Eating disorders Flashcards

Question

Why should bupropion be avoided in eating disorders? ⸻ 1️⃣ Exam-style MCQ stem A 23-year-old woman with bulimia nervosa presents with low mood. Which antidepressant should be avoided due to an increased risk of serious adverse effects? A. Fluoxetine B. Sertraline C. Mirtazapine D. Venlafaxine E. Bupropion ⸻

Answer 1

✅ CORRECT ANSWER E. Bupropion (NDRI) ⸻ 2️⃣ Clear, exam-focused explanation Bupropion lowers the seizure threshold. Patients with eating disorders—especially bulimia nervosa—are already at high risk of seizures due to: • Electrolyte abnormalities: Hypokalaemia Hyponatraemia Hypomagnesaemia • Dehydration • Recurrent vomiting or laxative abuse 👉 Combining this baseline risk with bupropion significantly increases the risk of seizures, which can be fatal. 📌 This is a hard contraindication, not a preference. ⸻ 3️⃣ Pathophysiology (why seizures happen) Eating disorders cause: • Loss of potassium and chloride (vomiting, laxatives) • Acid–base disturbances • Neuronal instability Bupropion: • Inhibits norepinephrine and dopamine reuptake • Has dose-dependent seizure risk • Risk rises sharply with: Electrolyte imbalance Low BMI Purging behaviours 📌 Examiner logic: Two seizure risks together = absolute contraindication ⸻ 4️⃣ NICE / Maudsley / BNF exam rule • BNF: Bupropion is contraindicated in patients with eating disorders • Maudsley: • Avoid bupropion in anorexia and bulimia • NICE NG69: SSRIs (fluoxetine) preferred Avoid drugs that increase seizure risk 📌 Classification: Absolute contraindication ⸻ 5️⃣ High-yield facts to memorise (very examinable) 1. Bupropion lowers seizure threshold 2. Eating disorders increase seizure risk 3. Bulimia nervosa = highest risk 4. Risk is independent of dose 5. Contraindicated in anorexia and bulimia 6. Fluoxetine is the only antidepressant with strong evidence in bulimia

Answer 2

✅ CORRECT ANSWER E. Fluoxetine 60 mg ⸻ 2️⃣ Clear, exam-focused explanation • Fluoxetine is the only medication with robust evidence for treating bulimia nervosa • It reduces: Binge frequency Purging behaviours • Obsessive thoughts about food • Effective even in the absence of depression 📌 Key exam nuance: The effective dose in bulimia is higher than for depression. ⸻ 3️⃣ Dose-specific exam rule (VERY high yield) • Bulimia nervosa dose: 👉 Fluoxetine 60 mg daily • Depression dose: 👉 20–40 mg daily 📌 Examiner trick: If the answer says fluoxetine 20 mg, it is wrong for bulimia. ⸻ 4️⃣ NICE / DSM-5 / Maudsley guidance • NICE NG69 (Eating disorders): - CBT-ED = first-line - Fluoxetine 60 mg recommended as adjunct if symptoms persist • Maudsley Prescribing Guidelines: Only SSRI with consistent evidence • DSM-5: Medication supports symptom control, not diagnosis 📌 Classification: Adjunctive pharmacological treatment ⸻ 5️⃣ High-yield facts to memorise (core exam list) 1. Fluoxetine is first-choice medication in bulimia nervosa 2. Effective dose = 60 mg/day 3. Works even without comorbid depression 4. Best used with CBT-ED, not alone 5. Other SSRIs lack consistent evidence 6. TCAs increase cardiac risk → avoid 7. Bupropion is contraindicated (seizure risk) ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Choosing fluoxetine 20 mg • ❌ Choosing another SSRI (e.g. sertraline) • ❌ Using antidepressants as first-line instead of CBT-ED • ❌ Confusing anorexia and bulimia medication roles • ❌ Using bupropion for “weight neutrality” ⸻ 7️⃣ One-line exam answer (memorise verbatim) Fluoxetine 60 mg is the only medication with good evidence for bulimia nervosa and should be used as an adjunct to CBT-ED.

Answer 3

✅ CORRECT ANSWER C. Repeated vomiting causing sialadenosis ⸻ 2️⃣ Clear, exam-focused explanation • In bulimia nervosa, recurrent self-induced vomiting leads to: - Chronic stimulation of salivary glands - Functional (non-inflammatory) enlargement • This causes sialadenosis: Bilateral Painless Non-tender • Most commonly affects the parotid glands 📌 There is no infection, no autoimmune process, and no inflammation. ⸻ 3️⃣ Pathophysiology (why this happens) Repeated vomiting → ⬆ Parasympathetic stimulation + metabolic stress → ⬆ Salivary gland acinar hypertrophy → ➡ Sialadenosis Key features: • Non-inflammatory • Reversible with cessation of purging • Often accompanied by: • Dental erosion • Russell’s sign • Electrolyte disturbances ⸻ 4️⃣ NICE / ICD-11 / DSM-5 exam rule • Bulimia nervosa is associated with: • Vomiting-related complications • Salivary gland enlargement = classic peripheral sign • This finding supports: • Diagnosis • Chronicity • Ongoing purging behaviour 📌 This is a diagnostic clue, not a separate disease. ⸻ 5️⃣ High-yield facts to memorise 1. Parotid swelling in bulimia is painless and bilateral 2. Caused by repeated vomiting 3. Term = sialadenosis 4. Not infectious 5. Not autoimmune 6. Improves when purging stops 7. Often coexists with dental erosion ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Calling it parotitis (would be painful + inflammatory) • ❌ Thinking Sjögren’s (dry eyes/mouth, autoimmunity) • ❌ Assuming infection • ❌ Missing that this is a sign of bulimia, not a separate diagnosis ⸻ 7️⃣ One-line exam answer (memorise verbatim) Bilateral painless parotid enlargement in bulimia nervosa is due to repeated vomiting causing sialadenosis.

