Eating/Sleep/Sexual Disorders Flashcards
1
Q
Feautures of AN
A
The main features of anorexia nervosa are:
● Very low body weight (defined as being 15% below
the standard weight, or body mass index (BMI) of less
than 17.5 kg/m2), which is maintained by restriction
of energy intake.
● Extreme concern about weight and shape, characterized by an intense fear of gaining weight and becoming fat and a strong desire to be thin.
● An undue influence of body weight or shape on
self-evaluation.
● Lack of recognition of the seriousness of low body
weight.
● ICD-10, but not DSM-5, includes amenorrhoea as a
criterion in women.
2
Q
Greatest incidence rates of AN
A
The incidence of anorexia nervosa based upon primary
care and mental health surveys is about 5 per 100,000.
Rates in the community are considerably higher.
Incidence is greatest among young women, with 40%
of all incident cases occurring in 15–19-year-old females.
3
Q
Heritability of AN
A
28-74%
4
Q
Etiology of AN
A
Genetics- heritability
Neurobiology- difficulty shifting between tasks, serotonin alterations, grey matter volume increased in OFC and insula
Sociocultural- response to dieting, not dieting itself
Psychological- perfectionism, low self esteem
Family- Minuchin et al. (1978) held that a specific pattern of
relationships could be identified, consisting of ‘enmeshment, overprotectiveness, rigidity and lack of conflict
resolution’. They also suggested that the development of
anorexia nervosa in the patient served to prevent dissent
within the family.
5
Q
Assessment of eating
A
What is a typical day’s eating? What are the mealtime
arrangements at home and at school/work?
To what degree is the patient attempting restraint?
Is there a pattern? Does it vary? Is eating ritualized?
Does the patient avoid particular foods? If so, why?
Does she restrict fluids?
What is the patient’s experience of hunger or of any
urge to eat?
Does she binge? Are these objectively large binges?
Does she feel out of control?
How do binges begin? How do they end? How often do
they occur?
Does she make herself vomit? If so, how?
Does she take laxatives, diuretics, emetics, or appetite
suppressants? If so, with what effects?
Does she fast for a day or longer?
Can she eat in front of others?
Does she exercise? Is this to ‘burn off calories’?
6
Q
Evidence for antidepressants in AN
A
Systematic reviews show no
clear effect of antidepressants on weight gain, maintenance, or psychological symptoms during re-feeding Antidepressants are also used to treat depression in
anorexia nervosa. The evidence for their effectiveness
in this situation is weak, and guidelines suggest that
antidepressants should not be used until it is apparent
that the symptoms are not merely due to starvation,
and that they persist during restoration of weight (
7
Q
First description of Bulimia
A
The syndrome of bulimia nervosa was
first described by Russell (1979) in an influential paper
in which he named the condition and described the key
clinical features in 30 patients who were seen between
1972 and 1978. The prevalence of bulimic behaviours
and the associated harms soon became apparent, and
the syndrome was first included in DSM-III.
8
Q
Classification of sleep-wake disorders in DSM V
A
Insomnia disorder Hypersomnolence disorder Narcolepsy Breathing-related sleep disorders Circadian rhythm sleep–wake disorders Non-rapid eye movement (REM) sleep arousal disorders Nightmare disorders REM sleep behaviour disorder Restless legs syndrome Substance/medication-induced sleep disorder
9
Q
Groups at +risk of persistent sleep problems
A
Groups at particular risk of persistent sleep problems
include young children and adolescents (Stores, 2015),
the elderly, the physically ill, and those with learning
disability (Heussler, 2016)
10
Q
Assessment of sleep problems
A
Screening questions
Do you sleep well enough and long enough?
Are you very sleepy during the day?
Is your sleep disturbed at night?
Sleep history Detailed history of the sleep complaint and a typical sleep–wake cycle Factors that improve or worsen sleep Effect on mood and functioning Past and present treatment History from bed partner Sleep diary Systematic 2-week or longer record
Possible investigations Video recording Actigraphy (wrist-worn) Polysomnography HLA typing Cerebrospinal fluid orexin (hypocretin) levels
11
Q
Sleep hygeine
A
Sleep environment Familiar and comfortable Dark Quiet Encourage
Bedtime routines
Consistent time for going to bed and waking up
Going to bed only when tired
Thinking about problems before going to bed
Regular exercise
Avoid Late-evening exercise Caffeine-containing drinks late in the day Using mobile devices or watching TV in bed Excessive alcohol and smoking Excessive daytime sleep Large late meals Too much time in bed lying awake
12
Q
Causes of excessive daytime sleepiness
A
Insufficient sleep Narcolepsy Depression Other medical disorders (e.g. hypothyroidism, Prader– Willi syndrome) Shift-work sleep disorder Use of sedative medications Obstructive sleep apnoea
13
Q
Cataplexy
A
The most striking of these REM-like states is cataplexy: sudden episodes
of partial or complete paralysis of voluntary muscles
14
Q
Important comorbidities in narcolepsy
A
Obesity
Depression
15
Q
Aetiology of narcolepsy
A
Type 1 narcolepsy is characterized by
cataplexy and by marked reduction of a peptide called
orexin-A (also called hypocretin-1) in the cerebrospinal
fluid (CSF). This occurs because of a severe and selective loss of the hypothalamic neurons that make this
peptide, which is known to be involved in regulation
of wakefulness. Type 2 narcolepsy is not associated with
cataplexy, and CSF orexin-A levels are normal; its diagnosis is therefore more challenging, and its biological
basis less well understood.
