CLINICAL Flashcards
symptoms of anorexia
weight: restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental, trajectory and physical health.
Fear: the individual usually experiences an intense and overwhelming fear of gaining weight or becoming fat. This fear is regardless of the person’s actual weight, and will often continue even when the person is near death from starvation. It is related to a person’s poor self-image, which is also a symptom of this disorder.
Distorted Body Image - The individual suffering from this disorder believes that their body weight, shape and size is directly related to how good they feel about themselves and their worth as a human being. Persons with this disorder often deny the seriousness of their condition and can not objectively evaluate their own weight.
Amenorrhoea - At least three consecutive menstrual cycles must be missed, if the woman was menstruating previously before the onset of the disorder. Specifically, a woman is considered to have amenorrhea if her periods occur only following hormone, e.g., oestrogen, administration.
features of anorexia
Onset It is now known that people of any age can have anorexia, but it commonly starts inthe teenage years. It affects around:1 fifteen-year-old girl in every 150. 1 fifteen-year-old boy in every 1000.
Course About 50% fully recover after one episode. About 30% follow an episodic pattern of weight gain and relapse over a number of years. About 20% never fully recover and may need hospitalisation.
Incidence Figures for 2007 found 1.9% of women and 0.2% of men experience anorexia in any year. Usually, the condition lasts for about 6 years.
Up to 4 marks for the description of the symptoms and/or features of anorexia
Dayna may experience Low body weight due to restricting the amount of food she eats. In order to be diagnosed with anorexia, Daynas weight may be less than is normally expected given her age and sex (1) She may also experience an intense fear of gaining weight or becoming fat (1) Another symptom Dayna may experience is a disturbance in the way in which she experiences her body weight or shape (1) She may not recognize the seriousness of her condition because it is likely that she has a poor self image and she may see herself as much larger than she really is (1).
biological explanation
serotonin
high levels of serotonin may lead to high levels of anxiety-binging purging behaviours in people with anorexia/not wanting to eat
heightened anxiety can lead to fear of gaining weight
-high levels of serotonin leads to the ventromedial hypothalamus is stimulated and makes the person feel full. as such they dont eat
- abnormal eating behaviour in people wth anorexia leads to them not wanting food and witout food serotonin cannot be produced in the brain and then theres a lowered level of serotonin which reduces anxiety
Bailer et al (2005)
Found that patients who are in remission from anorexia show increased levels of serotonin in the brain. This was related to the measures of anxiety shown in women. These women had high levels of anxiety and also serotonin a year after their remission. Suggesting that the serotonin rise is linked to increased anxiety that may be linked to the binge/purge form of anorexia
Evidence: Kaye and Frank (2002)
Kaye and Frank (2002) found through PET scans that fully recovered former patients had elevated serotonin levels, which suggests that anorexia may indeed be correlated with higher levels of serotonin.
biological explanation
dopamine
basal ganglia: associated with learning from experiences based on rewards
food is normally a primary reinforcer, leading to pleasure when consumed
- high levels of dopamine in the basal ganglia interferes with the ability to seek or respond to pleasurable activities
basal ganglia: associated with learning from experiences - changes the way the person interprets rewards
food is now disrupted with an overactive basal ganglia and now food leads to anxiety meaning the anorexic no longer wants to eat
Kaye et al (2005)
Kaye et al (2005) used a PET scan to compare dopamine activity in the brains of 10 women recovering from AN and 12 healthy controls. In the AN women, they found overactivity in dopamine receptors of the basal ganglia suggesting that this overactivity may cause individuals with AN to have difficulties associating good feelings with the things that most people find pleasurable such as food.
