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2007. anorexia. Facts. Highest mortality rate of mental illnesses Prevalence of 0.3% in young women Average of onset 15 yrs. Hallmarks of anorexia. Extreme overvaluation of shape and weight Physical capacity to tolerate extreme self imposed weight loss

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2007

anorexia


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Facts

  • Highest mortality rate of mental illnesses

  • Prevalence of 0.3% in young women

  • Average of onset 15 yrs


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Hallmarks of anorexia

  • Extreme overvaluation of shape and weight

  • Physical capacity to tolerate extreme self imposed weight loss

  • Use of over exercise and over activity to burn calories

  • Purging practices – self induced vomiting, misuse of laxatives, diuretics, slimming medication.

  • Body checking – mirror gazing


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ICD criteria for anorexia

  • Body weight 15% < expected BMI < 17.5

  • Weight loss self induced – avoid fattening foods + self induced vomiting, purging, over activity, use of appetite suppressants, diuretics

  • Body image distortion

  • Widespread endocrine disorder involving hypothalamic- pituitary-gonadal axis


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Endocrine disorder

  • Women

    • Amenorrhoea

  • Men

    • Loss of sexual interest or potency

  • Both

    • Growth hormone and cortisol may be raised

    • Abnormalities of insulin secretion

    • Changes in peripheral metabolism of thyroid hormones


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Causes

  • Genetic predisposition

  • Found in families with following traits

    • Obsessive

    • Perfectionist

    • Competitive

    • ? Autistic spectrum traits


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Causes

  • Precipitated as a coping mechanism against

    • Developmental challenges

    • Transitions

    • Family conflict

    • Academic pressures

    • Onset of puberty and adolescence

    • Sexual abuse

  • Also found in well functioning families


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Diagnosis

  • Often suspected by friends, family school

  • Special investigations not needed

  • Basic investigations

    • Blood tests ecg weighing provide opportunity for patient to return to discuss results and probe for psychological problems


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Physical; risk assessment

  • There is no safe cut off weight or BMI

  • Death unusual where low weight maitained purely by starvation

  • Death more likely if weight fluctuates grreately rather than being stable even if BMI < 12

  • Risk increased in patients that misuse substances or purge frequently


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Management

  • Takes 5-6 years from diagnosis to recovery

  • Up to 30% do not recover

  • Hospital admission correlated with poor outcome

  • Patients admitted voluntarily do better than those on compulsory admission

  • Brief hospital admission at times of crises associated with lower mortality


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ManagementTemporary acceptance of low weigth

  • Acceptance of low weight as long as it is stable and regularly monitored

  • Patients/family take responsibility for re feeding

  • Psychotherapeutic interventions

  • Separate dietetic advice

  • Weight gain is slow but avoids iatrogenic risks


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ManagmentEarly refeeding in hospital

  • Early refeeding in hospital

  • Exposes patient to iatrogenic complications such as infections

  • Exposed to pro anorexia culture form other patients

  • Weight maintenance not as good as home treatment


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Psychotherapy

  • Short term structured treatments such as CBT do not work

  • Long term wide ranging complex treatments such using psychodynamic understanding, systemic principles, and techniques borrowed from motivational enhancement therapy and dialectical behavioural therapy


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Management

  • Therapy involving whole family is superior

  • Sessions involving family and patient together give better family psychological adjustment

  • Weight gain greater when family seen separately from patient

  • Dynamically informed therapies both family and individual produce the best results


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Summary

  • Anorexia has highest mortality of all psychiatric disorders

  • Positive diagnosis of psychologically driven weight loss

  • Short term treatments (CBT) don’t help

  • Focussed family work effective in adolescents

  • No drugs are effective


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