Eating d/os, somatic d/os Flashcards
Etiology of factitous d/o imposed on another
Parents who neglect children, disregarding sx in a child who is truly ill
The parent who fabricates or generates factitious sx in a child who is otherwise healthy
A reaction to loss or a way to obtain attention and nurturing, a way to feel powerful, or a way of just acting out
Maternal hx of abuse or reported abuse
Rejection of the child
Use of the child to maintain control
Pathologic relationship with the child
Psychological reward received from the medical community because of the sick child
Common presentations of factitious d/o imposed on another
Bleeding from warfarin poisoning, phenolphthalein poisoning, exogenous exsanguination of a child, and use of colored substances to stimulate bleeding
Seizures
Recurrent apparent life-threatening events
Posoining with phenothiazines, hydrocarbons, salt, or imipramine
Apnea produced via carotid sinus pressure and suffocation
CNS depression produced via drugs
Diarrhea or vomiting secondary to the use of ipecac, laxatives, or salt
Fever, either feigned or actual
Rash from drug poisoning, scratching, caustics, or skin painting
Hypoglycemia from insulin or hypoglycemic agents
Hyperglycemia reports
Hematuria or guaiac-pos stools produced by traumatic injury to the urethra or anorectal area
Multiple infections with varied and often unusual organisms
Warning signs that should alert healthcare workers to the possibility of factitious d/o imposed on others
Unexplainable, persistent, or recurrent illnesses
Discrepancies among the hx, clinical findings, and child’s general health
A working dx of a rare d/o
Sx and signs that occur only in the mother’s presence
A mother who is extremely attentive and always in the hospital
A child who is frequently intolerant of tx
A mother who appears less worried about her child’s illness than about the medical staff
Seizures that do not respond to appropriate therapy
Families in which SIDS occurs
A mother with previous medical or nursing experience or an extensive hx of illness
Typical characteristics of a mother with factitious d/o imposed on others
Biologic mother
Past exposure and experience with the healthcare system
Past training or work as a nurse or medical receptionist
Excellent interactions with all medical staff
More concerned with appearance than with substance
Seemingly excellent care of the child in the hospital, yet, in some cases, less concern for the child than for herself
Inappropriate affect when discussing the child’s illness
Lack of emotion
Possible hx of factitious d/o imposed on self in the past
Past abuse, or at least a reported story of abuse
Possible reporting of falsehoods about their lives
Poor relationship skills
Poor coping skills
Workup for factitious d/o imposed on others
Usually need admission and consultation
Should try to install hidden cameras in the room according to protocols
If no physical cause of sx is found, should do a retrospective review of the child’s medical hx
CBC
Urine toxicology screen
Chem panels
Drug levels for suspected poisoning agents
Cultures
Coagulation tests
Sequential multiple analysis
Assays for RPR, TSH, and thyroid function
DNA typing
Separation test from the mother
DSM-5 criteria for factitious d/o imposed on others
Falsification of physical or psychological signs or sx, or induction of injury or disease in another, associated with identified deception
The individual presents another individual to others as ill, impaired, or injured
The deceptive behavior is evident even in the absence of obvious external rewards
The behavior is not better explained by another mental d/o, such as delusional d/o or another psychotic d/o
Stepwise approach to management of factitious d/o imposed on others
Obtain and verify the victim’s and family’s pertinent medical and social histories, previous hospitalizations, and medical records
Interview the other partner and any other family members alone, when the suspected perpetrator is not present
Admit the child to the hospital to observe the parent-child interactions, closely observe the suspected perpetrator, and determine the temporal relation between the sx and the perpetrator’s presence
Consider separating the child from the suspected perpetrator
During hospitalization and under close observation, obtain the necessary body-fluid samples for toxicology screens and any other relevant investigations; if a multidisciplinary team agrees, hidden cameras can be used
Arrange for social service, psychological, and psychiatric evals of the child and the suspected perpetrator
Assemble a team or task force to examine the records objectively before the suspected perpetrator is confronted
Inform the local child protection and law enforcement agencies before confronting the suspected perpetrator
After the suspected perpetrator has been informed of the dx, remove the child and other siblings at risk; relocate them to a place that is inaccessible to the suspected perpetrator
Recommend short-term and long-term psychological and psychiatric tx for the perp
Verify that long-term close monitoring will be provided by the court
Ensure that relevant reunification criteria are met before the court considers reunification
How to treat the abuse victim of factitious d/o imposed on others
Place child in safe environment
Tx may involve play therapy, individual therapy, or both, depending on age
Clarify the child’s health status
Child welfare or child protective services may have to be notified
How to treat the pt diagnosed with factitious d/o imposed on others
Identified problems must be appropriately managed
The pt must be able to break through denial and willing to undergo therapy
The pt must attempt to learn how to form relationships that are not associated with being ill
Parenting classes are also needed to teach the pt how to parent effectively while meeting his or her needs
What are possible predisposing characteristics of someone with factitious disorder imposed on self?
