Eating Disorders Lecture - part 2 Flashcards
1
Q
Co-morbidity with eating disorders
A
- More than half of those with AN have another mental illness
- 88-97% with BN have another mental illness
- Most common co-morbids include mood and anxiety disorders - depression, OCD, social anxiety
- Strong association with AN and autism spectrum disorders
- Substance abuse
- Can be part of EUPD - method to regulate emotions
2
Q
Where do eating disorders often originate from? - emotion wise
A
- Coping mechanism for different emotions - distraction, numbing
- Can help someone feel protected, more confident and less anxious - get compliments initially
- Can provide a sense of feeling special
- May present a barrier to engaging with treatment - feels part of self, people want to look after you more
3
Q
Causes of eating disorders
A
- Genetics
- Biological vulnerability
- Biological stress
- Psychological vulnerability
- Psychological stress
- Social/cultural
4
Q
Biological pre-disposing factors for eating disorders
A
- Genes
- Neurotransmitters - dopamine, serotonin, noradrenaline
- Hormones
- Physical illness/allergies eg always had to look at labels, T1DM
- FH depression, anxiety, addiction
5
Q
Psychological predisposing factors to eating disorder
A
- Low self esteem
- Feelings of ineffectiveness or lack of control
- Self identity
- History of depression/anxiety/mood intolerance
- Personality traits - perfectionism, obsessional
- Interpersonal style - struggle to recognise cues and emotional states of others
- Emotional processing - difficulty recognising own emotional state, expressing emotions and difficulty handling stress
- Thinking style - cognitively rigid, all or nothing thinking, can’t see bigger picture
6
Q
Social/environmental pre-disposing factors of eating disorders
A
- History of bullying - esp about weight
- Trauma - all forms abuse
- Stressful life events - grief, loss
- Difficult interpersonal relationships - conflict within family, high expectations, stressful family circumstances, overprotection
- Taking part in competitive sports - dancing, gymnastics
- Growing up in household that places value on appearance and dieting
But families not to blame
7
Q
Precipitating factors of ED
A
Biological:
* Puberty
* Physical illness/trauma
* Dieting and weight loss
Psychological
* Low mood/anxiety
* Sense of lack of control in other areas of life
Social/environmental
* Interpersonal problems - loneliness
* Transitions - taking on new role and new expectations eg moving to uni, new job
* Grief/loss
* Social media/diet culture
8
Q
Perpetuating factors of eating disorders - biological
A
- Effects of starvation - energy, euphoria
- Reduced sex drive - can be positive in terms of avoidance eg previous sexual abuse etc
9
Q
Psychological perpetuating factors for ED
A
- Feelings of control, protection and safety
- Sense of identity
- Numbing emotions
- Sense achievement
10
Q
Perpetuating factors ED social/environmental
A
- Reinforcement from others - positive comments
- Eliciting care from others
- Ability to avoid transitions, events and responsibilities
- Social media/the media/diet culture
11
Q
What happened with Minnesota study?
A
- Semi starved healthy men
- Initially preoccupied with food
- Then became agitated and found it difficult to rest
- More tired and withdrawn as weight dropped
- Very focused on their bodies - were not previously
- Some became worried about weight gain
- Many binged once able to eat, struggled to put weight on
Something with starvation changes brain and the way it functions - rigid
12
Q
Psychological effects of starvation
A
- Brain structure and self regulatory system (in forebrain) changes
- Anxiety and intense negative emotions increase (lose neurones)
- Both negative and positive emotions are numbed
- Coping ability reduces
- Thinking –> rigid, habits and routines become more rigid
13
Q
Functioning of self regulation system during starvation
A
Decreased effect:
* Social situations thoughts
* Emotional regulation
* Decision making
* Flexibility
* Abilty to plan
Increased effect:
* Compulsive behaviours
* Avoidance
* Anxiety
* Sensitivity
14
Q
People without ED vs people with them reaction to hunger
A
Without ED:
* Hunger –> irritable –> seek food
* Satiety –> sense of pleasure and reward (enjoyable)
With ED:
* Hunger –> sense of calm
* Eating/satiety –> anxiety and guilt
15
Q
Assessment of ED - 3 aspects
A
- Psychiatric assessment
- Medical
- Risk - psych and physical
16
Q
Eating disorder history
A
- History of ED
- Current pattern eating
- Mechanisms of weight control
- Attitudes to weight and shape
- Current mood symptoms
- Current anxiety symptoms
17
Q
Aspects of psych assessment of ED
A
- What’s happening?
