Dissociative and eating Disorders Flashcards
What is dissociation?
Transient disconnection from your thoughts experiences or consciousness
Is unconscious or a reflexive process
- usually a result of another illness and/or experiences of trauma
Can also be induced by some medications (especially MDMA)
Dissociative identity disorder (DID)
Previously = Multiple personality disorder
Disruption if identity characterized by two or more distinct personality states (“alters”)
- disruption of identity involves marked discontinuity in sense of self/agency/behavior/affect/memory/perception/cognition
- often will report having gaps of memory with everyday events, important personal info and/or traumatic events
- actions and “alters” are not accepted by cultural or religious practices*
- also in children, if DID is present, it is not better explained by imaginary playmates/fantasy play
patient usually knows this is going on
Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
most commonly seen in patients with PTSD/MDD/substance abuse disorders/somatoform disorders
tx = psychotherapies are the only known treatment approach
What is the major risk factor for dissociative identity disorder?
Most major risk factor = childhood trauma
Dissociative amnesia
Inability to recall important autobiographical information
- usually after a severe traumatic or stressful event and the amnesia is inconsistent with ordinary forgetting
there is no alternative personality
Symptoms cause clinically significant distress or impairment in social occupational or other important area and the symptoms are not attributable to substances or medical conditions.
- *often enters a “fugue” where they travel places to better find “themselves” and will often present to the hospital without knowing their personality and behaviors**
- this is due to amnesia of identity or autobiographical information
Epidemiology = 2-6%
Treatment: CBT and hypnosis is the only known treatment
Common differential diagnosis for dissociative amnesia
Dementia
Delirium
Post-ictal amnesia
Transient global amnesia
Trauma-related disorders
Substance-related amnesia
Malingering
Depersonalization vs derealization disorders
Depersonalization: detachment of ones body where they are on the outside to observe with respect to ones thoughts. (“Feel like I’m watching myself outside of my body”)
- is respect to self*
Derealization: detachment with respect to surroundings (“things around dont seem real”)
- almost always seen in trauma and is a defense against it (also PTSD)
- is respect to surroundings*
reality testing remains intact for both
there is usually NO psychosis associated
Who to screen for eating disorders?
Significant unexplained weight loss
Stigmata on physcial exam*
Highly restrictive diets
Negative body-related cognitions
OCD or food-related ritualistic behaviors
young women are more likely than men to have any eating disorder
Anorexia nervosa criteria
1) Self-induced starving leading to significantly low weight
- children <85% percentile in weight
- adult = BMI<18.5%
2) Also has an intense fear of gaining weight or being fat
3) distortions in a way in which ones body weight or shape is experienced
* need to also specific subtypes (restricting type, binge eating/purging)*
Restrictive anorexia subtype
During the last 3 months the individual has not engaged in recurrent episodes of binge eating or purging activity
- low BMI is due to extreme dieting or excessive exercising
Binge eating/purging anorexia subtype
During the last 3 months, individual episodes of binge eating and purging
- Low BMI is due to abuse of laxatives/diuretics/enemas, etc.
How is severity of anorexia measured?
BMI
Cause and risk factors of anorexia nervosa
Corticolimbic circuits and anterior insula are disrupted
Multiple neurotransmitter systems are also wonky
highly comorbid with MDD, panic disorder, OCD
prevalence = 0.6%
Physical exam findings in anorexia nervosa
Physical exam
- low BMI (key diagnostic)
- hypothermia
- Bradycardia (very common)
- hypotension (very common)
- xerosis (dry skin)
- lanugo (fine coarse hair)
- hair loss
- abdominal distention
- peripheral edema
- decreased bowel sounds on exam
Symptoms of anorexia nervosa
- Amenorrhea (very common)
- Exertion fatigue (very common)
- Weakness
- Cold intolerance
- Palpitations
- Dizziness
- Early satiety/bloating (late stage usually)
- constipation
- peripheral edema (late stage usually)
Most common medical complications of anorexia
CNS = enlarged ventricles and brain atrophy
cardiac = narrowed left ventricle, peripheral edema, MVP, cardiac fibrosis, diaphragmatic wasting and decreased cardiac diameter
cardiac symptoms are the most common cause of death in untreated anorexia nervosa
Hematologic = anemia, leukopenia and hypocellular bone marrow
Endocrine = low FSH/LH/estrogen, high prolactin/GH/cortisol
Metabolic = hypoglycemia, elevated AST/ALT, osteopenia, Hypercholesterolemia
Refeeding syndrome
In treatment of anorexia, this is a life treating complication if not handled properly
- rapid introduction of food when the body is switching from catabolic -> anabolic state results in massive increase in insulin release.
