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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 • 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 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 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 Causes Genetic predisposition Found in families with following traits Obsessive Perfectionist Competitive ? Autistic spectrum traits 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 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 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 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 Management Temporary 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 Managment Early 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 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 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 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