Anorexia nervosa

• Anorexia nervosa is an eating disorder characterised by restriction of energy intake resulting in low body weight and an intense fear of weight gain.
• Epidemiology:

  • More common in women
  • Risk highest in young people between ages 13-18
• Risk factors:

  • Female gender
  • Age - adolescent and young people
  • Family history of eating disorders, depression, or substance abuse
  • Previous criticism of eating habits and weight
  • Increased pressures to be slim e.g. ballet dancers
  • History of sexual abuse
  • Low self-esteem
  • Obsessive personality
  • BPD
• Clinical features:

  • Weight loss - 15% below expected or BMI less than 17.5
  • Amenorrhoea
  • Lanugo hair - fine, soft hair across most of body - nutritional deficiency and hypothermia
  • Hypotension
  • Hypothermia
  • Mood changes and body dysmorphia
  • Aggressive weight loss techniques - laxatives, diuretics, vomiting
• The SCOFF screening questionnaire:

  • S – Do you make yourself Sick because you feel uncomfortably full?
  • C – Do you worry you have lost Control over how much you eat?
  • O – Have you recently lost more than One stone (6.35 kg) in a three-month period?
  • F – Do you believe yourself to be Fat when others say you are too thin?
  • F – Would you say Food dominates your life?
• Assessment:

  • MEED (medical emergencies in eating disorders) guidelines
  • Guidelines on recognition and management
  • If an eating disorder is suspected refer immediately to community eating disorder service
  • Provide acute medical care for people with severe electrolyte imbalance, severe malnutrition, severe dehydration, signs of developing organ failure or high suicide risk
• bradycardia, hypothermia and postural blood pressure drop are all red flags for severe disease.
• • Sit-up, Squat–stand test: tests the patient's ability to sit up from lying and to squat down and stand back up. Scored from 0-3 with increasing risk with lower scores:
  • 0: unable to complete action
  • 1: requires the assistance of upper limbs
  • 2: noticeable difficulty
  • 3: no difficulty
• bradycardia, prolonged QT interval or arrhythmias are all signs of high-risk disease requiring urgent review.
• Adult management:

  • CBT-ED
  • MANTRA
  • SSCM
  • If above are ineffective - FPT - eating disorder focused focal psychodynamic therapy
• CBT-ED:

  • Individual eating disorder focused CBT
  • 40 sessions over 40 weeks with twice weekly sessions initially
  • Personalised plan to help them understand and cope with their feelings and disease
• MANTRA:

  • Maudsley anorexia nervosa treatment for adults
  • 20 sessions - weekly for the first 10 weeks, then tailored to the patient
  • Helps patient evaluate what is important to them and what causes their eating disorder
  • Aims to help patients develop a non-anorexic identity
• SSCM:

  • Specialist supportive clinical management
  • 20 sessions
  • Helps patient understand the relationship between their feelings, eating behaviour and disorder
  • Looks to establish a weight goal and encourage healthy eating
• For children and young people NICE advises anorexia nervosa focused family therapy as first line
• Amenorrhea (absence of periods) occurs due to disruption of the hypothalamic-pituitary-gonadal axis. There is a lack of gonadotrophins (LH and FSH) from the pituitary, leading to reduced activity of the ovaries (hypogonadism).
• Complications:

  • Amenorrhoea and fertility problems
  • Cardiac - arrhythmia, cardiac atrophy, sudden cardiac death
  • Low bone mineral density - causes anaemia, leukopenia and thrombocytopenia
  • Suicide
  • Anorexia has the highest mortality of any psychiatric condition
• Inpatient management:

  • NG tube insertion and feeding
  • Daily biochemical blood tests - monitor for refeeding syndrome
  • Frequent nursing observations
  • Prevention of symptomatic behaviours - water drinking, exercising
  • Daily ECG
  • Sedation of a resisting patient
• Factors that increase risk of refeeding syndrome:

  • Very low BMI
  • Pre-existing electrolyte abnormalities
  • Renal dysfunction or infection