1
Q
what are eating disorders
A
psychiatric conditions involving an unhealthy and distorted obsession with body image and food
2
Q
what are the 3 main eating disorders
A
- anorexia nervosa
- bulimia nervosa
- binge eating disorder
3
Q
in which population groups are eating disorders more common
A
females
young people
4
Q
what are the core clinical symptoms of anorexia
A
- restriction of food intake -> abnormally low body weight
- behaviours designed to prevent weight gain or continue loss
- excessive exercise
- fear of weight gain
- disturbance in perception of body
5
Q
what are medical complications of anorexisa nervosa
A
- Weight loss (e.g., 15% below expected or BMI less than 17.5)
- Amenorrhoea (absent periods)
- Osteoporosis
- Lanugo hair (fine, soft hair across most of the body)
- Hypotension
- Hypothermia
- Mood changes, including anxiety and depression
- cardiac
6
Q
what are associated behavioural symptoms of AN
A
- obessional behaviours around food
- episodes of binge eating followed by purging
- body checking
- hyperactivity
- frequent weighing
7
Q
what are associated pyschological symptoms of AN
A
- low self esteem
- social withdrawal
- perfectionism
- insomnia
8
Q
what is the core psychopathology of AN
A
- low self esteem: tend to value themselves based on weight and body shape rather than usual values of society
- due to distrubed body image, an emaciated patient typically believes they are overweight
- plus fear of weight leads to complex and exhaustive behviours to avoid gaining weight
9
Q
how does AN lead to amenorrhoea
A
disruption of HPG axis
- low levels of LH and FSH from the pituitary –> reduced activity of the ovaries (hypogonadism)
10
Q
what are examples of cardiac complications of AN
A
- arrhythmia
- cardiac atrophy
- sudden cardiac death
11
Q
how does osteoporosis arise in AN
A
- consequence of combination of low calcium and vitamin D, low weight, low circulating oestrogen
- bone density reversible with weight restoration
12
Q
how might hypokalaemia arise as a result of AN
A
- vomiting = loss of gastric acid –> metabolic alkalosis and hypoK
- laxative abuse
13
Q
what are common co-morbidities that might exist alongside AN
A
- depressive disorder
- OCD
- body dysmorphic disorder
- sleep disorder
14
Q
what is the most important prognostic sign of AN
A
severity of malnutrition
15
Q
what are poor prognostic factors of AN
A
- long length of illness at first presentation
- BMI < 14 at diagnosis
- older age of onset
- personality disorder
16
Q
what are the NICE management guidelines for AN
A
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM)
17
Q
what do NICE recommend as 1st line for children and young people with AN
A
anorexia focused family therapy
CBT 2nd line
18
Q
describe bulimia nervosa
A
tend to have normal weight unlike in anorexia - fluctuating weight
- binge eating followed by purging by inducing vomiting/taking laxatives to prevent calories from being absorbed
19
Q
what are signs of bulimia nervosa
A
- Erosion of teeth
- Swollen salivary glands
- Mouth ulcers
- Gastro-oesophageal reflux
- Calluses on the knuckles where they have been scraped across the teeth (called Russell’s sign)
20
Q
what are the 2 subtypes of BN
A
purging
non-purging
21
Q
what are the 3 core clinical symptoms of AN
A
- food restriction
- disordered body image
- fear of weight gain
22
Q
what is the pathophysiology of AN
A
- extreme starvation = reduction in hormones adrenaline + glucagon
- rise in hormone sensitive lipase = breakdown of fat –> FA + glycerol = ketones + glucose
- muscle –> aminio acids for gluconeogenesis
23
Q
what are the core clinical symptoms of bulimia nervosa
A
- frequent recurrent episodes of binge eating (at least once a week over at least 1 month)
- inappropriate compensatory behaviour to prevent weight e.g. fasting, vomiting
- preoccupation with body weight and shape
24
Q
what are the biochemical consequences of BN
A
- hypokalaemia –> weakness, cardiac arrhythmias, renal damage
- metabolic alkalosis and hypochloraemia
- laxatives + diuretics = fluid shifts, hyponatremia + metabolic acidosis
25
give 5 risk factors of BN
- fhx of eating disorder
- female
- age 15-40
- T1DM
- early menarche
- childhood obesity
26
what are the NICE recommendations for managing bulimia nervosa
* **referral for specialist care** is appropriate in all cases
* NICE recommend **bulimia-nervosa-focused guided self-help** for adults
* If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy **(CBT-ED)**
* children should be offered bulimia-nervosa-focused family therapy (FT-BN)
27
what is binge eating disorder
Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress
- person typically feels a loss of control
- **not a restrictive condition** like anorexia or bulimia, and patients are likely to be overweight
28
what are possible features of a binge
* A planned binge involving “binge” foods
* Eating very quickly
* Unrelated to feelings of hunger
* Becoming uncomfortably full
* Eating in a dazed state
29
