QuestionSBA
QuestionChoice
Both section 2 and section 3 of the Mental Health Act can be used to treat a patient against their wishes
31893
a
Section 2
QuestionChoice
Section 135 allows police to break into a property to take a person to a place of safety so that a mental health assessment can be carried out
31897
e
Section 135
QuestionChoice
Section 5(4) allows a qualified nurse to detain a patient in hospital for up to 6 hours until a fully registered doctor can assess the need for further detention. It cannot be used to treat patients against their wishes
31896
d
Section 5(4)
QuestionChoice
Section 5(2) gives doctors the ability to detain patients in hospital for up to 72 hours until a further assessment can be carried out to determine if further detention is necessary. It cannot be used to treat patients against their wishes
31895
c
Section 5(2)
QuestionChoice
Section 4 of the MHA is used in an emergency by a GP or Approved Mental Health Professional (AMHP) to allow 72 hours of assessment. It can later be switched to section 2 when admitted to hospital or later in admission at the end of the 72-hour window. It cannot be used to treat patients against their wishes
31894
b
Section 4
QuestionComment
Because they're in A&E do they not have to admitted under a 5(2) first? And then psych can come see them and put in place a section 2 for treatment? Thanks in advance:)
6213
QuestionComment
sec 5(2) and 5(4) are is not valid for A and E
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Virginija
QuestionComment
Section 5 applies to patient's in the ward rather than ED
24020
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Kinase Sclerosis
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Acute JAK
QuestionComment
In A and E surely they should be initially placed under a Section 4, then converted to a section 2?
7649
QuestionComment
This is what I was thinking as well. During my Psych placement, the psychiatrist told me it can sometimes take 5 days to get a section 2!
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Kinase Sclerosis
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Tachycardia Outpatient
QuestionComment
Section 2 can't be applied in an emergency department
11202
QuestionComment
In some hospitals the ED counts as a public place so think it can?
11596
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Neoplasia Pudendal
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MannyOA
QuestionComment
section 3 would be a better answer as she's already got a diagnosis and been assessed
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Endoscope Hematoma
QuestionComment
I'm pretty sure an explanation to a previous (similar) question said section 2 is specifically for 'assessment' and section 3 is specifically for 'treatment'
26254
QuestionComment
yeah but you can still give treatment under section 2
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Axillary Pudendal
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Acute Chronic
QuestionComment
Section 2 is assessment/investigation, she already has a formal diagnosis so should be a section 4 then section 3 when appropriate
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Gastro Complement
Concept
Chapter
# Summary

Anorexia nervosa is a severe psychiatric disorder characterized by extreme dietary restriction, an intense fear of gaining weight, and a distorted body image. This complex condition predominantly affects young individuals, particularly females, and poses significant health risks, including malnutrition, electrolyte imbalances, and potential life-threatening complications. It has the highest mortality rate of all psychiatric disorders.

# Definition

Anorexia nervosa is a serious mental health disorder characterized by self-imposed starvation and a relentless pursuit of extreme thinness. Individuals with anorexia nervosa have a distorted body image, viewing themselves as overweight even when they are dangerously underweight. There are two main subtypes:

- **Restrictive Subtype:** Characterized by minimal food intake and excessive exercise.
- **Bulimic Subtype:** Involves episodic binge eating followed by behaviors like laxative use or induced vomiting.

It is diagnosed based on specific criteria outlined in both the International Classification of Diseases, 11th Edition (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5):

**ICD-11 Criteria:**

To meet the ICD-11 criteria for anorexia nervosa, individuals must exhibit the following:

1. **Significantly Low Body Weight:** The individual's body weight is significantly below the normal or expected weight for their age and height.

2. **Fear of Gaining Weight:** There is an intense fear of gaining weight, or becoming fat, even when underweight.

3. **Distorted Body Image:** The individual has a distorted self-perception, with an overemphasis on their weight and shape.

4. **Restrictive Eating:** There is persistent restrictive eating, often leading to malnutrition.

**DSM-5 Criteria:**

The DSM-5 criteria for anorexia nervosa include the following:

1. **Restriction of Energy Intake:** The individual persistently limits their food intake, leading to low body weight relative to their age, sex, developmental trajectory, and physical health.

2. **Intense Fear of Gaining Weight:** A preoccupation with body weight or shape, as well as the fear of gaining weight, is a core feature.

3. **Body Image Disturbance:** A distorted body image, where the individual perceives themselves as overweight despite being underweight, is present.

The specific criteria may vary between ICD-11 and DSM-5, but the essential elements of severe dietary restriction, weight and shape preoccupation, and distorted body image are central to the diagnosis.  Note that BMI and amenorrhoea are no longer specifically mentioned in DSM-5 anymore.

# Epidemiology

Anorexia nervosa primarily affects adolescents and young adults, with a higher prevalence among females. However, it can occur in individuals of any age or gender. The condition is more common in industrialized countries and often co-occurs with other psychiatric disorders, such as depression and anxiety.
The incidence of anorexia nervosa is 6/100,000, with the highest incidence occurring between age 13-17. 