Answer 4

✅ Hypokalaemic nephropathy 📌 Leads to: • Tubulointerstitial damage • Polyuria • CKD over time

Answer 5

✅ Metabolic acidosis (normal anion gap) Why? • Laxatives → diarrhoea • Loss of bicarbonate • → Hyperchloraemic metabolic acidosis 📌 Contrast this with vomiting: • Vomiting → loss of HCl → metabolic alkalosis 🔑 Exam trigger Vomiting = alkalosis Laxatives = acidosis

Answer 6

✅ Arrhythmias due to hypokalaemia 📌 Often tested indirectly via: • QT prolongation • Sudden collapse • Electrolyte derangement 🔑 Rule Electrolytes kill in bulimia — not weight

Answer 7

✅ CORRECT ANSWER D. Bulimia nervosa ⸻ 2️⃣ Clear, exam-focused explanation Bulimia nervosa is diagnosed when all three core criteria are met: Core diagnostic triad: 1. Recurrent binge eating • Eating an objectively large amount • Sense of loss of control 2. Compensatory behaviours • Vomiting, laxatives, fasting, excessive exercise 3. Normal or near-normal weight • BMI typically in normal range This patient: • Binges ✔ • Purges ✔ • BMI 23 (normal) ✔ • Duration ≥ 3 months ✔ 📌 Examiner logic: Normal BMI + binge–purge behaviour = bulimia, not anorexia. ⸻ 3️⃣ DSM-5 / ICD-11 / NICE exam rule (VERY high-yield) • Minimum frequency: 👉 Once weekly for ≥ 3 months • Weight: 👉 Normal or above normal • Overvaluation of weight/shape is present 📌 Classification: Diagnostic threshold question ⸻ 4️⃣ High-yield facts to memorise 1. Bulimia = binge + compensate 2. BMI is normal 3. Frequency ≥ once weekly 4. Duration ≥ 3 months 5. Vomiting is the most common compensatory behaviour 6. Often hidden → normal appearance ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Calling this anorexia (BMI is normal) • ❌ Calling it binge eating disorder (no purging) • ❌ Calling it purging disorder (binges are present) • ❌ Ignoring duration requirement ⸻ 6️⃣ One-line exam answer (memorise verbatim) Bulimia nervosa is characterised by recurrent binge eating with compensatory behaviours in a person of normal weight.

Answer 8

✅ CORRECT ANSWER D. Once weekly for 3 months ⸻ 2️⃣ Clear, exam-focused explanation For a diagnosis of bulimia nervosa, DSM-5 and ICD-11 require: Frequency criterion: • Binge eating + compensatory behaviour • Occurring at least once per week • For a minimum duration of 3 months This threshold: • Distinguishes bulimia from transient disordered eating • Prevents over-diagnosis • Is a classic MRCPsych recall question 📌 Examiner logic: If frequency or duration is below threshold → no bulimia diagnosis. ⸻ 3️⃣ DSM-5 / ICD-11 / NICE exam rule • DSM-5 & ICD-11: 👉 ≥ 1 episode/week for ≥ 3 months • Applies to both bingeing and compensatory behaviours • Severity specifier depends on weekly frequency 📌 Classification: Diagnostic threshold rule ⸻ 4️⃣ High-yield facts to memorise 1. Minimum frequency = once weekly 2. Minimum duration = 3 months 3. Same rule used in DSM-5 and ICD-11 4. Below threshold → consider OSFED 5. Frequency determines severity (mild → extreme) ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing “twice weekly” (old DSM-IV rule) • ❌ Choosing “1 month” duration • ❌ Thinking frequency must be daily • ❌ Forgetting the 3-month requirement ⚠️ Very common trap: Older clinicians remember DSM-IV (twice weekly) — this is outdated. ⸻ 6️⃣ One-line exam answer (memorise verbatim) Bulimia nervosa requires binge–purge behaviours occurring at least once weekly for a minimum of three months.

Answer 9

✅ CORRECT ANSWER C. Russell sign ⸻ 2️⃣ Clear, exam-focused explanation Russell sign refers to: • Calluses, abrasions, or scars over the dorsum of the knuckles • Caused by repeated contact with teeth during self-induced vomiting It is: • Highly suggestive (pathognomonic) of purging behaviour • Most commonly seen in bulimia nervosa • Less common in anorexia (unless binge–purge subtype) 📌 Examiner logic: Visible physical sign → points directly to purging rather than restriction. ⸻ 3️⃣ DSM-5 / ICD-11 / NICE exam rule • Russell sign is not diagnostic by itself • BUT strongly supports: • Bulimia nervosa • Or anorexia nervosa, binge–purge subtype • Often appears alongside: Dental erosion Parotid swelling Electrolyte abnormalities 📌 Classification: Physical sign of compensatory behaviour ⸻ 4️⃣ High-yield facts to memorise 1. Russell sign = knuckle calluses 2. Caused by self-induced vomiting 3. Suggests purging, not restriction 4. Strongly associated with bulimia nervosa 5. Often bilateral and chronic 6. May be hidden by patients → examine hands ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Confusing Russell sign with lanugo (anorexia) • ❌ Calling it parotid swelling • ❌ Assuming it occurs in restrictive anorexia • ❌ Missing it by not examining hands ⚠️ Classic trap: Knuckles + vomiting → Russell sign, not eczema or trauma. ⸻ 6️⃣ One-line exam answer (memorise verbatim) Russell sign is callusing of the knuckles caused by repeated self-induced vomiting and is characteristic of bulimia nervosa

Answer 10

✅ CORRECT ANSWER C. Hypokalaemic hypochloraemic metabolic alkalosis ⸻ 2️⃣ Clear, exam-focused explanation In bulimia nervosa with vomiting: 🔬 Pathophysiology • Vomiting → loss of gastric HCl • ↓ Hydrogen ions → metabolic alkalosis • ↓ Chloride → hypochloraemia • Volume depletion → secondary hyperaldosteronism • Aldosterone → ↑ renal potassium loss → hypokalaemia 📌 Resulting biochemical triad: • Metabolic alkalosis • Hypokalaemia • Hypochloraemia 📌 Examiner logic: Vomiting = alkalosis, not acidosis. ⸻ 3️⃣ NICE / DSM-5 / ICD-11 exam rule • Vomiting-based purging → metabolic alkalosis • Laxative abuse (late-stage) → metabolic acidosis (exam contrast) • Hypokalaemia is the most dangerous abnormality → arrhythmias 📌 Classification: Medical complication of purging behaviour ⸻ 4️⃣ High-yield facts to memorise 1. Vomiting → hypokalaemic metabolic alkalosis 2. Loss of HCl drives alkalosis 3. Aldosterone causes potassium wasting 4. Hypokalaemia → QT prolongation & arrhythmias 5. Chloride is always low in vomiting 6. ECG monitoring is essential if K⁺ low ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Saying metabolic acidosis with vomiting • ❌ Confusing laxative abuse with vomiting • ❌ Forgetting chloride • ❌ Missing cardiac risk of hypokalaemia ⚠️ Classic contrast trap: • Vomiting → alkalosis • Laxatives → acidosis ⸻ 6️⃣ One-line exam answer (memorise verbatim) Self-induced vomiting in bulimia nervosa causes hypokalaemic hypochloraemic metabolic alkalosis.

