsion)

Question 30

How do you treat BN?

Answer 30

Treat medical complications SSRI (reduces bingeing by enhancing impulse control) Treat comorbid psych illness

Question 31

What questionnaire can you do for anorexia and bulimia

Answer 31

SCOFF questionnaire

Question 32

Explain the SCOFF questionnaire

Answer 32

S: Do you make yourself Sick because you feel uncomfortably full C: Do you ever worry you have lost Control on how much you eat O: Have you ever lost more than One stone (6kg) in 1 month F: Do you believe yourself to be Fat when others say you are thin F: Do you think that Food dominates your life

Question 33

When doing an electolyte/blood test in anorexia, what things are low and what things are high

Answer 33

Most things are LOW HIGH Cs and Gs: - Cortisol - Cholesterol - Carotinaemia - GH - Glucose - Salivary glands

Question 34

How do you manage anorexia nervosa

Answer 34

1. Psycho education: advise on nutrition and health 2. Treat co-morbid psych illness - depression, OCD, substance misuse 3. Nutritional management, weight restoration - set realistic weight gain target, set eating plan

Question 35

What kind of anorexia specific psychotherapies are available for AN in adults

Answer 35

Offer one of 3: CBT-ED MANTRA: Maudsley AN Treatment in Adults SSCM: Specialist Supportive Clinical Management

Question 36

What is CBT ED

Answer 36

``` addresses control, low self esteem, perfectionsism 40 sessions (once weekly) ```

Question 37

what is MANTRA

Answer 37

Maudsley AN Treatment in Adults Helps patient understand what is causing the anorexiaa and focus on 3hat is important to the patient 20 sessions

Question 38

What is SSCM

Answer 38

Specialist Supportive Clinical Management - explores the main problems that cause andorexia - educate about nutrition and how different eating habits cause symptoms 20 sessions

Question 39

What are therapies for AN in children

Answer 39

1. Family therapy | 2. CBT

Question 40

what other general therapies are good to consider for AN

Answer 40

motivational interviewing | interpersonal therapy

Question 41

How does family therapy for AN work

Answer 41

some sessions alone | other sessions with family

Question 42

In extreme cases, how can you enforce feeding?

Answer 42

Mental health act

Question 43

What kind of referrals can you do for AN

Answer 43

REFER ALL PTS WITH ED TO SPECIALIST TEAM IMMEDIATELY Severe: urgent referral to Community Eating Disorder Service Moderate: routine referral to CEDS Mild: support for 8 weeks, reccomend BEAT, refer to CEDS if no improvement

Question 44

What charity is good for AN

Answer 44

BEAT

Question 45

What kind of self help programme can you give for BN

Answer 45

BN focused guided self help programme for adults

Question 46

What is the general plan for BN for adults

Answer 46

1. self help programmee 4 weeks 2. CBT-ED 3. Consider trial of high dose fluoxetine for impulse control