EATING DISORDERS

1. Anorexia nervosa

 Anorexia nervosa (AN) is an eating disorder characterized by deliberate weight loss, an

intense fear of fatness, distorted body image, and endocrine disturbances.
 Low body weight, 15% below expected (or more) Adults- BMI 17.5 or less
 Self induced weight loss (name 5 methods?)
 Body Image Distortion overvalued idea, imposed low weight threshold
 Endocrine disorder: Hypothalmic- Pituitary- Ovarian Axis… symptoms?
 Delayed/ Arrested Puberty
 AN affects ♀ more than ♂ (10:1).
 Estimated incidence is 0.4 per 1000 yearly in ♂ and approximately 9 in 1000 ♀ will
experience it at some point in their lives.
 The typical age of onset is mid-adolescence.

History / information for child and adoslescent

 Source and nature of referral
 Description of presenting complaints- child’s view, parents view / guardian’s view
 Onset, frequency, intensity, duration etc
 Description of current functioning
 School, Peers, Family
 Personal/ Developmental History
 Pregnancy, labour, delivery, milestones, separations/ disruptions, physical illness
and meanings for parents, reaction to school, puberty
 Family History
 Personal and social hx of both parents, family development, current home life
 Information from observation of family interaction
 Information from observation of child
 Mental state, concerns, child alone if appropriate
 Physical exam results, Investigations
 Formulation, Management plan

Pathophysiology


Predisposing Precipitating Perpetuating

B  Genetics: Monozygotic twin studies have higher  Adolescence and  Starvation leads
concordance rates than dizygotic twins. puberty to neuroendocrine
 Family history: First degree relatives have changes that
higher incidence of eating disorders. perpetuate anorexia.
 Female.
 Early menarche.
P  Sexual abuse.  Criticism regarding  Perfectionism,
 Preoccupation with slimness. eating, body shape or obsessional/ anankastic
 Dieting behaviours starting in adolescence. weight. personality.
 Low self-esteem.
 Premorbid anxiety or depressive disorder.
 Perfectionism, obsessional/ anankastic
personality.
S  Western society: Pressure to diet in a society  Occupational  Occupation.
that emphasizes that being thin is beauty. or recreational pressure to  2 Western society.
 2Bullying at school revolving around weight. be slim, e.g. ballet dancers,
 2Stressful life events. models.

Clinical features - ICD 10

 Fear of weight gain.
 Endocrine disturbance resulting in amenorrhoea in females and loss of sexual interest
and potency in males.
 Emaciated (abnormally low body weight): >15% below expected weight or BMI <17.5
kg/m2.
 Deliberate weight loss with ↓ food intake or ↑ exercise.
 Distorted body image
 The above features must be present for at least 3 months and there must be the
ABSENCE of (1) recurrent episodes of binge eating; (2) preoccupation with
eating/craving to eat. 


Other features
 Physical: Fatigue, hypothermia, bradycardia, arrhythmias, peripheral oedema (due to
hypoalbuminaemia), headaches, lanugo hair (Fig. 6.1.2).
 Preoccupation with food: Dieting, preparing elaborate meals for others.
 Socially isolated, Sexuality feared.
 Symptoms of depression and obsessions.

Physical examination and investigations

Exam Ix
 Weight, height if not already known  FBC- Hb normal or elevated
 Physical signs of starvation and/ or vomiting:  Anemia, Leucopaenia, Thrombocytopaenia
 Loss of muscle mass  ESR- Normal or reduced
 Dry skin  U&E’s- Raised urea and creatinine, Hyponatremia,
 Brittle hair and nails hypokalemia, hypochloremic metabolic alkalosis
 Russell sign (callused skin over ip joints)  Glucose
 Fine, downy, lanugo body hair  LFTs
 Eroded tooth enamel  TFTs -Normal or Low T3, T4
 Peripheral cyanosis  Albumin, total protein- usually normal
 Hypotension  Cholesterol- may be Dramatically elevated (starvation)
 Hypothermia  Growth Hormone- normal or elevated
 Atrophy of breasts  Prepubertal levels of LH and FSH
 Swelling of parotid and submandibular glands  Low estradiol in females and low testosterone in males
 Swollen tender abdomen  Decreased serum magnesium, calcium, phosphate, zinc,
 Peripheral neuropathy copper
 Venous blood gas (VBG): Metabolic alkalosis (vomiting),
metabolic acidosis (laxatives)
 DEXA scan: To rule out osteoporosis (if suspected). 