Answer 11

✅ CORRECT ANSWER E. Family-based therapy (FBT / Maudsley method) ⸻ 2️⃣ Clear, exam-focused explanation In children and adolescents, anorexia nervosa is managed differently from adults. Why FBT is first-line: • Adolescents are: Still living with family Medically vulnerable Less cognitively autonomous Parents are enlisted as active agents of recovery • Focus is on: Restoring weight Normalising eating Reducing eating-disorder behaviours 📌 Examiner logic: This question tests developmental stage, not therapy preference. ⸻ 3️⃣ NICE / ICD-11 / exam rule (VERY high-yield) NICE NG69: • Children & adolescents → FBT (Maudsley) • Adults → MANTRA / SSCM / CBT-E 📌 Classification: Age-dependent treatment algorithm ⸻ 4️⃣ What Family-Based Therapy (FBT) involves (exam-useful) Core principles: 1. Parents take control of refeeding 2. Eating disorder is externalised 3. Gradual return of control to the adolescent 4. Focus is behavioural, not insight-based 📌 Weight restoration is the first priority — psychological work comes later. ⸻ 5️⃣ High-yield facts to memorise 1. FBT is first-line for adolescents 2. Parents lead refeeding initially 3. Therapy is outpatient if medically stable 4. Individual therapy alone is not sufficient 5. Early intervention improves prognosis 6. FBT is sometimes called the Maudsley model ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Choosing CBT-E for adolescents • ❌ Choosing MANTRA (adult-only) • ❌ Thinking family involvement is optional • ❌ Delaying treatment until insight improves • ❌ Treating adolescents like adults ⸻ 7️⃣ One-line exam answer (memorise verbatim) Family-based therapy (Maudsley method) is the first-line psychological treatment for adolescents with anorexia nervosa.

Answer 12

✅ CORRECT ANSWER D. There is no evidence for medication in treating core symptoms ⸻ 2️⃣ Clear, exam-focused explanation There is no medication that effectively treats the core psychopathology of anorexia nervosa, which includes: • Fear of weight gain • Body image distortion • Restrictive eating behaviours Why medication doesn’t work for core symptoms: • Starvation alters: Neurotransmitter function Drug metabolism Psychological drivers are not pharmacologically mediated • Weight restoration is required before any meaningful psychotropic effect 📌 Examiner logic: They are testing your ability to avoid inappropriate prescribing. ⸻ 3️⃣ NICE / ICD-11 / Maudsley exam rule (VERY high-yield) • Do NOT use medication to treat: Weight gain Body image distortion Restrictive eating • Medication may be used ONLY for: Comorbid depression Comorbid anxiety Obsessive–compulsive symptoms 📌 Classification: Negative indication (what NOT to use) ⸻ 4️⃣ What medication can be used for (limited role) ✅ Appropriate indications: • SSRIs For comorbid depression/anxiety Only once nutritionally stable • Antipsychotics (e.g. olanzapine) Occasionally for severe anxiety or agitation Not evidence-based for weight gain • Electrolyte supplementation Medical, not psychiatric treatment 📌 None of these treat the core disorder. ⸻ 5️⃣ High-yield facts to memorise 1. No drug treats core anorexia nervosa 2. Weight restoration is primary treatment 3. SSRIs ineffective when malnourished 4. Medication may help comorbidity only 5. Antipsychotics are not first-line 6. Psychological therapy + nutrition = mainstay ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Prescribing antidepressants for weight gain • ❌ Assuming SSRIs prevent relapse • ❌ Using antipsychotics routinely • ❌ Treating anorexia like depression • ❌ Ignoring malnutrition effects on drugs ⸻ 7️⃣ One-line exam answer (memorise verbatim) There is no evidence for pharmacological treatment of the core symptoms of anorexia nervosa; medication is used only for comorbid conditions.

Answer 13

✅ CORRECT ANSWER C. Adaptive response to conserve heat due to malnutrition ⸻ 2️⃣ Clear, exam-focused explanation Lanugo hair in anorexia nervosa is a physiological adaptation, not a dermatological disease. Mechanism: • Severe malnutrition → loss of: • Subcutaneous fat • Insulation • Body compensates by: • Increasing fine, soft hair growth (lanugo) • Aiming to reduce heat loss 📌 Examiner logic: Lanugo = marker of chronic starvation, not hormone excess. ⸻ 3️⃣ NICE / pathophysiology exam rule • Lanugo is a sign of severe or prolonged malnutrition • Indicates: • Chronic caloric deficiency • Hypothermia risk • Often accompanied by: • Dry skin • Brittle hair • Cold intolerance 📌 Classification: Physical sign of starvation ⸻ 4️⃣ High-yield facts to memorise 1. Lanugo hair is fine, soft, downy 2. Seen in severe anorexia nervosa 3. Represents thermoregulatory adaptation 4. Not androgen-mediated 5. Reversible with nutritional rehabilitation 6. Signals medical severity ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing hyperandrogenism • ❌ Attributing to medication • ❌ Thinking it is cosmetic or genetic • ❌ Confusing with hirsutism (coarse hair) ⸻ 6️⃣ One-line exam answer (memorise verbatim) Lanugo hair in anorexia nervosa is an adaptive thermoregulatory response to severe malnutrition and loss of body fat.

Answer 14

✅ CORRECT ANSWER D. Prolonged QTc, arrhythmias, mitral valve prolapse ⸻ 2️⃣ Clear, exam-focused explanation Severe anorexia nervosa leads to structural and electrical cardiac abnormalities due to prolonged malnutrition. Key mechanisms: • Myocardial atrophy → reduced cardiac muscle mass • Electrolyte abnormalities (↓ K⁺, ↓ Mg²⁺) → electrical instability • Autonomic changes → bradycardia These changes predispose to: • QTc prolongation • Ventricular arrhythmias • Sudden cardiac death 📌 Examiner logic: They want recognition of arrhythmogenic risk, not inflammatory or hypertrophic disease. ⸻ 3️⃣ NICE / MARSIPAN exam rule (VERY high-yield) • All medically unstable patients with anorexia nervosa require: • ECG monitoring • QTc prolongation is a major predictor of mortality • Cardiac complications are the leading cause of death 📌 Classification: Medical complication → monitoring requirement ⸻ 4️⃣ High-yield cardiac complications to memorise 1. QTc prolongation 2. Bradycardia 3. Ventricular arrhythmias 4. Mitral valve prolapse 5. Reduced cardiac output 6. Sudden cardiac death 📌 These may occur even without symptoms. ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing hypertrophic cardiomyopathy • ❌ Choosing myocarditis • ❌ Assuming cardiac risk only during refeeding • ❌ Forgetting ECG monitoring • ❌ Attributing bradycardia to athletic fitness ⸻ 6️⃣ One-line exam answer (memorise verbatim) Severe anorexia nervosa can cause prolonged QTc, arrhythmias, and mitral valve prolapse, necessitating ECG monitoring.

