Anorexia Nervosa Harpal Nandhra

Overview  Diagnostic Criteria  Screening Questionnaire  Clinical assessment  Indications for IP treatment  Principles of psychological treatment  Prognosis

History of ideas  William Gull 1874  Charles Lasegue 1873  Saint Catherine of Siena (14 th C)

F50.0 Anorexia nervosa  A. Weight loss, or in children a lack of weight gain, leading to a body weight of at least 15% below the normal or expected weight for age and height.  B. The weight loss is self-induced by avoidance of "fattening foods".  C. A self-perception of being too fat, with an intrusive dread of fatness, which leads to a self-imposed low weight threshold.  D. A widespread endocrine disorder involving the hypothalamic-pituitary- gonadal axis, manifest in the female as amenorrhoea, and in the male as a loss of sexual interest and potency (an apparent exception is the persistence of vaginal bleeds in anorexic women who are on replacement hormonal therapy, most commonly taken as a contraceptive pill).  E. Does not meet criteria A and B of Bulimia nervosa (F50.2).

Comments:  The following features support the diagnosis, but are not necessary elements: self-induced vomiting; self-induced purging; excessive exercise; use of appetite suppressants and/or diuretics.  If onset is pre-pubertal, the sequence of pubertal events is delayed or even arrested (growth ceases; in girls the breasts do not develop and there is a primary amenorrhoea; in boys the genitals remain juvenile). With recovery, puberty is often completed normally, but the menarche is late.

SCOFF QUESTIONNAIRE Do you make yourself Sick because you feel uncomfortably full? Do you worry you have lost Control over how much you eat? Have you recently lost more than One stone in a 3-month period? Do you believe yourself to be Fat when others say you are too thin? Would you say that Food dominates your life? Score one point for every “Yes” A score of 2 or more indicates a likely case of eating disorder. Extracted from: MORGAN, REID and LACEY (1999)

Clinical Assessment  Food intake history  Wt History  Exercise  Additional harmful behaviours  Menstrual Hx  Collateral

Cont  Body image  Mood  OCD  Cognition  Premorbid Personality 72% have at least one PD 72% have at least one PD Majority have Anankastic PD Majority have Anankastic PD

Physical examination  SUSS test  1. Sit-up: patient lies down flat on the floor and sits up without, if possible, using their hands.  2. Squat–Stand: patient squats down and rises without, if possible, using their hands.  Scoring (for Sit-up and Squat–Stand tests separately) 0: Unable 0: Unable 1: Able only using hands to help 1: Able only using hands to help 2: Able with noticeable difficulty 2: Able with noticeable difficulty 3: Able with no difficulty 3: Able with no difficulty

Indications for adm  Extremely low body weight Acute weight loss of 15-20% in 3 months Acute weight loss of 15-20% in 3 months BMI <13 BMI <13  Bradycardia or other cardiac dysrhythmias  Severe electrolyte abnormalities, especially of potassium, sodium, and phosphorus levels  Altered mental status or suicidality  Failure of outpatient treatment  Hypoglycaemia

Treatment  Restoration of BMI to 20  No role for psychotropic medication  Engagement of pt  Stepped care  Family therapy  Individual psychotherapy

Models of psychological treatment  ‘Control’  Bruch ‘sparrow in a golden cage’  Crisp ‘flight from growth’  CBT

Prognosis  Slow improvement over 15 years, but increasing mortality  1/3 recover in 3 years  1/3 recover in 6-9 years  18% mortality ( % pa)  AN complications 54%  Suicide 27%  Other 19%

Summary  Pathoplastic nature  SCOFF  SUSS test  Indications for adm  Restoration of normal BW and psychological treatment  Slow improvement over 15 years, but increasing mortality

Any Q