# Pathophysiology

- Anorexia nervosa is not due to a single causative factor, with complex biopsychosocial factors at play:
	- Biological factors include the presence of family history and genetic influence
	- Psychological: Presence of comorbid mental health disorders, such as anxiety, depression, obsessive-compulsive disorders or obsessive/perfectionist personalities
	- Social:  Maternal encouragement of weight loss or at risk professions such as models, dancers or sportspeople

# Clinical features

- History:
	- Preoccupation with food and calories
	- Starvation via restricting intake, purging (through induced emesis, diuretic or laxative abuse) or excessive exercise
	- Poor insight   
	- Overvalued, intrusive obsession with weight, shape and fear of becoming fat
	- Weight/calorie goals in mind regardless of their impact on physical health 
- Examination:
	- BMI <17.5 kg/m<sup>2</sup> (contrast with bulimia nervosa, where there may be many similar features, but the BMI is normal‚ a key distinguishing feature)
	- Hypotension
	- Bradycardia
	- Enlarged salivary glands
	- Lanugo hair (fine hair covering the skin)
	- Amenorrhoea (hypogonadotropic hypogonadism)
	- Additional features in the 'bulimic' subtype may include hypokalaemic hypochloraemic metabolic alkalosis, pitted teeth, parotid swelling, and scarring of the dorsum of the hand (Russell’s sign).

# Investigations

- Blood results:
	- Deranged electrolytes - typically low calcium, magnesium, phosphate and potassium 
	- Low sex hormone levels (FSH, LH, oestrogen and testosterone)
	- Leukopenia
	- Raised growth hormone and cortisol levels (stress hormones)
	- Hypercholesterolaemia
	- Metabolic alkalosis, either due to vomiting or use of diuretics 

# Management 

Management approaches are multi-faceted and tailored to the patient's specific needs. In adults, interventions may include:

- **Cognitive Behavioral Therapy for Eating Disorders (CBT-ED):** Focusing on changing thoughts and behaviors related to eating and body image.
- **MANTRA (Maudsley Model of Anorexia Nervosa Treatment for Adults):** Targeting the core beliefs behind anorexia.
- **Specialist Supportive Clinical Management (SSCM):** Providing a supportive framework for treatment.

For individuals under 18, AN-focused family therapy is often the first-line approach, with CBT-ED as a second-line option.

- **Medical**
	- Selective serotonin release inhibitors (SSRIs) may be used‚ these have not been shown to be effective at treating the anorexia nervosa directly, but may be effective for comorbid mental health issues, commonly depression and anxiety
- **Mental Health Act**
	- In some cases where the patient's life is considered at immediate risk, admission under the Mental Health Act with structured feeding (and in some cases nasogastric tube feeding) is warranted
	- Under the Mental Health Act, feeding is a treatment for anorexia nervosa and, as such, treatment can occur without patient consent under this framework

**Inpatient Admission:**

Indications for specialist inpatient programs may include severe or rapid weight loss, significant suicide risk, or inability to perform the SUSS test (sit-up, squat, and stand). Admission is also indicated if proximal muscle weakness suggests weak respiratory muscles.

If patients are very unwell the **MARSIPAN checklist** should be used to guide management.

# Complications 

- Refeeding syndrome:
	- A potentially fatal disorder that occurs when nutritional intake is resumed too rapidly after a period of low caloric intake
	- symptoms may include oedema, confusion and tachycardia
	- 	Rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces‚ these need to be replenished
	- Preventative measures include: 
	  - The provision of high-dose vitamins (eg. Pabrinex<sup></sup>) before feeding commences
	  - Monitoring with daily bloods and replenishing electrolytes early 
	  - Building caloric intake gradually with the help of a dietitian‚ NICE recommends that refeeding is started at no more than 50% of calorie requirement in 'patients who have eaten little or nothing for more than 5 days'
- Cardiac arrhythmias: 
	- These patients are at higher risk of arrhythmias and an ECG should be performed periodically, especially if they are complaining of cardiac symptoms (eg. palpitations, fainting episodes or dizzy/light-headed spells)
	- Bradycardia and prolonged QTc are often seen
- Osteoporosis‚ a long-term complication

# Prognosis

- Positive prognostic indicators include:
	- The presence of normal social‚ emotional milestones‚ this is important to form bonds with therapists during CBT
- Negative prognostic indicators include:
	- Presentation after the age of 20 years‚ difficult to reverse fixed beliefs
	- BMI <16 kg/m<sup>2</sup>
	- Marked anxiety when eating in front of others, which indicates issues with socialisation 
	- Binging/vomiting responds less well to CBT than starvation

# NICE Guidelines 

[NICE Guidelines: Eating Disorders](https://www.nice.org.uk/guidance/ng69)
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Quesmed Tutorial: Psychiatry
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Section 2 of the Mental Health Act allows detention for up to 28 days for the assessment of a person with a mental disorder, requiring two doctors' recommendations and an AMHP's involvement.
A 19-year-old female with a background of anorexia nervosa is brought to the emergency department by her mother, who is concerned about her physical health. Her mother reports that she hasn't eaten anything in 5 days. On examination, she appears cachectic, has a heart rate of 55 beats per minute, and a blood pressure of 85/50mmHg. The patient refuses to be admitted to hospital.

The multi-disciplinary team are all in agreement that this patient should be admitted for artificial feeding. Under which section of the Mental Health Act should this be done?
a