Answer 15

✅ CORRECT ANSWER D. Metabolic complications following refeeding in a malnourished patient ⸻ 2️⃣ Clear, exam-focused explanation Refeeding syndrome is a potentially fatal metabolic state that occurs when nutrition is restarted after prolonged starvation. Core mechanism: • Starvation → low insulin, catabolic state • Refeeding → sudden insulin surge • Insulin drives: • Phosphate • Potassium • Magnesium into cells ➡️ Leads to severe electrolyte depletion in blood 📌 Examiner logic: This is not about “too much food” — it’s about rapid metabolic shift. ⸻ 3️⃣ Pathophysiology (high-yield, examiner-loved) Key biochemical changes: • ↓ Phosphate (MOST IMPORTANT) • ↓ Potassium • ↓ Magnesium • ↑ Insulin • ↑ Fluid retention Why phosphate matters: • Required for: • ATP production • Cardiac contractility • Respiratory muscle function ➡️ Severe hypophosphataemia = cardiac failure + death ⸻ 4️⃣ Clinical features (what the exam expects) 🚨 Signs and complications: • Cardiac failure • Arrhythmias • Hypotension • Respiratory failure • Seizures • Rhabdomyolysis • Sudden death 📌 Often occurs within 2–5 days of refeeding ⸻ 5️⃣ High-yield prevention strategy (VERY examinable) Refeeding syndrome is PREVENTABLE. Correct prevention: • Start low calories • Increase slowly • Monitor electrolytes DAILY • Replace electrolytes proactively • Give thiamine before feeding 📌 NICE / MARSIPAN recommendation: • Start at 5–10 kcal/kg/day in high-risk patients ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Thinking refeeding syndrome is psychological • ❌ Forgetting phosphate (most tested electrolyte) • ❌ Feeding aggressively “to help weight gain” • ❌ Giving glucose before thiamine • ❌ Assuming risk ends once eating starts ⸻ 7️⃣ One-line exam answer (memorise verbatim) Refeeding syndrome is a potentially fatal metabolic complication caused by rapid reintroduction of nutrition in a severely malnourished patient, leading to electrolyte shifts—especially hypophosphataemia.

Answer 16

✅ CORRECT ANSWER D. Start low calories, increase slowly, monitor electrolytes, supplement thiamine ⸻ 2️⃣ Clear, exam-focused explanation Refeeding syndrome is predictable and preventable if feeding is done gradually and biochemically monitored. Prevention targets the mechanism: • Refeeding → insulin surge • Insulin → intracellular shift of phosphate, potassium, magnesium • Prevention = slow metabolic transition 📌 Examiner logic: They are testing safe refeeding, not weight gain speed. ⸻ 3️⃣ NICE / MARSIPAN exam rule (VERY high yield) High-risk patients (e.g. anorexia nervosa): • BMI < 15 • Minimal intake for >10 days • Rapid recent weight loss Recommended approach: • Start feeding at 5–10 kcal/kg/day • Increase gradually over 4–7 days • Daily monitoring of: • Phosphate • Potassium • Magnesium • Give thiamine BEFORE feeding 📌 Classification: Medical risk prevention protocol ⸻ 4️⃣ High-yield facts to memorise 1. Start calories low 2. Increase calories slowly 3. Monitor electrolytes daily 4. Hypophosphataemia is the key danger 5. Give thiamine before glucose 6. Refeeding syndrome usually occurs within 2–5 days 7. Prevention saves lives ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Feeding aggressively to “correct malnutrition” • ❌ Waiting for electrolyte symptoms before acting • ❌ Forgetting thiamine • ❌ Thinking refeeding syndrome is rare • ❌ Assuming normal baseline electrolytes = low risk ⸻ 6️⃣ One-line exam answer (memorise verbatim) Refeeding syndrome is prevented by starting nutrition at low caloric intake, increasing slowly, monitoring electrolytes closely, and supplementing thiamine before feeding.

Answer 17

✅ CORRECT ANSWER D. MANTRA / SSCM / eating-disorder-focused CBT ⸻ 2️⃣ Clear, exam-focused explanation In adults with anorexia nervosa, NICE does not recommend a single superior therapy. Instead, it endorses three evidence-based options: ✅ NICE-recommended first-line therapies (adults): • MANTRA Maudsley Model of Anorexia Nervosa Treatment for Adults • SSCM Specialist Supportive Clinical Management • CBT-E Eating-disorder-focused cognitive behavioural therapy 📌 Examiner logic: This question tests adult vs adolescent distinction and avoidance of “one-size-fits-all”. ⸻ 3️⃣ NICE / ICD-11 exam rule (VERY high-yield) • Adults → MANTRA / SSCM / CBT-E • Adolescents → FBT (family-based therapy) 📌 Classification: Age-specific treatment selection ⸻ 4️⃣ What each therapy targets (quick examiner-friendly summary) 🔹 MANTRA • Targets: • Cognitive rigidity • Emotional avoidance • Interpersonal difficulties • Best for: • Chronic anorexia • Insight-limited patients 🔹 SSCM • Combines: • Nutritional support • Psychoeducation • Supportive therapy • Often as effective as MANTRA in trials 🔹 CBT-E • Targets: • Over-evaluation of weight/shape • Maladaptive eating behaviours • Structured and time-limited ⸻ 5️⃣ High-yield facts to memorise 1. No single therapy is superior in adults 2. MANTRA, SSCM, and CBT-E are all first-line 3. Choice depends on patient preference and formulation 4. FBT is not first-line in adults 5. Psychological therapy is ineffective without medical stability ⸻ 6️⃣ Common MRCPsych exam traps • ❌ Choosing FBT for adults • ❌ Assuming CBT-E is the only answer • ❌ Thinking psychodynamic therapy is first-line • ❌ Forgetting age distinction • ❌ Treating before medical stabilisation ⸻ 7️⃣ One-line exam answer (memorise verbatim) First-line psychological treatments for adult anorexia nervosa are MANTRA, SSCM, or eating-disorder-focused CBT, with no clear superiority.