- the insulin release and storage of glucose into glycogen results in mass decrease in phosphate and potassium since these are used in the formation of glycogen
caused by hypophosphatemia, hypomagnesia and hypokalemia
Symptoms:
- CHF
- seizures
- rhabdomyolysis
- seizures
- hemolysis
- will kill if not corrected*
Treatment: refeed slowly and monitor potassium and phosphate levels
- also SSRIs and psychotherapy
Prognosis of anorexia
Usually poor
- overall mortality is 5-18%
- is considered among the top 3 most deadly of all psychiatric disorders
60% of these mortalities is cardiac related
25% of these mortalities is suicide related
Treatment of anorexia
1st line = psychotherapy (especially family therapy/CBT) and nutritional rehabilitation (get them to eat food/nourishment somehow
also use SSRIs/SNRIs/mirtazapine for patients with suicide ideology or bad mind set if present
also if AN ideologies are super bad, could consider antipsychotics (olanzapine), however it’s pretty rare for it too be this bad
Ethical challenges with anorexia
Patients often have poor or superficial insight into the severity of their illness
- they often try to lie or reason with the physician just to get away
Online cultures may perpetuate unrealistic or romantic idealization about the disease
Bulimia nervosa criteria
1) Recurrent episodes of binge eating and purging
* *always are either at 18.5 BMI or slightly higher (> 18.5) (NEVER low BMI)**
2) Recurrent inappropriate compensatory behaviors in order tot RS and prevent weight gain
- vomiting, laxatives, enimas, diuretics
Both of the above behaviors must be present at least once a week for at least 3 months
Classifications:
- mild = 1-3 episodes a week
- moderate = 4-7 episodes a week
- severe = 8-13 episodes a week
- extreme = 14+ episodes a week
Treatment and course of bulimia
Usually better prognosis but can progress to anorexia if not treated or monitored
Treatment = CBT and SSRIs are first line
- better evidence for SSRI use in bulimia
Medical sequelae of bulimia nervosa
Bilateral parotid swelling due to hyperplasia from overuse
Dental erosion
Hypokalemia, hyperchloremic metabolic alkalosis
Mallory-Weiss tears (esophageal tears)
Boerhaaves syndrome (esophageal ruptures)
GERD
Pancreatitis
Tachycardia
Ipecac-induced myopathy
Constipation
Russels sign (caluses on knuckles from inducing self vomiting)
THERE WILL BE NORMAL OR SLIGHTLY ABOVE NORMAL BMI
Binge-eating disorder
most common eating disorder period
Recurrent episodes of binge-eating WITHOUT excessive purging/exercise.
Must occur at least once a week for 3 months
very high risk of getting diabetes
Severity = how often is it happening a week
- mild = 1-3
- moderate 4-7
- severe 8-13
- extreme - 14+
ARFID diagnostic criteria
Avoid and restrict food disorder
An eating or feeding disturbance associated with one fo the following
- significant weight loss
- significant nutritional deficiency
- dependence on enteral feeding or oral/nutritional supplements
- marked interference with psychosocial deficiencies
- Body weight or shape usually doesn’t change, if changes are underweight or normal BMI (never overweight)*
- DOESNT have convictive or negative cognitive feelings towards their body (difference between bulimia and anorexia)*
SCOFF screening tool
Needs at least 2 positive to be a positive screening for eating disorder
S: do you make yourself SICK because you feel uncomfortably full?
C: do you worry you have lost CONTROL over how much you eat?
O: have you recently lost one STONE (14 lbs) within the last 3 months?
F: do you believe you are FAT even though others say your skinny or fine?
F: would you say that FOOD dominates your life?
Epidemiology of DID
1-2% prevalence
More common in women than men
Highly associated with
1) PTSD
2) MDD
3) substance abuse
4) somatoform disorders
Specific cardiac complications with anaerobic nervosa
Structural
- muscle atrophy and decreased ventricular diameter
- cardiac fibrosis
- MVP
- cardiac effusions
Functional
- bradycardia
- hypotension
- QT elongation
- diastolic heart failure
cardiac complications are the #1 cause of death
Treatment for binge-eating disorder
1st line is CBT and SSRIs
- 2nd line is lisdexamfetamine
Easiest way to differentiate eating disorders
1) does the patient have a BMI < 18.5? = AN/ARFID
- does the patient have negative body cognitions? = AN
2) does the patient have BMI > 18.5? = BN/BED
- does the patient purge excessively? = BN
