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Unethical to force someone who has competence to take treatment under a section of the mental health act. However, pt with anorexia are doing themselves serious bodily harm and are thus a danger to themselves  due to their mental illness. Therefore, doctor must act in patient’s best interest as they and their colleagues see fit and order to treat the pt often by force feeding. This can also undermine the doctor/patient relationship in future interactions.

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Metabolic:

Dehydration, hypoglycaemia, impaired glucose tolerance, hypoproteinaemia à fluid loss in to tissues from intravascular space, hypokalaemia, hyponatraemia, hypocalcaemia, vitamin deficiencies, hypercholesterolaemia

Endocrine:

Amenorrhoea in women and loss of libido/impotence in men due to decrease gonadotropins, oestrogens and testosterone

Increased growth hormone, cortisol, sex hormone binding globulin

Decreased T3

Cardiovascular:

Arrhythmias (hypocalcaemia) and ECG changes

Hypotension, bradycardia, peripheral oedema, congestive heart failure

Mitral valve prolapse

GI:

Parotid enlargement and tooth enamel erosion

Constipation, peptic ulceration, acute pancreatitis

Renal:

Renal failure, partial diabetes insipidus, renal calculi

Neurological:

Seizures, peripheral neuropathy, enlarged ventricles

Haematological:

Iron-deficiency anaemia, leucopaenia, thrombocytopaenia

MSK:

Osteoporosis, muscle cramps/tetany (hypocalcaemia and dehydration/hyponatraemia)

Other:

Hypothermia, infection, dry skin, brittle hair, lanugo, look out for Russell’s sign – callouses on dorsal aspect of knuckles cause by repeated self-induced vomiting

Refeeding syndrome:

During a fast, body switches to fatty and amino acids as main fuel source. Electrolytes become depleted during time of fasting. Upon return to normal nutrition, blood sugar levels rise causing concomitant rise in insulin. The anabolic processes that follow (glycogen, fat and protein synthesis) require phosphate, magnesium and potassium. Serum electrolytes fall leading to cardiac arrhythmia and failure.

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.Support for eating disorders should:

include psychoeducation about the disorder

include monitoring of weight, mental and physical health, and any risk factors

be multidisciplinary and coordinated between services

involve the person's family members or carers (as appropriate).

When treating anorexia nervosa, be aware that:

helping people to reach a healthy body weight or BMI for their age is a key goal

Psychological treatment for anorexia nervosa in adults

individual eating-disorder-focused cognitive behavioural therapy (CBT-ED):

typically consist of up to 40 sessions over 40 weeks, with twice-weekly sessions in the first 2 or 3 weeks. Aim to reduce the risk to physical health and any other symptoms of the eating disorder. Encourage healthy eating and reaching a healthy body weight cover nutrition, cognitive restructuring, mood regulation, social skills, body image concern, self-esteem, and relapse prevention. Create a personalised treatment plan based on the processes that appear to be maintaining the eating problem. Explain the risks of malnutrition and being underweight. Enhance self-efficacy include self-monitoring of dietary intake and associated thoughts and feelings.

Maudsley Anorexia Nervosa Treatment for Adults (MANTRA):

Typically consist of 20 sessions, with:

weekly sessions for the first 10 weeks, and a flexible schedule after this up to 10 extra sessions for people with complex problems, base treatment on the MANTRA workbook. Motivate the person and encourage them to work with the practitioner. Be flexible in how the modules of MANTRA are delivered and emphasised. When the person is ready, cover nutrition, symptom management, and behavior change. Encourage the person to develop a 'non‑anorexic identity'. Involve family members or carers to help the person:  understand their condition and the problems it causes and the link to the wider social context and change their behaviour.

specialist supportive clinical management (SSCM):

Typically consist of 20 or more weekly sessions (depending on severity). Assess, identify, and regularly review key problems. Aim to develop a positive relationship between the person and the practitioner. Aim to help people recognise the link between their symptoms and their abnormal eating behaviour. Aim to restore weight. Provide psychoeducation, and nutritional education and advice. Include physical health monitoring . Establish a weight range goal. Encourage reaching a healthy body weight and healthy eating. Allow the person to decide what else should be included as part of their therapy.

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Fasted state:

When the pancreas detects a decrease in blood glucose levels, it secretes glucagon. Glucagon is the main hormone in the fasted state. During the fasted state, glycogen is broken down by glucose into the liver and released into the blood to increase blood glucose levels to supply tissues and organs where it will be used to make energy at ATP and Co2 as a waste product.

Gluconeogenesis also occurs in the fasted state in the liver where liver proteins are broken down into amino acids, which are converted to ketoacids which can be used to make more glucose. (Urea is a by. product). During the fasted state in order for liver to keep up with the glucose demand by the body, adipose tissues begin to breakdown triglyceride stores, into free fatty acids and glycerol. Glycerol will enter the liver and enter gluconeogenesis, to make more glucose. The fatty acids can be utilised by the heart. Skeletal muscle has its own glycogen stores so during the fasted state, it can break it down to form glucose units which then are used to make ATP. However its glycogen stores are limited so muscle will then use free fatty acids as a source of energy. The free fatty acids in the bloodstream can also enter the liver where they are oxidised to produce  lots of acetyl CoA. During prolonged fasted state there is so much Acetyl CoA that it cant enter the Krebs cycle as normal. So therefore it must be converted to something else, so it participates in ketogenesis, the synthesis of ketone bodies. Ketone bodies are molecules which can be used as a source of energy during prolonged fasting. There are 3 types of ketone bodies produced by liver in fasting, 1. acetone, 2.acetoacetate and 3. B-hydroxy butamate. Ketone bodies are used mainly by the brain for energy as they can be broken down into acetyl CoA which can enter the Krebs cycle and be used to make ATP. During prolonged starvation the heart will also use ketone bodies. Eventually ketone bodies in the blood plasma, will be higher than blood glucose levels. After weeks of starvation skeletal muscle will start to breakdown muscle protein into amino acids for a source of energy. The amino acids will go to the liver to be made into glucose. Glucagon promotes glycogen breakdown, gluconeogenesis and lipolysis.