 Questionnaires: e.g. eating attitudes test (EAT).
 ECG and ECHO

Complications
 Usually due to effects of STARVATION or VOMITING

Metabolic  Hypokalaemia, hypercholesterolaemia, hypoglycaemia, impaired glucose tolerance, deranged

LFTs, ↑ urea and creatinine (if dehydrated), ↓ potassium, ↓ phosphate, ↓ magnesium, ↓
albumin and ↓ chloride.
Endocrine  ↑ Cortisol, ↑ growth hormone, ↓ T3 and T4. ↓ LH, FSH, oestrogens and progestogens leading
to amenorrhoea. ↓ Testosterone in men.
GI  Enlarged salivary glands, pancreatitis, constipation, peptic ulcers, hepatitis.
CV  Cardiac failure, ECG abnormalities, arrhythmias, ↓ BP, bradycardia, peripheral oedema.
Renal  Renal failure, renal stones.
Neuro  Seizures, peripheral neuropathy, autonomic dysfunction.
Haem  Iron deficiency anaemia, thrombocytopenia, leucopenia.
MSK  Proximal myopathy, osteoporosis.
Others  Hypothermia, dry skin, brittle nails, lanugo hair, infections, suicide.

DDX and comorbidity

DDX Comorbidity
 Depression  Depression
 OCD  Anxiety
 Chronic Physical illness Disorder
 Bulimia nervosa.  OCD
 Eating disorder not otherwise specified (EDNOS)  Body
One third of patients referred for eating disorders have EDNOS (eating disorders not Dysmorphic
otherwise specified). EDNOS closely resembles anorexia nervosa, bulimia nervosa, Disorder
and/or binge eating, but does not meet the precise diagnostic criteria.
 Schizophrenia
 Alcohol / substance misuse
 Binge eating disorder
Recurrent episodes of binge eating without compensatory behaviour such as vomiting,
fasting, or excessive exercise.

Prognosis : Mortality rate: 10-15% (2/3 physical, 1/3 suicide) 1/3 recover, 1/3 partial
recovery, 1/3 chronic course
 Management

B P S
 Treatment of medical complications,  Psycho-education about nutrition 4 Cognitive  Voluntary
e.g. electrolyte disturbance behavioural therapy organizations
 SSRIs for co-morbid depression or  Cognitive analytic therapy Self-help
OCD  Interpersonal psychotherapy groups
 The aim of treatment as an inpatient  Family therapy
is for a weight gain of 0.5–1 kg/week  Psychological treatments should normally be for
and as an outpatient of 0.5 kg/week. at least 6 months’ duration.

 Restoration of healthy weight

 Treatment of psychological disorders, changing behaviours / thoughts that originally led
to disorder.
 Patient reviewed regularly in OPD, monitoring of Bloods, weight and creation of
therapeutic alliance. Clinical nurse specialists/OT /CBT therapists concurrently involved.
 Consider SSRI/other antidepressants if indicated
 Dietician input if available
 FIRSTLY: DIETETIC INPUT AND REFEEDING
 Patients are at risk of refeeding syndrome which causes metabolic disturbances (e.g.
↓ phosphate) and other complications
 A potentially life-threatening syndrome that results from food intake
(whether parenteral or enteral) after prolonged starvation or
malnourishment, due to changes in phosphate, magnesium and potassium.
 It occurs as a result of an insulin surge following increased food intake.
 Biochemical features include fluid balance abnormalities, hypokalaemia,
hypomagnesaemia, hypophosphataemia and abnormal glucose metabolism.
 The phosphate depletion causes reduction in cardiac muscle activity which
can lead to cardiac failure.
 Prevention: Measure serum electrolytes prior to feeding and monitor
refeeding bloods daily, start at 1200 kcal/day and gradually increase every 5
days, monitor for signs such as tachycardia and oedema.
 If electrolyte levels are low, they will need to be replaced either orally or
intravenously depending upon the severity of electrolyte depletion.

 Risk assessment for suicide and medical complications is absolutely vital.

