Behavioural disorders (F5) Flashcards
Eating disorders
Classification
Anorexia nervosa
Epidemiology
Co-morbidities
Anorexia nervosa
Clinical features
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Anorexia nervosa
Main physical features
S/S
Ix
Cx
Symptoms:
Cold intolerance
Amenorrhoea, Loss of libido
Poor sleep
Constipation
Dizziness
Signs:
Emaciation
Dry skin
Lanugo hair
Salivary gland swelling
Cold peripheries, hypotension, bradycardia, arrhythmia
Peripheral edema
Proximal muscle weakness
Ix:
Low FSH/LH/ Estradiol
Low thyroid hormones
High Cortisol, GH
Low glucose
Cx:
Pancytopenia: anemia, leucopenia, thrombocytopenia
Long QT, arrhythmia
Delayed gastric emptying and gut motility
Hypercholesterolemia
HypoK, HypoPO4, Dehydration
Anorexia nervosa
Course and prognosis
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Anorexia nervosa
DSM-5 classification
Rest In Peace Dull Underweight Lady
RIPDUL
Restrict energy intake causing significantly low body weight
Intense fear of gaining weight or becoming fat
Persistent behaviour to stop weight gain
Disturbed experience of body weight
Undue influence of weight or shape on self-evaluation
Lack of recognition of seriousness of low body weight
Restricting = dieting, fasting, excessive exercise
Binge-eating/ purging
Anorexia nervosa
Biological factors
MZ 55%
Familial illness - 12X risk FDR
Anorexia nervosa
Psychological factors
Anorexia nervosa
Social factors
Precipitating
- Puberty, life event, comorbid illness, weight loss
Anorexia nervosa
History taking questions
Eating pattern: Restriction, Binging, Purging, Exercise
Attitude: Weight, Body image, Disorder, Formulation (3Ps)
Risk: Medical, Suicide, BMI (<13.5 for admission)
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Anorexia nervosa
D/dx
Bulimia
Avoidant/ restrictive food intake disorder
Atypical eating disorder (neither AN or BN)
OCD (about food)
Social phobia (about eating in public)
Body dysmorphic disorder (defect in body not weight)
Genuine medical diseases
*
Anorexia nervosa
Management
Admit if BMI <14 or complicated
Nutritional rehab: Supervised meal, stop exercise, nutritionist
Psychotherapy, Psychoeducation: MAUDSLEY Family therapy, MANTRA therapy, CBT-E
Support: Self-help, online support, day hospital support
Lifestyle: Regular weighing, food diary
Medication: Olanzapine (Anti-histamine S/E) +/- Chlorpromazine, Antidepressant
Nutritional rehabilitation for anorexia nervosa
Anorexia nervosa
Refeeding syndrome S/S, Pathogenesis
Mx
Due to high insulin surge»_space; cell reuptake»_space; HypoMg, PO4, K
Anorexia nervosa
General Psychotherapy
Anorexia nervosa
Family therapy
Anorexia nervosa
Social support
Anorexia nervosa
Medical therapy
Bulimia nervosa
Epidemiology
S/S
Binging + Purging/ Fasting/ Excessive exercise
+ Physical cx of vomiting and stimulant laxative
+ Associated depression
Bulimia nervosa
Clinical course
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Bulimia nervosa
DSM-5 criteria
BICBUN
Binge- Innapropriate Compensation- Both 1/w 3 months - Undue influence - Not AN
Binging: large amount of food, lack of control over eating
Inappropriate compensation to prevent weight gain: vomiting, laxatives, diuretics, fasting, excessive exercise
Both Binging and behaviour at least once a week for 3 months
Unduly influence/ self-evaluation based on body weight or shape
Not during AN
Bulimia nervosa
Causes
*
Bulimia nervosa
Management
CBT- E specific for BN
Psychosocial intervention: Cognitive analytic therapy, MI, family therapy
Drugs: SSRI (esp. fluoxetine)
Sleep disorders
Define sleep
Regulation of sleep-wakefulnessS
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Sleep cycles and EEG patterns
Sleep cycles
1 = 5% = Theta waves
2 = 45% = Sleep spindles/ K complex
3&4 = 25% = Delta waves
REM sleep = 25% = low amp, high frequency, Saw tooth waves
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REM vs NREM sleep
Sleep disorder
DSM-5 classification
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Sleep disorder
Investigations
Sleep diary
Actigraphy
Polysomnography
Multiple Sleep Latency Test (Nap test during day) for narcolepsy - MSLT
Maintenance of wakefulness test (staying awake) - MWT
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Insomnia
Definition (important)
Classification
Acute = lasting less than 3 months with identifiable stressor
Chronic = At least 30 minute delay in falling asleep/ awake/ early wakening; occur at least 3 times per week for at least 3 months
Etiology of primary insomnia
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Insomnia
Clinical feature
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Insomnia
DSM-5 criteria
Dissatisfaction with quality or quanitity with difficulty in:
Initiating, Maintaining, Early morning wakening
At least 3 nights/ week, at least 3 months
Despite adequate opportunities for sleeping
Not due to another sleep-wake disorder
Not due to substance, any co-existing mental or medical disorder
*
Insomnia
D/dx
Normal: Short sleepers, Inadequate opportunities for sleep
Situational insomnia: life event
Circadian rhythm sleep-wake disorder
Restless leg syndrome
OSA
Narcolepsy +/- cataplexy: Sleep paralysis, sleep hallucinations, excessive daytime sleepiness
Parasomnia: Intermittent waking, difficulty resuming sleep
*
Insomnia
Investigations
*
Insomnia
Management
CBT-I
Drugs: Z-drugs, Ramelteon, Low dose Doxepin (TCA)
Others: melatonin, promethazine
Alternatives: Mindfulness practice, hypnosis, TCM
Daytime sleepiness
Definition
Causes
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Daytime sleepiness
Assessment
Idiopathic hypersomnia
S/S
Dx
Mx
Narcolepsy
Definition
Etiologies
Sleep invades wakefulness: Hypnagogic hallucination, Cataplexy, Sleep paralysis
Wakefulness invades sleep: Fragmented sleep
Orexin deficiency
HLA- DQB1- 0602
Posterior hypothalamic/ Midbrain lesion
Narcolepsy
Clinical features
4 core:
- Daytime sleepiness
- Hypnagogic hallucination
- Cataplexy
- Sleep Paralysis
Narcolepsy
Diagnosis
*
Narcolepsy
Cause
S/S
Ix
Management
Sleep wake control disorder: sleep into waking hours, wakefulness into sleep
Cause: OREXIN deficiency, HLA-DQB1-0602, posterior hypothalamic or midbrain lesions
S/S: Daytime sleepiness, Cataplexy (type 1) with transient muscle weakness under 2 minutes, Hypnagogic hallucinations (vivid frightening experiences), Sleep paralysis (between REM and wakefulness), Fragmented sleep
Ix:
Polysomnography: early REM entry, spontaneous waking, light NREM sleep
MSLT: At least one immediate sleep onset REM sleep out of 4 naps
Low CSF Orexin-A
Mx: Sleep hygiene + MODAFINIL + SSRI/SNRI + SODIUM OXYBATE
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Compare REM and NREM Parasomnia
Early sleep = NREM and later sleep = REM
NREM - Sleep walking, Sleep/Night Terror, Sleep related eating disorders
- First half of night
- Seconds to minutes
- Begin in early childhood, resolve by teenage
- Open eyes
- No recall
REM – Nightmare disorder, Sleep paralysis, REM-Sleep behaviour disorder
- Latter half of night
- Lasting seconds
- Older male
- Closed eyes
- Reasonable dream recall
Somnambulism
S/S
Mx
Sleep-related eating disorder, confusional arousal, night terrors
Define
Sleep paralysis
S/S
Mx
Sleep paralysis = REM disorder
Nightmare disorder
S/S
Mx
Nightmare disorder = REM disorder
REM sleep behavior disorder
S/S
Mx
Breathing related sleep disorders
S/S
Mxs
Restless leg syndrome and periodic limb movement disorder
Definition
S/S
Mx
Periodic limb movement of sleep (PLMS) = at least 5 limb movements lasting 0.5s-10s with 5s-90s interval: characteristic limb movements, quite common in elderly
PLM disorder (PLMD) = Sleep disturbance ONLY due to PLM
Restless leg syndrome = Unpleasant Urge to move legs during inactivity/ at evening
Mx:
* Avoid caffeine
* Gabapentin, Pregabalin, Levodopa, Pramipexole, Opioid, Clonazepam
Circadian sleep-wake rhythm disorders
Investigations
Circadian sleep-wake cycle disorder
Types
Management
- Delayed = Night Owl = Melatonin + early bedtime
- Advanced = Too sleepy at night = Bright light therapy
- Non-24h = Blind people with day-night reversal = Timed Melatonin
- Irregular = Demented people with short sleeps/ wakefulness = Melatonin + Structured daytime activity
- Jet lag = Timed light exposure + Melatonin
- Shift work = Sleep hygiene, hypnotics, melatonin, CBT-I + Caffeine, Scheduled naps
Sexual dysfunctions and orgasm disorders
Classification
Paraphilic disorders
Gender dysphoria
Classification
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Sexual dysfunction
Common dysfunctions in M/F
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Sexual response cycle
4 phases
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Causes of sexual dysfunction
Phase 1 (desire) sexual dysfunctions
Phase 2 (Excitement) Sexual dysfunctions
Phase 3 (orgasm) sexual dysfunctions
Pain-related sexual dysfunctions
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Sexual dysfunctions
Investigations
Management
Sexual dysfunction clinic: Advice, reassurance, Relationship counselling, Sex therapy
Organic cause: Urology clinic, screen for vascular/ neurological/ hormonal/ genital problems
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Paraphilia
Classification
Definition
Paraphilia
Etiologies
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Paraphilia
Management
Gender dysphoria
Definition
Causes
Gender dysphoria
Management