- When did it begin?
- Symptoms?
- Why unwell?
- Feelings about illness?
- What help do they want/need?
18
Q
History of eating disorder - assessment
A
19
Q
Current pattern of eating history - ED assessment
A
20
Q
Mechanisms of weight control history - ED
A
Where do they get pills from? - part of Risk
21
Q
Attitudes to weight and shape - ED assessment
A
22
Q
Physical symptoms to check for in ED assessment
A
- Refeeding syndrome can cause oedema
23
Q
Driving rules and BMI
A
- Advise not to drive if BMI under 15
24
Q
Risk assessment - ED assessment
A
- Current/past deliberate self harm
- Current and past suicidal thoughts inc plans and intent
- Risk to others inc children
- Risk from others
- Other risks - eg hypoglycaemia and falls etc
- Driving -
25
Physical examination - BMI and traffic light system grading of physical risk
* Red - BMI under 13 or rapid weight loss of more than 1kg per week in undernourished patient
* Amber - BMI 13-14.9 or recent weight loss 0.5-1kg per week in undernourushed patient
* Green - BMI more than 15 or recent weight loss of less than 0.5kg per week or fluctuating weight
26
General exam signs of ED
* Cachexia
* Signs of dehydration
* Lanugo hair
* Russells sign
* Salivary gland enlargement
27
HR for adults with ED
* Red - less than 40bpm
* Amber - 40-50
* Green - more than 50
28
BP physical examination risk of ED
* Red - standing BP under 90, associated with recurrent syncope, postural drop over 20mmHg or increase in HR over 30bpm
* Amber - standing BP more than 90, occassional syncope, postural drop 15mmHg or increase in HR up to 30
* Green - normal standing BP, normal CV orthostatic changes, normal rhytym
29
Temperature physicla signs ED risk
* Red - under 35.5 or under 35 axillary
* Amber - under 36
* Green - above 36
30
Hydration status physical examination ED risk
* Red - fluid refusal, severe dehydration 10%
* Amber - severe fluid restriction, moderate dehydration (5-10%)
* Green - minimal fluid restriction, no more than mild dehydration (<5%)
31
Testing muscle power SUSS test
* Red - unable to sit up from lying flat or to get up from squat at all or only by using upper limbs for help
* Amber - unable to sit up or standd from squat without noticable difficulty
* Green - able to sit from lying flat and stand from squat with no difficulty
32
Inv for ED
Bedside:
* Full obs - as above
* ECG
* Blood glucose
Bloods:
* FBC
* U&E
* LFT
* Bone profile
* TFT
* Mg
33
What happens to thyroid in biological adaptation to low weight?