 Little evidence to show that therapeutic work done with patients who are severely
underweight is of any benefit
 Admit to hospital if
 Medical complications are significant.. Eg BW <75% expected weight for height,
dehydration, electrolyte imbalance, symptomatic bradycardia, cardiac
complications, suicide risk, failure of outpatient treatment
 In cases where insight is clouded, use of the MHA (or Children Act) for life-saving
treatment, may be required.
 GOALS for admission: Address physical/ psych complications, Healthy eating plan,
RISKS of re-feeding: cardiac decompensation +/- CCF
 MDT
 Psychiatrist
 Community Psychiatric Nurse
 Dietician
 Psychologist
 Family Therapist
 Social Worker

2. Bulimia nervosa
 Bulimia nervosa (BN) is an eating disorder characterized by repeated episodes of
uncontrolled binge eating followed by compensatory weight loss behaviours and
overvalued ideas regarding ‘ideal body shape/weight’.
 Bingeing episodes- with persistent preoccupation with food and craving
 Attempts to counteract excess calorie intake by purging e.g. self-induced vomiting,
laxative abuse, appetite suppressants
 Morbid dread of fatness
 Self-set low weight threshold
 Possible hx of AN or atypical AN
 BN typically occurs in young women. The estimated prevalence in women aged 15–40 is
1–2%.
 Whereas AN is thought to be more prevalent in higher socioeconomic classes, BN has
equal socioeconomic class distribution

Pathophysiology

 The aetiology of BN is very similar to AN, but whereas there is a clear genetic
component in AN, the role of genetics in BN is unclear.
 When patients with BN binge
 due to strong cravings, they
 tend to feel guilty and as a
result undergo compensatory
 behaviours such as vomiting,
 using laxatives,
exercising
 excessively and alternating
 with periods of starvation.
 This may result in
large
 fluctuations in weight, which
 reinforce the compensatory
 weight loss
behaviour, setting up a vicious cycle
 Predisposing Precipitating Perpetuating
B  Female sex  Early onset of puberty/  Co-morbid mental
 Family history of eating disorder, mood menarche health problems
disorder, substance misuse or alcohol abuse .
 Early onset of puberty
 Type 1 diabetes
 Childhood obesity
P  Physical or sexual abuse as a child  Perceived pressure to  Low self-esteem,
 Childhood bullying be thin may come from perfectionism
 Parental obesity culture (e.g. Western  6Obsessional
 Pre-morbid mental health disorder society, media and personality
 Preoccupation with slimness profession)
 Parents with high expectations  6Criticism regarding
 Low self-esteem body weight or shape
S  Living in a developed country  Environmental  Environmental stressors
 6Profession (e.g. actors, dancers, models, stressors
athletes)  Family dieting
 6Difficulty resolving
 conflict.

Subtypes
 Purging type: The patient uses self-induced vomiting and other ways of expelling food
from the body, e.g. use of laxatives, diuretics and enemas.
 Non-purging type: Much less common. Patients use excessive exercise or fasting after a
binge. Purging-type bulimics may also exercise and fast but this is not the main form of
weight control for them.
 NOTE: ICD-10 does not differentiate between purging and non-purging.

Clinical features - ICD 10

Behaviours to prevent  Compensatory weight loss behaviours include: self-induced vomiting, alternating
weight gain periods of starvation, drugs (laxatives, diuretics, appetite suppressants,
(compensatory) amphetamines, and thyroxine), and excessive exercise. NOTE: diabetics may omit or
reduce insulin dose.
Preoccupation with  A sense of compulsion (craving) to eat which leads to bingeing. There is typically
eating regret or shame after an episode.
Fear of fatness  Including a self-perception of being too fat.
Overeating  At least two episodes per week over a period of 3 months.

Other features / complictaions

 Normal weight: Usually the potential for weight gain from bingeing is counteracted by
the weight loss/purging behaviours.
 Depression and low self-esteem.
  7Irregular periods.
 Signs of dehydration: ↓ blood pressure, dry mucous membranes, ↑ capillary refill time,
↓ skin turgor, sunken eyes.
 Consequences of repeated vomiting and hypokalaemia

Hypokalaemia Repeated vomitting

 A potentially life-threatening
complication of excessive vomiting.
 Low potassium (<3.5 mmol/L) can
result in muscle weakness, cardiac
arrhythmias and renal damage.
 Mild hypokalaemia requires oral
replacement with potassium-rich
foods (e.g. bananas) and/or oral
supplements (Sando-K).
 Severe hypokalaemia requires
hospitalization and intravenous
potassium replacement.
 CVS : Arrhythmias, mitral valve prolapse, peripheral oedema.
 GI : Mallory–Weiss tears, ↑ size of salivary glands especially
parotid
 Met / renal : Dehydration, hypokalaemia, renal stones, renal
failure.
 Dental : Permanent erosion of dental enamel secondary to vomiting
of gastric acid
 Endo : Amenorrhoea, irregular menses, hypoglycaemia, osteopenia.
 Dermato : Russell’s sign (calluses on back of hand due to abrasion
against teeth).
 Pulmonary : Aspiration pneumonitis.
 Neuro : Cognitive impairment, peripheral neuropathy, seizures.