Having had other mental disorders or medical conditions in childhood or adolescence that resulted in extensive medical attention
Holding a grudge against the medical profession or having had an important relationship with a physician in the past
Having a personality d/o
What factors may raise the possibility that the illness is factitious?
Dramatic or atypical presentation
Inconsistencies between hx and objective findings
Details that are vague and inconsistent, though possibly plausible on the surface
Long medical record with multiple admissions at various hospitals in different cities
Knowledge of textbook descriptions of illness
Admission circumstances that do not conform to an identifiable medical or mental d/o
An unusual grasp of medical terminology
Employment or education in a medically related field
Psedologia fantastica
Presentation in the ED during times when old medical records are difficult to access or when experienced staff are less likely to be present
Clues that may arise during tx of factitious d/o imposed on self
Has few visitors despite giving a hx of holding an important or prestigious job or a hx that casts the pt in a heroic role
Acceptance, with equanimity, of the discomfort and risk of diagnostic procedures
Acceptance, with equanimity, of the discomfort and risk of surgery
Substance abuse, esp of prescribed analgesics and sedatives
Sx or behaviors that are only present when the pt is aware of being observed
Controlling, hostile, angry, disruptive, or attention-seeking behavior during hospitalization
Evidence of pathologic lying in areas other than the presenting sx
Fluctuating clinical course, including rapid development of complications of a new pathology if the initial workup findings prove negative
Giving approximate answers to questions
DSM-5 criteria for factitious d/o imposed on self
Same as factitiious d/o imposed on others, except imposed on self
Tx of factitious d/o imposed on self
Treat comorbid conditions and complications arising from the induced illness
Providers shoudl not abandon their belief in and advocacy for pts unless RFs for factitious d/o are present or suggestive signs of this condition arise
Thorough wrapping of affected areas to prevent access
Psychotherapy should focus on establishing and maintaining a relationship with the pt
Pharmcologic tx is only used for comorbid psych d/os. Caregivers should routinely copy each other on every progress note and prescription written
For hospitalized pts, limit activities to the unit and minimize the time they spend alone
Etiology of somatic symptom d/o
Heightened awareness of nl bodily sensations
Reduced volume of the amygdala and brain connectivity between the amygdala and brain regions controlling executive and motor function
Children raised in homes with a high degree of parental somatization
Sexual abuse can pose an increased risk
Poor ability to express emotions
Reduced threshold for tactile and pain perception
DSM-5 criteria for somatic symptom d/o
One or more somatic sx that are distressing or result in significant disruption of daily life
Excessive thoughts, feelings, or behaviors related to the somatic sx or associated health concerns as manifested by at least one of the following:
-Disproportionate and persistent thoughts about the seriousness of one’s sx
-Persistently high level of anxiety about health or sx
Excessive time and energy devoted to these sx or health concerns
Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 mos)
Labs for somatic symptom d/o
Thyroid function studies Pheochromocytoma screen UDS Blood studies Psychological testing- MMPI
Tx of somatic symptom d/o
In ED, obtain necessary studies to r/o physical causes
Regular, noninvasive medical assessment
CBT
Etiology of illness anxiety d/o
Decreased plasma neurotrophin 3 levels and platelet serotonin levels
RFs: lower educational level, lower income, hx of childhood illness of abuse
Pts misinterpret bodily sx by augmenting and amplifying their somatic sensations
DSM-5 criteria for illness anxiety d/o
Preoccupation with having or acquring a serious illness
Somatic sx are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate
There is a high level of intensity about health, and the individual is easily alarmed about personal health status
The individual performs excessive helath-related behaviors or exhibits maladaptive avoidance
Illness preoccupation has been present for at least 6 mos, but the specific illness that is feared may change over that period of time
The illness-related preoccupation is not better explained by another mental d/o
Screening tools for illness anxiety d/o
Health Anxiety Inventory
Illness Attitude Scale
Whitely Index of Hypochondriasis
Somatoform Disorders Symptom Checklist
Tx of illness anxiety d/o
CBT
Establish a firm therapeutic alliance with the pt
Educate the pt regarding the manifestations of hypochondriasis
Often consistent reassurance
Optimize the pt’s ability to cope with the sx, rather than trying to eliminate the sx
Avoid performing high-risk, low-yield invasive procedures
Close collaboration among all treating providers to prevent investigative duplication
Pharmacotherapy only for comorbid psychiatric d/os
CV complications of anorexia nervosa
Bradycardia Hypotension Decreased size of the cardiac silhouette Decreased left ventricular mass associated with abnl systolic function EKG: -Sinus bradycardia -ST-segment elevation -T-wave flattening -Low voltage -Rightward QRS axis
Endocrine and metabolic complications of anorexia nervosa
