Behavioural disorders (F5) Flashcards by Max Kam

Eating disorders

Classification

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Anorexia nervosa

Epidemiology
Co-morbidities

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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

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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

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Anorexia nervosa

Biological factors

MZ 55%
Familial illness - 12X risk FDR

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Anorexia nervosa

Psychological factors

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Anorexia nervosa

Social factors

Precipitating
- Puberty, life event, comorbid illness, weight loss

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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

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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

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Nutritional rehabilitation for anorexia nervosa

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Anorexia nervosa

Refeeding syndrome S/S, Pathogenesis
Mx

Due to high insulin surge&raquo_space; cell reuptake&raquo_space; HypoMg, PO4, K

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Anorexia nervosa

General Psychotherapy

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Anorexia nervosa

Family therapy

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Anorexia nervosa

Social support

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Anorexia nervosa

Medical therapy

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Bulimia nervosa

Epidemiology
S/S

Binging + Purging/ Fasting/ Excessive exercise
+ Physical cx of vomiting and stimulant laxative
+ Associated depression

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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

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Bulimia nervosa

Causes

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Bulimia nervosa

Management

CBT- E specific for BN
Psychosocial intervention: Cognitive analytic therapy, MI, family therapy
Drugs: SSRI (esp. fluoxetine)

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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

# * REM vs NREM sleep

Sleep disorder DSM-5 classification

# * 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

# * 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

# * Insomnia Clinical feature

# * 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

# * 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

# * 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

1. Delayed = Night Owl = Melatonin + early bedtime 1. Advanced = Too sleepy at night = Bright light therapy 1. Non-24h = Blind people with day-night reversal = Timed Melatonin 1. Irregular = Demented people with short sleeps/ wakefulness = Melatonin + Structured daytime activity 1. Jet lag = Timed light exposure + Melatonin 1. Shift work = Sleep hygiene, hypnotics, melatonin, CBT-I + Caffeine, Scheduled naps

Sexual dysfunctions and orgasm disorders Classification

Paraphilic disorders Gender dysphoria Classification

# * Sexual dysfunction Common dysfunctions in M/F

# * Sexual response cycle 4 phases

# * Causes of sexual dysfunction

Phase 1 (desire) sexual dysfunctions

Phase 2 (Excitement) Sexual dysfunctions

Phase 3 (orgasm) sexual dysfunctions

Pain-related sexual dysfunctions

# * Sexual dysfunctions Investigations Management

Sexual dysfunction clinic: Advice, reassurance, Relationship counselling, Sex therapy Organic cause: Urology clinic, screen for vascular/ neurological/ hormonal/ genital problems

# * Paraphilia Classification Definition

Paraphilia Etiologies

# * Paraphilia Management

Gender dysphoria Definition Causes

Gender dysphoria Management