Physical examination and investigations

Exam Ix
 Weight, height if not already known  FBC- Hb normal or elevated
 Physical signs of starvation and/ or vomiting:  Anemia, Leucopaenia, Thrombocytopaenia
 Loss of muscle mass  Amylase, lipid, glucose
 Dry skin  U&E’s- Raised urea and creatinine, Hyponatremia,
 Brittle hair and nails hypokalemia, hypochloremic metabolic alkalosis
 Russell sign (callused skin over ip joints)  LFTs
 Fine, downy, lanugo body hair  TFTs -Normal or Low T3, T4
 Eroded tooth enamel  Decreased serum magnesium, calcium, phosphate, zinc,
 Peripheral cyanosis copper
 Hypotension  Venous blood gas (VBG): Metabolic alkalosis (vomiting),
 Hypothermia metabolic acidosis (laxatives)
 Atrophy of breasts  Questionnaires: e.g. eating attitudes test (EAT).
 Swelling of parotid and submandibular glands  ECG
 Swollen tender abdomen
 Peripheral neuropathy

DDX and comorbidity

DDX Comorbidity
 Depression  Depression
 OCD  Anxiety
 Chronic Physical illness Disorder
 Eating disorder not otherwise specified (EDNOS)  OCD
 One third of patients referred for eating disorders have EDNOS (eating disorders not  Body
otherwise specified). EDNOS closely resembles anorexia nervosa, bulimia nervosa, Dysmorphic
and/or binge eating, but does not meet the precise diagnostic criteria. Disorder
 Alcohol / substance misuse
 Organic causes of vomiting, e.g. gastric outlet obstruction.
 Binge eating disorder
Recurrent episodes of binge eating without compensatory behaviour such as vomiting,
fasting, or excessive exercise.

Management
 Important to institute pattern of regular diet, so to minimise effect of starvation and
craving
 From a biological perspective, electrolytes should be monitored carefully for any
potential disturbances, and should be replaced accordingly where appropriate.
 Risk assessment for suicide. Co-morbid depression and substance misuse are common.
 Inpatient treatment is required for cases of suicide risk and severe electrolyte
imbalances.
 The Mental Health Act is not usually required, as BN patients have good insight and are
motivated to change.
 Approximately 50% of BN patients make a complete recovery in comparison with AN
where roughly 20% make a full recovery.
Bio  A trial of antidepressant should be offered and can ↓ frequency of binge eating/ purging. Fluoxetine
(usually at high dose, 60 mg) is the SSRI of choice. Treat medical complications of repeated vomiting,
e.g. potassium replacement. Treat co-morbid conditions
Psych  Psychoeducation about nutrition, CBT for bulimia nervosa (CBT-BN is a specifically adapted form of
CBT). Interpersonal psychotherapy is an alternative.
Social  Food diary to monitor eating/purging patterns, techniques to avoid bingeing (eating in company,
distractions), small, regular meals, self-help programmes.

AN vs BN

AN
 Are significantly underweight.
 8Are more likely to have endocrine
 abnormalities such as amenorrhoea.
 8Do not have strong cravings for food.
 8Do not binge eat.
 8May have compensatory weight loss behaviours
(excluding purging).
BN
 Are usually normal weight/overweight.
 8Are less likely to have endocrine
 abnormalities.
 8Have strong cravings for food.
 8Have recurrent episodes of binge eating.
 8Have compensatory weight loss behaviours.

AN BN
 Amenorrhoea  Binge eating
 No friends (socially isolated) Obvious weight loss  Use of drugs to prevent weight gain Low potassium
 Restriction of food intake Emaciated  Irregular periods
 Xerostomia (dry mouth)  Mood disturbances
 Irrational fear of fatness  Irrational fear of fatness
 Abnormal hair growth (lanugo hair)  Alternating periods of starvation