Kaye (2011) also reported that in women with anorexia nervosa, increased levels of dopamine activity increased anxiety, whereas in ‘normal’ controls the increased dopamine-induced feelings of pleasure. This may suggest why women with AN often experience high levels of anxiety associated with food - something that most people would find pleasurable.
weakness of biological explanatiin
This explanation is reductionist, only considering neurotransmitters as a cause, and as such drugs developed only treat those causes. Drugs used to treat other disorders linked to levels of serotonin and dopamine such as SSRIs and antipsychotics are not very effective in treating anorexia. Suggesting that the disorder is unlikely to be purely related to the levels of these neurotransmitters. Other factors might be involved like genetic predisposition or lifetime experiences
The biological explanation has criticisms, mainly that these altered levels of neurotransmitters could be a result of poor nutrition. For example, Haleem (2012) suggests that serotonin production was influenced with restrictive diets, tryptophan which is an amino acid which is the chemical precursor of serotonin for example can only be gained through food. A restricted diet could lead to a low level of available tryptophan, leading to the brain up-regulating serotonin production. As such neurotransmitter dysregulation might be a side effect of anorexia, rather than being the cause.
biological treatment
SSRI
Generally an antidepressant drug. Functions by blocking serotonin receptors and preventing the serotonin in the synapse from being reabsorbed into the neurons. This increases overall availability of serotonin in the synapse.
As serotonin (as suggested in the previous lesson) is linked to AN, it has been used to help treat AN.
It is thought that in patients with comorbid conditions such as depression and anxiety, the use of medication to treat these symptoms may also enable the patient to benefit more readily from psychological therapies that are used to treat AN. Which is why the treatments are used in conjunction with other therapies
-A common SSRI is Fluoxetine.
It has been used to treat anxiety and depressive comorbid symptoms of patients with AN.
Kaye et al (2001) suggests that drugs like this might be useful in preventing relapse into AN.
SNRI: Serotonin-Noradrenaline Reuptake Inhibitor:
Is a drug that works similarly to SSRIs, but also functions to increase availability of noradrenaline. Which also has helped with anxious moods
This demonstrates that scientists and researchers are becoming more aware that more than one neurotransmitter is involved
biological treatment
antipsychotic
Antipsychotic drugs act as dopamine antagonists. They occupy dopamine D2 receptors in the neurons but DO NOT activate them.
They do not affect the availability of dopamine, but can lessen the effects of dopamine
Some of these drugs have lead to weight gain (such as chlorpromazine) in AN patients (Dally and Sargant, 1966) And also seem to have some effect in regulating the overactive dopamine system in people with anorexia
Newer “second generation” antipsychotics also seem to be effective. They also work on antagonizing receptors of serotonin 5HT as well
One drug of particular interest is called Olanzapine, which targets both dopamine receptors and also serotonin receptors.
This drug seems to have an effect on weight gain and also reducing obsessive thoughts about food in those with AN.
evalutaion of biological treatments anorexia
Atypical antipsychotics drugs also seem to improve anorexia symptoms Jensen and Mejlhede (2000) found case studies of 3 patients who had taken Olanzapine.
The patients showed an increase in positive body image which was also more realistic of what they actually looked like
This demonstrates that atypical antipsychotics can also help treat the symptoms of a distorted perception of one’s body shape or size
Counterpoint:The problem is to convince the patient to start and to continue with olanzapine therapy within the first 2 months, because it takes a few weeks before a full antipsychotic effect is achieved. As these drugs take time to have effects, it may be difficult to convince participants to start or continue to take them, as there are many side effects such as constipation and dizziness
A weakness is that in a systematic review of studies, the effectiveness of drugs in treating anorexia is being challenged. Lebow et al (2013) found that people with anorexia who take atypical antipsychotics do have increases in BMI and body satisfaction, but they were not significantly different than those in placebo groups.
Some instances were actually associated with greater anxiety and worse overall symptoms when compared to controls. This demonstrates that as a whole, that drug therapies might not actually be an effective treatment for anorexia.
However, even effective drugs still might just be tackling symptoms. These drugs target neurotransmitters directly, but there may be other causes to this disorder such as genetics, social factors and psychological reasons that the drug cannot target.
If these other factors are the cause of the disorder, then drug therapies only alleviate symptoms rather than treating the cause of the disorder.
non bio expl anorexia
Social Learning Theory for Anorexia
Anorexia was is an eating disorder that was first diagnosed in the West (America and Europe) and was quite rare in eastern cultures.
