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Eating disorders for physio

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Richard Duffy

on 14 April 2014

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Transcript of Eating disorders for physio

Eating Disorders
Dr Richard Duffy MRCPsych
Special lecturers in Psychiatry
UCD

Outcome improves with time

Most make a full recovery

Poor outcome may be associated with
Depression
Personality disorder
Substance abuse
PROGNOSIS
Psychotherapy
CBT
Group Therapy

Pharmacotherapy
SSRI’s, 50-70% reduction in binging
MANAGEMENT
Serotonin dysregulation
Low CSF 5HIAA and HVA correlated with binge frequency
Reduced CSF CCK
Increased CSF AVP/ADH
Higher psychoticism and neuroticism scores than AN and controls
Low self esteem
External locus of control
More substance abuse 20%
High prevalence of social phobia
40% have major depression
AETIOLOGY
MZ 23 : DZ 9
Prevalence in adolescents, young women 1-3 %
More even distribution amongst socioeconomic groups than AN
Age onset 18y (> AN)
F 10:M 1
Prevalence may be increasing
EPIDEMIOLOGY
SYMPTOMS AND SIGNS
Morbid fear of fatness
Distorted body image
Overwhelming urge to binge, later followed by guilt and disgust
Self induced vomiting 90 %, Laxatives 30%
Stealing and substance abuse
Depression
Older than anorexics
Possibly normal weight, usually just under or over
Anorexia nervosa
Atypical depression
Medical disorder
Part of Borderline Personality Disorder
DIFFERENTIAL
DIAGNOSIS
DSM CRITERIA
50% good, 30% intermediate, 20% poor
Poor outcome
Older age onset/ presentation, longer duration illness, lower weight, bulimic activity. Mortality rate 5 % per decade
Suicide 200x increase
In those that die
54% due to complications of d/o
27% due to suicide
PROGNOSIS
Atypical antipsychotics for weight gain
SSRI’s may reduce behaviour/ improve mood
MANAGEMENT
Rapid fall in serum K+, Mg and PO4, and marked fluid retention.
Consequences: Cardiac failure and arrythmias, respiratory failure, rhabdomyolysis with renal damage, seizures, confusion, coma and death if untreated.
REFEEDING
SYNDROME
1-2 kg/ week
Serotonergic systems;
Addictive element – ‘buzz’ attached to starvation : adrenaline, endorphins, ketones
Low self esteem and perfectionism implicated.
A a struggle for control/sense of identity and effectiveness
Dependent relationship with a passive father
Guilt over aggression toward an ambivalently mother
High rates of obsessive, impulsive and inhibited traits
Anorexic patients associated with Cluster C personality disorders
Bulimic patients associated with Cluster B personality disorders
Enmeshed, rigid and overprotective families
Lack of conflict resolution
Higher rates of sexual abuse (not specific to eating disorders though)
Cult of thinness/ history of dieting/ culture
Excess physical illnesses as children
AETIOLOGY
Increased rates in First Degree Relatives (FDR’s) of probands
MZ 56%: DZ 5%
Increased rates of mood disorders in FDR’s
Prevalence 1-2/ 1000 women (i.e. rare)
Peak onset 15-19 y
F 10:M 1
In higher SE groups, private schools (1%), ballet dancers (7%)
Prevalence is not increasing
EPIDEMIOLOGY
ECG abnormalities
Hypotension
Bradycardia
Congestive cardiac failure
Delayed gastric emptying
Pancreatitis
Constipation
Parotid enlargement Dental erosion
PHYSICAL AND PSYCHOLOGICAL
SIGNS/ COMPLICATIONS

Amenorrhoea/ loss of libido
Reproductive system atrophy
Dehydration
Hypothermia / cold intolerance
Hypoglycaemia
iK+, iNa+, iCa
Vitamin deficiencies
Hypercholesterolemia
Deranged LFT’s
Morbid fear of fatness/ excessive pursuit of thinness
Denial of problem, Distorted body image
Fear of losing control of eating
Problems with separation and independence
Depressive feelings/ suicidal ideas
Obsessional thoughts/ rituals (improve with weight gain)
Preoccupation with thoughts of food (enjoys cooking for others, doesn’t like eating in public)
Other causes of weight loss (esp. onset >40y)
GI disease
Brain tumor
Occult malignancy
AIDS
Superior Mesenteric Artery syndrome
Hyperthyroidism
Depression and Schizophrenia
DIFFERENTIAL DIAGNOSIS
Self imposed weight loss of 15% body weight (younger patients, failure to gain), BMI <17.5
Intense fear of gaining weight (loss of appetite rare)
Disturbance in perception of shape or size of body
Amenorrhoea (absence of at least 3 menstrual cycles)
DSM CRITERIA
Recurrent episodes of binge-eating
In a discrete period of time , amounts definitely larger than most people would eat
Sense of lack of control over eating during an episode
Recurrent self induced vomiting, laxative/ diuretic/ enemas/ medication/ over-exercising to prevent weight gain
Binge/ compensatory behaviour at least twice a week for 3 months
Self evaluation unduly influenced by body shape/ weight
Iron deficiency anaemia
Osteoporosis
Muscle cramps
Renal failure
Dry skin
Brittle hair and nails
Lanugo hair
Increase in ventricle: brain ratio
Seizures
Peripheral neuropathy
Anorexia nervosa
Bulimia Nervosa
Rigid dieting is most common precipitant
Prior to onset, more likely to be overweight
1/3 of patients have a hx of AN and 1/3 a hx of obesity
Mother uses daughter as an easily available therapist
Higher rates of CSA
Genetic Factors
Environment
Personality
Case Study 1
Hannah is a 47y.o. lady who attends physiotherapy following a low impact wrist fracture. You suspect she might have an eating disorder. She has never seen a psychiatrist
What symptoms might make you suspicious of this?
What sign might make you suspicious of this?
What is the differential diagnosis?
What is the diagnostic criteria for these?
Related to vomiting
Dental erosion and toothache
Parotid gland enlargement
Russell’s sign (callouses on back of hand)
Oedema
Conjunctival haemorrhages
Related to purgative abuse
Rectal prolapse
Diarrhoea
Constipation
Related to binges
Gastric dilatation
Biochemical abnormalities
Case Study 2
Pauline is a 19y.o. who has been admitted medically due to complications of her anorexia nervosa. You are asked to see her as she needs assistance mobilising as her BMI was 14.8. While working with her she acts inappropriately and becomes confused
What are the complications of AN?
What could explain her behavior?
Neurotransmitters
Genetic factors
Environmental factors
Psychological Factors
Neurotransmitters
Pharmacotherapy
Weight restoration
Psychotherapy
Family therapy esp. young restricting anorexics (<22y)
Older anorexics use CBT
Avoid support groups
Metabolic
Endocrine
Gastrointestinal
Cardiovascular
Neurological
Others
Full transcript