The predominant genetic association to narcolepsy
is HLA-DQB1*06:02
16
Q
Treatment of narcolepsy
A
Stimulants
Modafanil
Amphetamines
Venlafaxine, clomipramine can decrease cataplexy
17
Q
Kleine-Levin Syndrome
A
This very rare secondary sleep disorder consists of episodes of somnolence, increased appetite, and hypersexuality, often lasting for days or weeks, with long
intervals of normality between them. It usually affects
adolescent boys. The symptoms suggest a hypothalamic
disorder, but its aetiology is unknown. There is no established treatment, but stimulants, lithium, and other
mood stabilizers, are used.
18
Q
Night terrors
A
A few hours after going to sleep, the child,
while in stage 3–4 non-REM sleep, sits up and appears
terrified. They may scream, and they usually appear
confused. There are marked increases in heart rate and
respiratory rate.
After a few minutes the child slowly settles and returns
to normal calm sleep. There is little or no dream recall.
A regular bedtime routine and improved sleep hygiene
have been shown to be helpful.
19
Q
In what stage does sleep walking occur
A
non-REM sleep
5-12 yo, 15% walk in their sleep at least once
20
Q
Rapid eye movement sleep behaviour disorder
A
Rapid eye movement (REM) sleep behaviour disorder is a parasomnia that should be considered when behavioural
problems, particularly agitation or aggression, occur during the night. It is thought to occur when the normal
atonia of REM sleep is lost, so that dreams are acted out.
It is more common in the elderly, particularly men. It is
associated with, and can precede the onset of, neurodegenerative disorders, particularly Parkinson’s disease and
Lewy body dementia (Boeve et al., 2013). Clonazepam
and donepezil may be effective
21
Q
Risk factors for RLS
A
2.5%
of the population having significant symptoms. Risk factors include female gender, pregnancy, ageing, low iron
status, and parkinsonism.
22
Q
How do mood stabilisers impact sexual function
A
Lower bioavailability of testosterone
23
Q
Drugs that may impair sexual function
A
Therapeutic agents Diuretics and antihypertensive agents ● β-blockers, calcium channel blockers, spironolactone Antidepressants and mood stabilizers ● SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, lithium Anxiolytics and hypnotics ● Benzodiazepines Antipsychotics Antihistamines and histamine H2 -receptor antagonists ● Diphenhydramine ● Ranitidine Parkinson’s disease medications Misused substances Alcohol, heroin, amphetamine, MDMA, cocaine, marijuana
24
Q
Treatments for sexual dysfunction
A
Advice, information, and reassurance Treatment of underlying cause Psychological methods Sexual skills training Sex therapy (including sensate focus exercises) CBT Marital therapy Systematic desensitization Educational intervention Drug treatments PDE-5 inhibitors Other physical treatments Vacuum devices Dilators
25
Systematic investigations of paraphilias
The systematic investigation of these disorders began in the 1870s. Krafft-Ebing,
a professor of psychiatry in Vienna, wrote a systematic
account of paraphilias in his book Psychopathia Sexualis,
which was first published in 1886
26
Aetiology of gender dysphoria
Genetic- In a study of twins
with gender dysphoria, 39% of monozygotic twins were
concordant for gender dysphoria, whereas none of the
dizygotic twins were concordant
Sex-dimorphic brain structure and function
Psychosocial processes
27
Which of the following is not true about sexual addiction?
A. Individuals who engage addictively in one form of
sexual behavior are likely also to engage addictively
in other forms of sexual behavior.
B. Sexual addiction is usually a chronic disorder.
C. There is a higher prevalence of sexual addiction
among women.
D. Obsessions and compulsions with sexual content can
occur in individuals with obsessive-compulsive disorder
(OCD).
E. Hypersexual behavior can occur in individuals with
bipolar disorder.
The answer is C
There is a higher prevalence of sexual addiction in men than in
women. The same is true of paraphilias. Theories as to the reason
for this include the higher levels of testosterone in men (testosterone
is the libido driving hormone in both men andwomen) and
the particular challenge little boys face during the oedipal phase
of development. At this time, the boy must give up his identification
with the primary caregiver—usually the mother—and
instead identify with his father. Other factors cited as contributants
to sex addiction include a history of abuse (whether sexual,
emotional, or physical) or having been an “eroticized child,” that
is, the object of a highly seductive parent.
28
With regard to innervation of sex organs, all of the following
are true except
A. Penile tumescence occurs through the synergistic activity
of parasympathetic and sympathetic pathways.
B. Clitoral engorgement results from parasympathetic
stimulation.
C. Vaginal lubrication results from sympathetic stimulation.
D. Sympathetic innervation is responsible for ejaculation.
E. Sympathetic innervation facilitates the smooth muscle
contraction of the vagina, urethra, and uterus during
orgasm.