what are positive blood findings in restrictive eating disorders
* Anaemia (low haemoglobin)
* Leucopenia (low white cell count)
* Thrombocytopenia (low platelets)
* Hypokalaemia (low potassium – due to vomiting or excessive laxatives)
## Footnote
Reduced bone marrow activity causes normocytic normochromic anaemia, leucopenia (with low neutrophils and low lymphocytes) and thrombocytopenia
30
what management might severe cases of eating disorders require
compulsory admission for observed refeeding and monitoring for refeeding syndrome
31
what is the most widely used questionnaire for detecting eating disorder
EDE-Q questionnaire
32
describe the pathophysiology of refeeding syndrome
- during prolonged starvation, **intracellular potassium, phosphate and magnesium are depleted**
- electrolytes **move from inside the cells to the blood** to maintain normal serum levels in the absence of dietary intake
- **cell metabolism reduces to conserve energy**, resulting in a loss of intracellular electrolytes
- During refeeding, various mechanisms **shift magnesium, potassium and phosphate out of the blood and sodium into the blood**
- **Carbohydrate** intake causes an **increase in insulin**, which **drives glucose, potassium and phosphate into cells**
- sodium/potassium ATP-pump actively pumps potassium into the cells and sodium out of the cells
- **insulin** causes **extra sodium reabsorption** in the kidneys
33
what are the overall electrolyte imbalances caused by refeeding syndrome
* Hypomagnesaemia
* Hypokalaemia
* Hypophosphataemia
* Fluid overload
34
how is refeeding syndrome managed
**local protocol under specialist supervision**
* Slowly reintroducing food with limited calories
* Magnesium, potassium, phosphate and glucose monitoring
* Fluid balance monitoring
* ECG monitoring in severe cases
* Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine
35
what are ICD-11 essential features of anorexia nervosa (2)
1. persistent pattern of restrictive eating or other behaviours aimed at establishing abnormally low body weight: fasting, choosing low calories food, hiding food
2. excessive preoccupation with body, weight and shape
36
what are ICD-11 essential features of bulimia nervosa (3)
- frequent, recurrent episodes of binge eating: once a week or more over period of at least 1 month
- repeated inappropriate compensatory behaviours to prevent weight gain
- excessive preoccupation with body weight or shape similar to AN
37
what are the ICD-11 essential features of binge eating disorder (3)
- frequent, recurrent episodes of binge eating: Once a week or more over a period of 3 months, discrete period of time, loss of control
- symptoms/behaviours not accounted for by another medical codition/mental disorder and not due to substance/medication
- marked distress about pattern of binge eating
38
what is the binge eating disorder cycle
39
what are ICD-11 essential features of ARFID
- pattern of eating is not motivated by preoccupation with body weight or shape
- restricted food intake and consequent weight loss or other impact on physical health or related functional impairment not due to: unavailability of food, not related to another medical condition
40
what are the features that ARFID does not have in common with other eating disorders
- does not affect body image
- dietary restriction not for specific purpose of losing weight
- does not have any features of behaviour associated with other eating disorders
41
what are **biological** predisposing factors to eating disorders
- genes
- neurotransmitters
- hormones
- FHx depression, anxiety, addiction
42
what are **psychological** predisposing factors to eating disorders
- low self esteem
- feelings of ineffectiveness or lack of control
- personality traits: perfectionism, obsessional
43
what are precipitating factors for an eating disorder (3)
- biological: puberty, physical illness/trauma, dieting
- pyschological: low mood, sense of lack of control
- social: interpersonal problems, grief/loss, social media
44
what are the psychological effects of starvation
- brain structure and self regulatory system in forebrain change
- anxiety and intense negative emotions increase
- coping ability reduces
- thinking becomes more rigid
45
how might an ED cause sick euthyroid syndrome
biological adaptation to low weight: body adjusts free T4 to reduce metabolic requirements
- reduced metabolic rate
- reduced body temp
- bradycardia
46
when might a pt with eating disorder require inpatient admission
patients wants to change but not progressing with outpt treatment
- pt is in immediate danger
- no adequate treatment locally
47
what are other disorders that might affect eating
- emetophobia
- depression
- OCD
- unclassified eating disorders
48
what are the symptoms of re feeding syndrome
- oedema
- SOB
- N&V
- HTN
49
what are the complications of refeeding syndrome
- arrhythmias
- HF
- muscle weakness
- rhabdo
- seizures
PSYCHIATRY
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