The diagnosis has increased worldwide since the 70s, coinciding with Western media spreading worldwide (Iancu et al., 1994)
Social Learning Theory for Anorexia
Attention A person may pay attention to a role model that is anorexic/thin
Retention A person recalls the desirable figure, diet tips and tricks that the model presents to them (virtual or in person)
Reproduction The person may replicate the behaviour the model presents
Motivation The model may be hugely famous/popular. The person is motivated to copy them due to a want of those things.
Role model Similar age, sex, looks or has other desirable characteristics (wealth). Which makes a person look up to them
operant condtionint
Evaluation of the non-biological sociocultural explanation:
1.Identification 2.Justification 3.Elaboration
Research evidence:
Becker et al
Exposure to western media has affected the mental self-image of young girls.
Jones and Crawford (2006) assessed the role of teasing and the development of beauty standards.
They found that overweight girls and underweight boys were more likely to be teased by their peers. Suggesting that through teasing, peers serve to reinforce gender based ideals on the “need” for women to be thin. As such AN may be learned disorder through positive punishment by peers. As such operant conditioning can be a source of disordered eating behaviors.
However, there are many reported cases of anorexia in blind people, who cannot observe others. For example Thomas et al (2012) studied ‘Ms A’, who described herself as having ‘3% of full vision’ but formally diagnosed at age 14. This disputes the argument that social learning theory can explain anorexia because there are cases where even without observations of models, people had anorexia As such observing role models may not be the reason behind the development of anorexia
Counterpoint:
Illness is quite rare in society, other factors must combine with socio-cultural factors as well. Many people are exposed to these models and culture of “thinness”. As small proportions of the population develop these eating disorders.
While socio-cultural factors are involved, there are also alternative biological explanations that predispose people to more likely develop anorexia.
For example:
Therefore, considering both biological and social explanations are well evidenced, perhaps it is possible that some individuals are biologically predisposed to AN but that social conditions influence the development of the disorder
NON BIO TREATMENT ANOREX
A specific form of Cognitive Behavioural Therapy (CBT) has been developed for AN, called Enhanced CBT (CBT-E).
CBT-E is conducted on a one-to-one basis between the patient with AN and the therapist, with most patients receiving about 20 therapy sessions (although sometimes more may be required for serious cases).
Initially a detailed interview takes place, usually over two sessions, to allow the therapist to assess the patient’s symptoms (e.g. fear, distorted body image) and their suitability for treatment using CBT-E. It aims to adjust the thoughts, emotions and behaviours of those with anorexia.
The CBT-E programme takes place through four defined stages:
*Stage 1 focuses on rapidly changing the patient’s eating behaviour. The patient is weighed on a weekly basis and regular eating is encouraged over a 3-4 week period. Patients are also given information about AN to ensure they understand the disorder and what it involves.
This weighing and eating is an attempt to target the BEHAVIOUR of the patients
What symptoms can we link it to:
*Stage 2 is usually a progress update for both the patient and therapist on any changes noticed so far in terms of weight gain and eating behaviour.
If progress is not being made in improving the patient’s weight or behaviour then the therapist can try to discover why this might be the case.
The cognitive beliefs of “I will become disgusting” or “I will instantly become fat” or “I will be a failure” are identified.
What symptoms can we link it to:
*Stage 3 is the main treatment phase consisting of 8-10 weekly sessions that aim to directly address symptoms such as the patient’s distorted body image, the reasons behind their eating behaviour including any potential ‘triggers’ in their life for changes in their eating, and how their therapy is interacting with the rest of their lives.
Beliefs are targeted and challenged.
Triggers like social media, trauma or certain social environments are identified and patient instructed to avoid or process why those trigger anorexic behaviour.
What symptoms can we link it to:
*Stage 4 usually involves 3 appointments around 2 weeks apart. This is where the patient is encouraged to look to the future and think about how to manage their own eating behaviour and thought patterns going forward.