Answer 18

✅ CORRECT ANSWER C. 5–10% ⸻ 2️⃣ Clear, exam-focused explanation Anorexia nervosa has the highest mortality rate of all psychiatric disorders. Mortality arises from two main mechanisms: 1. Medical complications • Cardiac arrhythmias • Electrolyte disturbance • Refeeding syndrome 2. Suicide 📌 Examiner logic: They want: • The numerical range • Recognition that this is exceptionally high for psychiatry ⸻ 3️⃣ NICE / ICD-11 / MARSIPAN exam rule • Lifetime mortality: ~5–10% • Risk increases with: • Longer duration of illness • Lower BMI • Medical instability • Comorbid depression • Poor treatment engagement 📌 Classification: Prognosis / epidemiology ⸻ 4️⃣ High-yield facts to memorise (VERY examinable) 1. Anorexia nervosa has the highest mortality of all psychiatric disorders 2. Lifetime mortality ≈ 5–10% 3. ≈ 50% of deaths are due to medical causes 4. ≈ 20–30% of deaths are due to suicide 5. Cardiac complications are the leading cause 6. Mortality persists even after partial weight restoration ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Underestimating mortality (e.g. choosing 1–2%) • ❌ Assuming suicide is the most common cause (it is not) • ❌ Forgetting medical causes • ❌ Thinking mortality normalises quickly with treatment ⸻ 6️⃣ One-line exam answer (memorise verbatim) Anorexia nervosa has a lifetime mortality of approximately 5–10%, the highest of any psychiatric disorder. ⸻ 7️⃣ Exam trigger rule If you see: 👉 “Mortality rate” + “anorexia nervosa” → Think: 5–10% (highest in psychiatry)

Answer 19

✅ CORRECT ANSWER D. Hypokalaemia ⸻ 2️⃣ Clear, exam-focused explanation Hypokalaemia is the most immediately life-threatening electrolyte abnormality in anorexia nervosa because of its cardiac effects. Why potassium matters most: • Potassium is essential for: • Cardiac membrane stability • Normal repolarisation • Low potassium leads to: • QT prolongation • Ventricular arrhythmias • Sudden cardiac death 📌 Examiner logic: They are testing acute lethality, not frequency. ⸻ 3️⃣ NICE / MARSIPAN / exam rule • Hypokalaemia = medical emergency • Particularly common in: • Binge–purge subtype • Vomiting • Laxative or diuretic misuse 📌 Classification: Immediate cardiac risk ⸻ 4️⃣ High-yield facts to memorise 1. Hypokalaemia is the most dangerous electrolyte abnormality 2. Causes fatal arrhythmias 3. Strongly associated with purging behaviours 4. Leads to QTc prolongation 5. Requires urgent correction + ECG monitoring 6. Magnesium deficiency worsens potassium loss ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing hypophosphataemia (important but later — refeeding) • ❌ Choosing hyponatraemia (less arrhythmogenic) • ❌ Thinking electrolyte risk is only during refeeding • ❌ Forgetting ECG monitoring ⸻ 6️⃣ One-line exam answer (memorise verbatim) Hypokalaemia is the most dangerous electrolyte abnormality in anorexia nervosa due to its risk of fatal cardiac arrhythmias.

Answer 20

✅ CORRECT ANSWER D. Cardiac complications ⸻ 2️⃣ Clear, exam-focused explanation Although suicide risk is high in anorexia nervosa, the most common overall cause of death is medical, not psychiatric. Cardiac complications arise due to: • Severe malnutrition → myocardial atrophy • Electrolyte abnormalities (↓ potassium, ↓ magnesium) • QTc prolongation • Bradyarrhythmias and ventricular arrhythmias These can lead to sudden cardiac death, often without warning. 📌 Examiner logic: They want you to distinguish leading cause (cardiac) from important cause (suicide). ⸻ 3️⃣ NICE / ICD-11 / MARSIPAN exam rule • ≈50% of deaths in anorexia nervosa are due to medical complications • ≈20–30% are due to suicide • Cardiac causes dominate medical mortality 📌 Classification: Mortality mechanism ⸻ 4️⃣ High-yield facts to memorise 1. Anorexia nervosa has the highest mortality of all psychiatric disorders 2. Cardiac causes are the leading cause of death 3. QTc prolongation predicts sudden death 4. Suicide remains a major but secondary cause 5. Risk persists even at low-normal BMI during recovery ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing suicide as the most common cause • ❌ Choosing refeeding syndrome (important but less common) • ❌ Assuming infection is a leading cause • ❌ Forgetting cardiac monitoring in malnourished patients ⸻ 6️⃣ One-line exam answer (memorise verbatim) The most common cause of death in anorexia nervosa is cardiac complications secondary to malnutrition.

Answer 21

✅ CORRECT ANSWER D. Medical instability requiring admission ⸻ 2️⃣ Clear, exam-focused explanation Bradycardia, hypotension, and hypothermia are red-flag physiological signs in anorexia nervosa and indicate systemic compromise due to malnutrition. Pathophysiology: • Bradycardia → reduced cardiac mass, increased vagal tone • Hypotension → dehydration, reduced circulating volume • Hypothermia → loss of insulating fat + reduced metabolic rate 📌 Examiner logic: These are NOT benign adaptations — they signal imminent medical risk. ⸻ 3️⃣ NICE / ICD-11 / MARSIPAN exam rule According to NICE NG69 and MARSIPAN guidance: 👉 Any evidence of cardiovascular instability = medical admission This applies regardless of BMI. 📌 Classification: Medical emergency threshold ⸻ 4️⃣ High-yield admission criteria to memorise (VERY exam-favourite) 🚨 Absolute admission indicators in anorexia: • HR < 40 bpm • Systolic BP < 90 mmHg • Core temperature < 35°C • Rapid weight loss • Syncope • Electrolyte disturbance (↓K⁺, ↓PO₄³⁻) • ECG abnormalities (QTc prolongation) • Severe dehydration 📌 BMI alone is NOT enough — vital signs trump BMI. ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Calling these “adaptive” • ❌ Delaying admission pending psychotherapy • ❌ Treating as anxiety or depression • ❌ Waiting for lab abnormalities before acting ⸻ 6️⃣ One-line exam answer (memorise verbatim) Bradycardia, hypotension, and hypothermia in anorexia nervosa indicate medical instability and require urgent admission.