* Adjusts free T4 to reduce its metabolic requirments - sick euthyroid syndrome
* = reduced resting metbolic rate, reduced temp and bradycardia
* Do not treat with thyroxine - make worse
34
Anorexia nervosa effects on body - medical complications
35
Medical complications of bulimia
| Often advise to use mouthwash after vomitting to reduce risk of acid dam
36
Managing medical emergencies in ED
* Use traffic light system to assess risk
* If need help - ask
* Use MEED guidelines - medical emergencies in eating disorders
37
Cause of refeeding syndrome (starvation and refeeding) - biochemical
38
Biochemical changes you get with refeeding syndrome
* Hypophosphataemia
* Hypomagnesaemia
* Hypokalaemia
* Vitamin deficiency
* Fluid retention --> oedema
39
Refeeding syndrome consequences
* Sodium retention and extracellular fluid expansion + thiamine deficiency --> congestive cardiac failure
* Cardiac arrythmias from deficiencies of K+, phosphate and Mg
* Neuro - delirium, neuropathy, seizures
* Respiratory failure - poor ventilation function
* Rhabdomyolysis - low phosphate causes muscle weakness and myalgia
* Thrombocytopenia and impaired blood clotting - low phosphate
40
Management of refeeding syndrome
* Specialist management - with dietician
* Close blood monitoring - daily
* Oral supplements and IVs may be needed
41
Management of anorexia nervosa - general points
* Psychoeducation about disorder
* Monitor weight, MH, physical health and risk factors
* Involve family/carers
* Aim to keep healthy weight/BMI
* Offer dietary advice as part of MDT - encourage multivitamins, meal planning and regular eating. Not more than 4hrs without eating etc
42
Psychotherapy for adults with anorexia
* Individual CBT-ED
* Individual maudsley anorexia nervosa treatment for adults - MANTRA
* Individual speciliast supportive clinical management - SSCM
* Individual docal psychodynamic therapy (FPT)
43
Psychotherapy for children with anorexia
* Anorexia family focused therapy (FT-AN) - first line
* Individual CBT-ED
* Individual adolescent focused psychotherapy for anorexia nervosa (AFP-AN) - 2nd line
44
Management bulimia nervosa - adults
* Guided self help in milder cases
* Otherwise - 20 sessions individual CBT-ED
45
Treatment for bulimia nervosa - children and young people
* Bulimia nervosa focused family therapy - FT-BN
* Individual CBT-ED (second line)
46
Treatment for binge eating disorder
* Stabilise eating and stop bingeing - not aimed at losing weight
* Guided self help programme - 1st line
* If ineffective after 4 weeks - group CBT-ED
* If not available, consider individual CBT
| Same in children
47
Treatment of OSFED
* Treatment for eating disorder it most closely resembles
48
Aim of therapy for ED
* Shift motivational position - hard work, so need motivation
* Restore healthy weight
* Help cope with life and express selves without resort to dietary restriction
* Get lifes back on track
49
Why is anorexia so difficult to treat?
* Egosyntonic - feels right
* Frightening - to gain weight, buy larger clothes
* Ambivalence - want to get better but also don't want to. Sometimes seen as seperate unhelpful part of person
50
When do we admit those with ED?
* Last resort usually
* Wants change but not progressing as outpatient
* OR immediate danger
* OR no adequate treatment locally
We can admit someone and detain them under MHA and feed against wishes if really necessary - always better to avoid this if possible
51
Capacity and use of MHA in eating disorders
* If they are at medical risk and refuse - need to be assessed for capacity and treated under appropriate criteria (common law in emergency if lack capacity or MHA)
* Impairment is often in their ability to rationally balance consequences of treatment that results in weight gain against their extreme fear of gaining weight
* If unsure - speak with MH liason team, ED consultant specialist
52
Outcomes of bulimia
50-70% recover completely
Rest have relapse and remitting course
53
Outcomes anorexia nervosa
* Around half fully reover
* 33% improve
* 20% remain chronically unwell
* Best chance of recovery is within 3 years of onset and when younger, first episode
* Outcome poor if disease lasts 10yrs or longer
* Average duration is 8yrs
54
Mortality rate AN
* Higher than any other MH disorder
* 4 in 5 related to physical causes
* 1 in 5 related to suicide
55
What predicts good outcome from ED?
* Motivation to change
* Short duration of illness
* Lower level of severity
* Onset during adolescence - brain neuroplasticity
* Good family function/support
* Lack of co-morbid conditions
56
Charities help for ED
* First steps
* Beat eating disorders
57