This includes drawing up an agreed plan about how to prevent relapse. A post-treatment review around 5-6 months later will also be set up to see how the patient has been
What symptoms can we link it to:
Evaluation
The CBT-E programme takes place through four defined stages:
*Stage 1 focuses on rapidly changing the patient’s eating behaviour. The patient is weighed on a weekly basis and regular eating is encouraged over a 3-4 week period. Patients are also given information about AN to ensure they understand the disorder and what it involves.
This weighing and eating is an attempt to target the BEHAVIOUR of the patients
What symptoms can we link it to:
*Stage 2 is usually a progress update for both the patient and therapist on any changes noticed so far in terms of weight gain and eating behaviour.
If progress is not being made in improving the patient’s weight or behaviour then the therapist can try to discover why this might be the case.
The cognitive beliefs of “I will become disgusting” or “I will instantly become fat” or “I will be a failure” are identified.
What symptoms can we link it to:
*Stage 3 is the main treatment phase consisting of 8-10 weekly sessions that aim to directly address symptoms such as the patient’s distorted body image, the reasons behind their eating behaviour including any potential ‘triggers’ in their life for changes in their eating, and how their therapy is interacting with the rest of their lives.
Beliefs are targeted and challenged.
Triggers like social media, trauma or certain social environments are identified and patient instructed to avoid or process why those trigger anorexic behaviour.
What symptoms can we link it to:
*Stage 4 usually involves 3 appointments around 2 weeks apart. This is where the patient is encouraged to look to the future and think about how to manage their own eating behaviour and thought patterns going forward.
This includes drawing up an agreed plan about how to prevent relapse. A post-treatment review around 5-6 months later will also be set up to see how the patient has been
What symptoms can we link it to:
schizophrenia
Delusions A delusion is a distorted belief. The individual does not feel in control of their own thoughts and feelings. E.g. They may believe their neighbour is plotting against them.
Hallucinations Hallucinatory voices are most common. These are voices that do not exist, but feel real to the person hearing them. The content of the voices is very variable but often takes the form of a running commentary on the person’s behaviour.
Disorganised speech eg frequent derailment or incoherence This arises when the train of thought is disrupted and the person’s speech is so jumbled that it becomes meaningless.
Grossly disorganised or catatonic behaviour This refers to unusual body movements and includes the adoption of odd postures, uncontrolled limb movements and sometimes, compete frozen immobility.
Negative symptoms eg affective flattening, alogia or avolition Negative symptoms involve losses of emotion, interests, pleasure etc. They are associated with social withdrawal, apathy and indifference to personal welfare and hygiene.
features of schizophrenia
Incidence and prevalence (rate of occurring)
* In most countries around the world the prevalence of schizophrenia is about 1% in the population aged over 18.
The onset of the disorder usually occurs between the ages of 15 and 45.
- It is equally common in males and females, but it usually occurs in males four to
five years earlier than in females. This difference has not yet been adequately explained.
*Childhood schizophrenia is occasionally diagnosed but it is rare.
COURSE
* It is an episodic illness in which periods of psychotic disturbance are usually seen with more normal periods of functioning.
- The emergence of psychotic symptoms usually occurs after a period of a few weeks or months in which changes in mood and behaviour are evident to people close to the sufferer but specific symptoms have not yet appeared. During this period, individuals often suffer from low mood and anxiety and experience difficulties in social relationships and in concentrating on work and study.
- The active phase of the disorder follows and a psychotic episode may last from one to six months but can extend to a year. Inter- episode functioning varies greatly between individuals – better inter-episode functioning is associated with better prognosis.
PROGNISIS
The rule of thirds.
- About one third of patients has a single episode or a few brief episodes of schizophrenia and then recovers fully.
- Another one-third has occasional episodes of the disorder throughout their lives and functions reasonably effectively between episodes.
- The remaining third deteriorate over a series of increasingly incapacitating episodes.
Those patients for whom schizophrenia comes on suddenly tend to have a better prognosis (outlook); the same is true for patients who have more positive symptoms.