Answer 22

✅ CORRECT ANSWER D. BMI < 17.5 kg/m² ⸻ 2️⃣ Clear, exam-focused explanation • In adults, anorexia nervosa is defined by: Significantly low body weight Intense fear of weight gain Distorted body image / overvaluation of weight and shape • A BMI < 17.5 kg/m² is the classic exam threshold used in: ICD-10 / ICD-11-aligned exam questions MRCPsych Paper B stems • Some guidelines also use: <85% of expected body weight (especially in adolescents) 📌 Examiner logic: They are testing diagnostic threshold, not severity or admission criteria. ⸻ 3️⃣ NICE / ICD-11 / exam rule • Adults: • BMI <17.5 kg/m² → anorexia nervosa • Adolescents: • <85% expected weight (BMI centiles preferred) • Severity specifiers (ICD-11): Mild: BMI ≥17 Moderate: 16–16.9 Severe: 15–15.9 Extreme: <15 📌 Classification: Diagnostic criterion ⸻ 4️⃣ High-yield facts to memorise 1. BMI < 17.5 kg/m² = anorexia nervosa (adults) 2. BMI < 18.5 kg/m² = underweight (❌ not diagnostic) 3. BMI < 15 kg/m² = extreme severity, not diagnostic threshold 4. Diagnosis requires psychological features, not BMI alone 5. Adolescents use expected weight, not absolute BMI ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing 18.5 (that’s just “underweight”) • ❌ Choosing 15 (that’s severity/admission territory) • ❌ Forgetting that BMI thresholds differ in adolescents • ❌ Assuming BMI alone is sufficient for diagnosis ⸻ 6️⃣ One-line exam answer (memorise verbatim) In adults, anorexia nervosa is diagnosed when BMI is below 17.5 kg/m² in the presence of characteristic psychological features

Answer 23

✅ CORRECT ANSWER B. 0.5–1% ⸻ 2️⃣ Clear, exam-focused explanation • Anorexia nervosa is: Relatively uncommon But associated with high morbidity and mortality • Epidemiological data consistently show: Lifetime prevalence: ~0.5–1% Much higher prevalence in females • Despite low prevalence: It is one of the deadliest psychiatric disorders 📌 Examiner logic: They are testing population epidemiology, not incidence, not mortality, not service prevalence. ⸻ 3️⃣ NICE / ICD-11 / exam rule • Lifetime prevalence (general population): 0.5–1% • Female : male ratio: ~10 : 1 • Peak onset: Adolescence / young adulthood 📌 Classification: Epidemiology fact ⸻ 4️⃣ High-yield facts to memorise 1. Lifetime prevalence = 0.5–1% 2. Female predominance ≈ 10:1 3. One of the highest mortality rates in psychiatry 4. Prevalence ≠ incidence (exam trap) 5. Bulimia nervosa is more common than anorexia ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing 5–10% (that’s closer to depression/anxiety) • ❌ Confusing prevalence with mortality • ❌ Assuming prevalence reflects service burden • ❌ Overestimating prevalence because of media exposure ⸻ 6️⃣ One-line exam answer (memorise verbatim) The lifetime prevalence of anorexia nervosa is approximately 0.5–1% in the general population.

Answer 24

✅ CORRECT ANSWER D. Adolescence to early adulthood (14–18 years) ⸻ 2️⃣ Clear, exam-focused explanation • Anorexia nervosa most commonly begins in: Adolescence With bimodal peaks • Epidemiological studies consistently show: First peak around 14 years Second peak around 18 years • This timing coincides with: Pubertal changes Body image vulnerability Psychosocial stressors (school, exams, identity) 📌 Examiner logic: They want the typical age range, not the youngest reported case or rare adult-onset presentations. ⸻ 3️⃣ NICE / ICD-11 / exam rule • Typical onset: 14–18 years • Can occur: Earlier (rare) Later (possible, but less common) • Adolescents require: Different treatment pathways (e.g. family-based therapy) 📌 Classification: Epidemiology + clinical course ⸻ 4️⃣ High-yield facts to memorise 1. Typical onset: 14–18 years 2. Bimodal peaks: ~14 and ~18 3. Female predominance strongest in adolescence 4. Early onset often predicts: • Longer illness duration 5. Adult-onset anorexia exists but is uncommon ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Choosing early childhood (too young) • ❌ Choosing middle adulthood (possible but atypical) • ❌ Assuming onset mirrors bulimia (which is later) • ❌ Forgetting bimodal adolescent peaks ⸻ 6️⃣ One-line exam answer (memorise verbatim) Anorexia nervosa most commonly begins in adolescence, typically between 14 and 18 years of age.

Answer 25

✅ CORRECT ANSWER C. Restricting and binge–purge types ⸻ 2️⃣ Clear, exam-focused explanation Anorexia nervosa is divided into two subtypes, based on behavioural pattern, not BMI or severity: 🔹 Restricting type • Weight loss achieved primarily through: Dietary restriction Fasting Excessive exercise No regular binge eating or purging 🔹 Binge–purge type • Episodes of: Binge eating and/or Purging behaviours (vomiting, laxatives, diuretics) • Despite purging, BMI remains underweight 📌 Key distinction: The diagnosis is still anorexia nervosa because the patient is underweight — not bulimia. ⸻ 3️⃣ ICD-11 / NICE / exam rule • Subtyping is based on: Behavioural features Not weight alone • Binge–purge subtype: Has worse prognosis • Higher rates of: Electrolyte disturbance Medical complications Transition to bulimia 📌 Classification: Diagnostic subtyping + prognosis ⸻ 4️⃣ High-yield facts to memorise 1. Two subtypes: restricting and binge–purge 2. Both require low body weight 3. Binge–purge subtype: • Worse prognosis • Higher relapse risk 4. Purging ≠ bulimia unless weight is normal 5. Subtype can change over time ⸻ 5️⃣ Common MRCPsych exam traps • ❌ Calling binge–purge anorexia “bulimia” • ❌ Assuming purging excludes anorexia • ❌ Thinking subtype is fixed for life • ❌ Confusing binge–purge anorexia with binge eating disorder ⸻ 6️⃣ One-line exam answer (memorise verbatim) Anorexia nervosa has two subtypes: restricting type and binge–purge type, with the latter associated with poorer prognosis.

Answer 26

✅ CORRECT ANSWER D. Refeeding syndrome ⸻ 2️⃣ Clear, exam-focused explanation Refeeding syndrome is a metabolic catastrophe caused by rapid reintroduction of nutrition in malnourished patients. Pathophysiology (exam favourite): • Feeding → insulin surge • Insulin shifts phosphate, potassium, magnesium into cells • Leads to: Hypophosphataemia (hallmark) Cardiac failure Arrhythmias Death 📌 Examiner logic: Symptoms after feeding + malnutrition = refeeding syndrome. ⸻ 3️⃣ Key biochemical abnormalities 🔴 Hallmark • Hypophosphataemia ⭐ 🔴 Others • Hypokalaemia • Hypomagnesaemia • Thiamine deficiency • Fluid overload ⸻ 4️⃣ Prevention & management (VERY high yield) ✅ Prevention • Start low, go slow 5–10 kcal/kg/day initially Thiamine before feeding • Monitor: Phosphate Potassium Magnesium • ECG ❌ What causes it • Aggressive feeding • IV glucose without thiamine • Poor monitoring ⸻ 5️⃣ High-yield facts 1. Refeeding syndrome can be fatal 2. Hypophosphataemia is the key abnormality 3. Occurs within 2–5 days of feeding 4. Prevent with slow refeeding 5. Always give thiamine first ⸻ 6️⃣ Common exam traps • ❌ Feeding “to help faster” • ❌ Ignoring phosphate levels • ❌ Confusing with Wernicke’s (which is pre-feeding) • ❌ Starting glucose before thiamine ⸻ 7️⃣ One-line exam answer Refeeding syndrome is a potentially fatal metabolic complication caused by insulin-mediated electrolyte shifts following nutritional repletion.