Amenorrhea Reduction in fertility Multiple small follicles in the ovaries Decreased uterine volume and atrophy Decrease in T3 and T4 Increase in reverse T3 Neurogenic DI Osteopenia
GI complications of anorexia nervosa
Constipation
Prolonged GI transit
Alterations in antral motility
Gastric atrophy
Neurologic, integumentary, and renal complications of anorexia nervosa
Cerebral atrophy and loss of brain volume Generalized muscle weakness Dry, scaly skin Brittle hair and nails Increased lanugo-type body hair Increase in BUN Decreased GFR Disturbances of calcium, magnesium, and phosphorous
Predisposing factors to anorexia nervosa
Female sex FHx of eating d/os Perfectionistic personality Difficulty communicating negative emotions Difficulty resolving conflict Low self-esteem Maternal psychopathology
Etiology of anorexia nervosa
Genetic factors Disruption of serotonergic and dopaminergic pathways Societal influences Struggles with independence and autonomy Identity conflicts
ROS of anorexia nervosa
Physical health and mental health concerns Amenorrhea Concentration and decision-making concerns HAs Irritability Cold hands or feet Consipation Dry skin or hair loss Social withdrawal Fainting or dizziness Obsessiveness (food) Lehargy
SCOFF questionnaire for eating d/os
Do you make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you lost more than one stone (14 lb) in a 3-mo period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
PE of anorexia nervosa
Hypotension Bradycardia Hypothermia Dry skin Lanugo body hair Acrocyanosis Atrophy of the breasts Swelling of the parotid and submandibular glands Peripheral edema Thinning hair Loss of muscle mass Orthostatic lowered BP or pulse Low blood glucose Low parathyroid hormone levels Elevated liver function Low WBC
DSM-5 criteria for anorexia nervosa
Restriction of energy intake relative to requirements, leading to a significantly low body wt in the context of age, sex, developmental trajectory, and physical health. Significantly low wt is defined as a wt that is less than minimally nl, or for children and adolescents, less than that minimally expected
Intense fear of gaining wt or of becoming fat, or persistent behavior tha interferes with wt gain, even though at a significantly low wt
Disturbance in the way in which one’s body wt or shape is experienced, undue influence of body wt or shape on self-evaluation, or peristent lack of recognition of the seriousness of the current low body wt
Labs for anorexia nervosa
Physical and mental status evaluation CBC with ESR -WBC typically low with thrombocytopenia -ESR is nl Metabolic panel -Hyponatremia -Hypokalemia -Hypoglycemia -Elevated BUN -Hypokalemia hypochloremia metabolic alkalosis with vomiting -Acidosis with laxative abuse UA Pregnancy test Fecal occult blood Thyroid function tests Prolacting Serum FSH
Approach considerations for tx of anorexia nervosa
Admit to hospital for extremely ill, cardiac dysrhythmias, or severe metabolic abnormalities
-May need refeeding
-Should be taken on slowly with consult with nutritionist or dietician
May need transfer to inpatient psychiatric facility afterwards
Psychotherapy strategies available that treat anorexia nervosa
Insight-oriented Cognitive analytic CBT Enhanced CBT Cognitive remediation Interpersonal therapy Motivational enhancement therapy Dynamically informed therapies Group therapy Family based therapy Specialist supportive clinical management
Etiology of bulimia nervosa
Elevated serotonin
7 repeat allele of the D4 receptor gene
Suppression of CCK and ghrelin after meals
Difficulties with self-esteem, affective self-regulation, impulsivity, perfectionism, body image distortion, susceptibility to triggers of a binge-purge cycle, and poor coping skills
Childhood anxiety
Hx of childhood trauma and neglect
Reduced beta-endorphin
Sx of bulimia nervosa
Dizziness Lightheadedness Palpitations Pharyngeal irritation Abdominal pain Blood in vomitus Difficulty swallowing Bloating Flatulence Constipation/obstipation Amenorrhea
Eating Disorder Screen for Primary Care questionnaire
Are you satisfied with your eating patterns?
Do you ever eat in secret?
Does your wt affect the way you feel about yourself?
Have family members suffered from an eating d/o?
Do you currently suffer with or have you in the past suffered with an eating d/o?
Physical findings in bulimia nervosa
Bilateral parotid enlargment Erosions of the lingual surface of the teeth Loss of enamel Periodontal dz Extensive dental caries Callosities, scarring, and abrasions on the knuckles Telogen effluvium Acne Xerosis Nail dystrophy Scarring from cutting, burning, and other self-induced trauma Hypothermia Hypotension Edema Bradycardia or tachycardia
DSM-5 criteria of bulemia nervosa
A. Recurrent episodes of binge-eating. An episode of binge eating is characterized by both of the following:
1. Eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances
2. A sense of lack of control over eating during the episode
B. Recurrent inappropriate compensatory behaviors in order to prevent wt gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other meds, fasting, or excessive exercise
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a wk for 3 mos
D. Self-evaluation is unduly influenced by body shape and wt
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Workup for bulimia nervosa
Comprehensive blood chemistry panel: significant vomiting- hyokalemia metabolic alkalosis. Laxative abuse: normokalemic metabolic acidosis. R/o hyponatremia, hypocalcemia, hypophosphatemia, hypomagnesemia CBC UA Urine toxicology Pregnancy test Amylase EKG DEXA