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8.What is the referral criteria for primary to secondary care for an eating disorder? 

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8.What is the referral criteria for primary to secondary care for an eating disorder? 

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Once an eating disorder is suspected, referral to secondary care for specialist advice and management is recommended in most cases, with a view to transfer back to the primary care once stable or in remission.
Occasionally, treatment may be delivered in a primary care setting, under the overall supervision of a specialist community eating disorders team.
The urgency of the referral will depend on an initial risk assessment.

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9. What is the diagnostic criteria of an eating disorder and what investigations would you do?

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9. What is the diagnostic criteria of an eating disorder and what investigations would you do?

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-Taking a thorough history is very important, especially looking out for amenorrhoea, vegan diets, abuse of laxatives, diuretics, enemas.
-Also look for other common psychiatric disorders such as OCD
-O/E: check weight, height, BMI of less than 17.5 is diagnostic, fat distribution may be low therefore showing protruding bony structure, fine hair-lanugo, short stature and fractures indicating poor nutrition + growth, erosion of tooth enamel ,swollen salivary glands indicating a sign of repetitive vomiting. Also look out for signs of dehydration.
-Lab tests: FBC= leukopenia, thrombocytopenia, serum chemistry=hypokalaemia, hypochloraemia, elevated serum bicarb levels, elevated urea levels, urinalysis=ketonuria
-Also do ECG, pregnancy test, bone densitometry, hormone levels.
SCOFF screening questions to ask (to adults) include:
1.Do you make yourself Sick because you feel uncomfortably full?

2.Do you worry you have lost Control over how much you eat?

3.Have you recently lost more than One stone in a 3 month period?

4.Do you believe yourself to be Fat when others say you are too thin?

5.Would you say that Food dominates your life?

*One point for every “yes”; a score of ≥2 indicates a likely case of anorexia nervosa or bulimia
Single measures such as just SCOFF or BMI should not be used to determine whether a disorder is present and if it should be treated. Need to take the whole picture into account.

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12. What are the mental health conditions associated with eating disorders? (self-harm) Sarmad

·         Eating disorders are a complex mental health disorder that are often generated by multiple factors and associated with specific co-morbidities

·         The most common mental health conditions that form comorbidities f patients suffering from Anorexia Nervosa includes:

o   Depression

o   Bipolar

o   Anxiety disorder

o   PTSD

o   OCD

o   Borderline PD

o   Insomnia

o   Substance abuse

·         The relevancy of these associated mental health disorders is that it aids in the overall understanding of the formation/development of an eating disorder. Features from a mental disorder can overlap with that of an eating disorder and in effect intensify/affect one or the other

·         Clinically such comorbidities increase the risk of relapse and overall poorer recovery outcomes

·         It is important that when treating an eating disorder, we must consider and address any related mental health comorbidities and treat them together

·         This relates to the holistic approach of treating the whole person rather than a single eating disorder

15. Explain the laws associated with the mental health act and when to admit Rachel? (indications) Sarmad

·         The mental health act 1983 & 2007 contains a code of practise which details what can and cannot be done in regard to detention of mental health patients

·         ‘Detention’ is referred to as being ‘sectioned’ under the MHA

·         Key sections include: sections can be put in place by AMHP (approved MH professional)

o   Section 2, detained for assessment, 21 days

o   Section 3, detained for treatment, 6 months (needs to be treated, pose a risk, health &safety)

o   Section 4, emergency only required 1 doctor approval

o   Section 5, holding power, doctors and nurses have the power to stop patients from leaving the hospital

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1. Describe the normal mechanism of hunger. (review breakdown of nutrients) Bea

2. What are Physiological changes metabolism during in starvation? Emma

3. What are the types of eating disorders and what are their signs/symptoms Erin

4. Epidemiology and aetiology of eating disorders? Matt

5. What are the methods of inducing weight loss? Sophie

6. What are the risk factors for developing an eating disorders? (predisposing, environmental..) Matt

7. What are they medical complications of having an eating disorder? (malnutrition, refeeding syndrome) Kamuran

8. What is the referral criteria for primary to secondary care for an eating disorder? Tuba

9. What is the diagnostic criteria of an eating disorder and what investigations would you do? Tuba

10. What medical and psychological treatments are used to treat eating disorders and when would they be used? Which are offered on the NHS Emma

11. Describe the motivation for change cycle and how does it apply to patients with eating disorders? Sophie

12. What are the mental health conditions associated with eating disorders? (self harm) Sarmad

13. What are the ethical issues surrounding competence and non-compliance with treatment? Kamuran

14. What are the differentials for a young adult presenting with abnormal weight loss? Bea

15. Explain the laws associated the mental health act and when admit Rachel? (indications) Sarmad