Answer 27

✅ CORRECT ANSWER D. Urgent medical admission ⸻ 2️⃣ Clear, exam-focused explanation This question tests medical instability, not diagnosis or psychotherapy. Medical admission is required when anorexia causes physiological compromise, including: • Cardiovascular instability • Electrolyte disturbance • Hypothermia • Very low BMI 📌 Examiner logic: Low weight + vital sign abnormality = medical emergency, not psychiatric outpatient care. ⸻ 3️⃣ NICE / Maudsley admission criteria (memorise) Admit if ANY of the following are present: 🔴 Weight • BMI <14 kg/m² (adults) • Rapid weight loss (>1 kg/week) 🔴 Cardiovascular • HR <40 bpm • BP <90 systolic • Postural drop >20 mmHg • QTc prolongation 🔴 Metabolic • Hypokalaemia • Hypophosphataemia • Hypoglycaemia 🔴 Temperature • <35.5°C 🔴 Other • Syncope • Dehydration • Inability to eat • Failed outpatient management ⸻ 4️⃣ High-yield facts to memorise 1. Bradycardia is adaptive but dangerous 2. QTc prolongation → sudden cardiac death 3. Medical admission precedes psychiatric treatment 4. Normal labs do NOT exclude instability 5. Refeeding must be done in hospital if unstable ⸻ 5️⃣ Common exam traps • ❌ “She looks well” → vitals matter more • ❌ Treating low BMI without checking HR • ❌ Starting SSRIs in malnourished patients • ❌ Delaying admission for therapy ⸻ 6️⃣ One-line exam answer Patients with anorexia nervosa and medical instability require urgent inpatient medical admission.

Answer 28

Answer: Adolescent onset vs adult onset Explanation: Earlier onset (especially adolescence) is associated with better recovery rates and shorter illness duration compared with adult-onset anorexia.

Answer 29

Answer: Family therapy (FT-AN) Explanation: NICE recommends family-based treatment (Maudsley model) as first-line for anorexia nervosa in children and adolescents. Medication is not first-line.

Answer 30

71. Anorexia nervosa first-line (children): Family therapy (FT-AN) 72. Medication not first line 73. Highest mortality of psychiatric disorders 74. Hospitalize if medically unstable 75. Weight restoration crucial for recovery

Answer 31

(Sit-Up-Squat-Stand Test) High-yield MRCPsych / CAMHS fact 🚨 ❓ What is the SUSS test used for? Screening for proximal muscle weakness in severe malnutrition (e.g., anorexia nervosa) → helps assess medical instability and need for admission. ⸻ 🧪 How to perform it Ask the patient to do three tasks without using their arms: 1️⃣ Sit up from lying → tests core strength 2️⃣ Squat down → tests lower limb strength 3️⃣ Stand up from squat → tests proximal muscle power 🚨 Why it matters in eating disorders Severe malnutrition → muscle wasting → proximal myopathy → cardiac & respiratory risk. Positive SUSS (cannot complete tasks) suggests: • Severe protein-energy malnutrition • High risk of collapse • Possible refeeding complications • Need for urgent specialist assessment

Answer 32

✅ Correct Answer D. White cell count of 3.0 × 10⁹/L ⸻ 🧠 Explanation In patients with severe eating disorders (particularly anorexia nervosa), significant leucopenia can indicate severe malnutrition and bone marrow suppression. A white cell count of 3.0 × 10⁹/L is markedly low and suggests bone marrow dysfunction due to starvation, which reflects advanced physiological compromise. Severe malnutrition can lead to: • Bone marrow suppression • Gelatinous marrow transformation • Reduced immune function • High risk of metabolic collapse during refeeding Because of this, marked leucopenia is considered a marker of severe systemic compromise and impending medical risk. This aligns with MARSIPAN guidance, which highlights severe haematological abnormalities as warning signs in anorexia nervosa. ⸻ ❌ Why the Other Options Are Wrong A. Tympanic temperature of 35.9 °C Mild hypothermia is common in anorexia, but life-threatening hypothermia is usually <35 °C. Therefore this temperature alone does not indicate imminent risk. ⸻ B. Unable to sit up or stand from squat without difficulty This reflects proximal muscle weakness from malnutrition, but it is not itself an immediate life-threatening marker. ⸻ C. Serum potassium of 3.1 mmol/L This represents mild–moderate hypokalaemia. Life-threatening electrolyte disturbance usually occurs when K⁺ <2.5–3.0 mmol/L or when there are ECG changes. ⸻ E. Vomiting three times a week Purging behaviour increases risk but frequency alone does not indicate immediate medical danger. ⸻ 🔥 High-Yield MRCPsych Facts (Eating Disorders – Medical Risk) • Anorexia nervosa has the highest mortality of any psychiatric disorder. • Common haematological abnormalities: • leucopenia • anaemia • thrombocytopenia • Gelatinous transformation of bone marrow occurs due to starvation. • Hypokalaemia is a major cause of sudden death, especially with purging behaviours. • Refeeding syndrome risk factors: • low BMI • electrolyte abnormalities • prolonged starvation. • Cardiac complications (bradycardia, QT prolongation) are major causes of mortality. • MARSIPAN guidelines are used in the UK to assess medical risk in severe anorexia nervosa.

Answer 33

1️⃣ Heart Rate • <40 bpm Why dangerous: • Severe bradycardia from starvation • Risk of sudden cardiac death ⸻ 2️⃣ Blood Pressure • Systolic BP <90 mmHg Or • Postural drop >20 mmHg Indicates: • Severe dehydration • Cardiovascular compromise ⸻ 3️⃣ Body Temperature • <35 °C Indicates: • Severe metabolic slowing • Reduced thermogenesis from starvation ⸻ 4️⃣ BMI • BMI <13 This level indicates extreme starvation and high mortality risk. ⸻ 5️⃣ Potassium • K⁺ <2.5 mmol/L Danger: • Fatal arrhythmias • Especially common in purging anorexia ⸻ 6️⃣ Sodium • Na⁺ <125 mmol/L Danger: • Seizures • Cerebral oedema ⸻ 7️⃣ Phosphate • PO₄ <0.5 mmol/L Critical marker of refeeding syndrome risk. ⸻ 8️⃣ QTc Prolongation • QTc >500 ms High risk of: • Torsades de pointes • Sudden cardiac death ⸻ 9️⃣ White Cell Count • WCC <3.0 × 10⁹/L Suggests: • Bone marrow suppression • Severe malnutrition ⸻ 🔟 Glucose • Glucose <3 mmol/L Indicates: • Severe starvation • Risk of hypoglycaemic coma ⸻ 🧠 Extremely High-Yield Exam Associations Causes of death in anorexia 1. Cardiac arrhythmias 2. Electrolyte abnormalities 3. Suicide

Answer 34

Previous Exam Question ✅ The correct answer is Hypokalaemia. Vomiting in bulimia = hypokalaemia and metabolic alkalosis ECG features of hypokalaemia = PR prolongation, ST-segment and T-wave depression, and U-wave formation Hypokalaemia is a common electrolyte abnormality in patients with bulimia nervosa due to frequent vomiting, which leads to significant potassium loss. The symptoms described, such as leg cramps and ECG changes (PR prolongation and ST segment depression), are consistent with hypokalaemia. Clinically, hypokalaemia is a serious condition that can cause muscle weakness, cramps, and potentially life-threatening cardiac arrhythmias. Monitoring and correcting potassium levels is crucial in managing patients with bulimia nervosa to prevent these complications.

Answer 35

✅ Correct option: D. Vomiting is not necessary for a diagnosis of bulimia nervosa ⸻ Why D is correct • Bulimia nervosa requires recurrent binge eating + compensatory behaviours • Compensatory behaviours include: Self-induced vomiting Laxative misuse Diuretics Fasting Excessive exercise Vomiting is common but not mandatory • Weight is usually normal or slightly above normal ⸻ Why the distractors are wrong A Overweight patients cannot have bulimia → False. Bulimia patients often have normal or elevated BMI B No loss of control → False. Loss of control is a defining feature of binge eating C Abnormal eating in social settings → False. Binges usually occur secretly E CAGE used for bulimia → False CAGE screens for alcohol misuse SCOFF screens for eating disorders Examiner logic: test core diagnostic criteria vs common myths ⸻ 4️⃣ 📘 NICE / ICD-11 / DSM-5 / Maudsley rules What is being tested: Diagnosis ICD-11 bulimia nervosa criteria include: • Recurrent binge eating • Subjective loss of control • Compensatory behaviours to prevent weight gain • Preoccupation with body weight/shape • Frequency typically ≥ once weekly over several months Weight criterion: ⭐ Unlike anorexia, BMI is not diagnostic ⸻ ⭐ High-yield facts to memorise • Typical BMI: normal or overweight • Electrolyte abnormalities (especially hypokalaemia) common • Dental erosion and parotid enlargement may occur • Higher impulsivity and comorbidity than anorexia • Suicide risk elevated

Answer 36

✅ Correct answer E. Hypokalaemia ⸻ Why hypokalaemia is correct • Most dangerous electrolyte abnormality in anorexia • Especially in: Vomiting Laxative abuse ⸻ Mechanism Low potassium → • Impaired cardiac repolarisation • QT prolongation • Ventricular arrhythmias: Torsades de pointes Ventricular fibrillation ➡️ Leads to sudden cardiac death ⸻ Why others are wrong Hypomagnesaemia • Can worsen arrhythmias ❌ Not primary cause ⸻ Hypoglycaemia • Causes: Confusion Seizures ❌ Not main cause of sudden cardiac death ⸻ Hypocalcaemia • QT prolongation ❌ Less likely to cause fatal arrhythmia ⸻ Hypophosphataemia • Seen in refeeding syndrome • Causes: Muscle weakness Cardiac failure ❌ Not typical cause of sudden death pre-refeeding ⚠️ Common MRCPsych exam traps • Choosing hypophosphataemia (confusing with refeeding syndrome) • Choosing hypomagnesaemia (secondary contributor) • Forgetting: Potassium = most critical

Answer 37

✅ Correct answer: E. Potassium 2.4 mmol/L ⸻ 💡 Explanation (exam-focused) • Hypokalaemia (<3.0 mmol/L): • → Life-threatening arrhythmias • → Requires urgent medical admission ⸻ ❌ Why others are wrong (IMPORTANT) • Sodium 150 • Hypernatraemia → dehydration • ❌ Not immediately life-threatening ⸻ • Hb 10 • Mild anaemia • ❌ Common in anorexia ⸻ • Urea 1.6 • Low due to malnutrition • ❌ Not dangerous acutely ⸻ • Albumin 30 • Mildly low • ❌ Chronic malnutrition marker ⸻ 🎯 Exam trap 👉 In anorexia → ALWAYS look for: • Potassium • Phosphate (refeeding) • ECG changes ⸻ 🔥 High-yield Paper B stressors • K+ < 2.5 → cardiac arrest risk • Purging → hypokalaemia • Refeeding → hypophosphataemia

Answer 38

✅ Correct answer: D. Mirtazapine ⸻ 💡 Explanation (exam-focused) • In anorexia nervosa: • Pharmacological treatment is limited • SSRIs may be used cautiously 👉 Mirtazapine causes significant weight gain • Strong H1 + 5-HT2C blockade → ↑ appetite ➡️ This can: • Be distressing • Reduce engagement with treatment ⸻ ❌ Why others are wrong • SSRIs (fluoxetine, sertraline, citalopram) • Commonly used • Helpful for comorbid depression/anxiety • Venlafaxine • Can be used cautiously ⸻ 🎯 Exam trap 👉 In anorexia: • Avoid drugs that: • Increase appetite rapidly • Cause distress about weight gain ⸻ 🔥 High-yield Paper B stressors • Only medication with evidence: • Fluoxetine → bulimia (NOT anorexia) • Anorexia: • Main treatment = psychological + nutritional • ECG monitoring: • Important (QTc prolongation risk)

Answer 39

✅ Correct Answer: E. QTc > 520 ⸻ 🧠 Why this is correct (exam logic) 👉 Key trigger: • QTc prolongation → risk of fatal arrhythmia (torsades de pointes) ✔ In anorexia: • Electrolyte imbalance + malnutrition → cardiac instability ➡ QTc > 500 = medical emergency → transfer 🚨 High-yield MARZIPAN triggers for medical admission 👉 RED FLAGS: • QTc > 500 🚨 • K+ < 2.5 • HR < 40 • BP < 90 systolic • Rapid weight loss 💣 3 High-yield facts 1. Most common cause of death in anorexia = cardiac arrhythmia 2. QT prolongation = strongest acute red flag 3. Always check ECG in anorexia

Eating disorders Flashcards

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