The answer is C
Innervation of the sexual organs is mediated primarily through
the autonomic nervous system (ANS). Penile tumescence occurs
through the synergistic activity of two neurophysiologic
pathways. A parasympathetic (cholinergic) component mediates
reflexogenic erections via impulses that pass through the
pelvic splanchnic nerves (S2, S3, and S4). A thoracolumbar
pathway transmits psychologically induced impulses. Both parasympathetic and sympathetic mechanisms are thought to
play parts in relaxing the smooth muscles of the penile corpora
cavernosa, which allow the penile arteries to dilate and cause the
inflow of blood that results in penile erection. Relaxation of cavernosal
smooth muscles is aided by the release of nitric oxide, an
endothelium-derived relaxing factor. Clitoral engorgement and
vaginal lubrication also result from parasympathetic stimulation
that increases blood flow to genital tissue.
Evidence indicates that the sympathetic (adrenergic) system
is responsible for ejaculation. Through its hypogastric plexus,
the adrenergic impulses innervate the urethral crest; the muscles
of the epididymis; and the muscles of the vas deferens, seminal
vesicles, and prostate. Stimulation of the plexus causes emission.
In women, the sympathetic system facilitates the smooth muscle
contraction of the vagina, urethra, and uterus that occurs during
orgasm.
The ANS functions outside of voluntary control and is influenced
by external events (e.g., stress, drugs) and internal events
(hypothalamic, limbic, and cortical stimuli). It is not surprising,
therefore, that erection and orgasm are so vulnerable to dysfunction.
29
```
Which part of the brain is directly involved in sexual drive
in mammals?
A. Temporal lobe
B. The limbic system
C. Neo cortex
D. Frontal lobe
E. Parietal lobe
```
The answer is B
The limbic system is directly involved with elements of sexual
drive. In all mammals, the limbic system is involved in behavior
required for self-preservation and the preservation of the species.
30
Among the following, the sexual dysfunction not correlated
with phases of the sexual response cycle is
A. sexual aversion disorder
B. vaginismus
C. premature ejaculation
D. postcoital dysphoria
E. male erectile disorder
The answer is B
Seven major categories of sexual dysfunction are listed in the
DSM-IV-TR: (1) sexual desire disorders, (2) sexual arousal disorders,
(3) orgasm disorders, (4) sexual pain disorders, (5) sexual
dysfunction due to a general medical condition, (6) substanceinduced
sexual dysfunction, and (7) sexual dysfunction
NOS.
31
Which of the following statements is true about paraphilias?
A. Paraphilias are usually not distressing to the person
with the disorder.
B. Paraphilias are found equally among men and
women.
C. According to the classic psychoanalytic model, paraphilias
are caused by a failure to complete the process
of genital adjustment.
D. With an early age of onset, paraphilias are associated
with a good prognosis.
E. Paraphilias such as pedophilia usually involve vaginal
or anal penetration of the victim.
The answer is C
Paraphilias, according to the classic psychoanalytic model, are
caused by a failure to complete the process of genital adjustment.
However bizarre its manifestation, the paraphilia provides an
outlet for the sexual and aggressive drives that would otherwise
have been channeled into proper sexual behavior. Paraphilias are
usually distressing to the person with the disorder. Paraphilias are
not found equally among men and women. As usually defined,
paraphilias seem to be largely male conditions. Paraphilias with
an early age of onset are associated with a poor prognosis, as are
paraphilias with a high frequency of the acts (Table 20.1), no guilt
or shame about the acts, and substance abuse. Paraphilias such
as pedophilia usually do not involve vaginal or anal penetration
of the victim. The majority of child molestations involve genital
fondling or oral sex.
32
```
The term partialism refers to fetishes involving
A. a specific item of clothing
B. a nonsexual body part
C. a specific type of material
D. a nonsexual behavior
E. a specific food item
```
The answer is B
The term partialism refers to fetishes involving non sexual body
parts (e.g., a foot fetish). Individuals who achieve sexual gratification
with the use of objects, most commonly women’s undergarments,
shoes, stockings, or other clothing items, are fetishists.
Fetishists often collect the object of their sexual gratification.
Some of the more common objects are women’s lingerie or specific
materials such as silk, leather, or fur. Fetishism has been
exclusively described in men and often exists with other paraphilias.
33
Research has indicated that
A. a majority of married people are unfaithful to their
spouses
B. the median number of sexual partners over a lifetime
for men is six and for women two
C. vaginal intercourse is considered the most appealing
type of sexual experience by a large majority of men
and women
D. masturbation is more common among those 18 to
24 years old than among those 24 to 34 years old
E. the percentage of single women reporting “usually
or always” having an orgasm during intercourse is
greater than the percentage of married women reporting
this
The answer is C
A 1994 study, which was based on a representative United
States population between the ages of 18 and 59, found the
following:
1. Eighty-five percent of married women and 75 percent of married
men are faithful to their spouses.
2. Forty-one percent of married couples have sex twice a week
or more compared with 23 percent of single persons.
3. Cohabiting single persons have the most sex of all, twice a
week or more.
4. The median number of sexual partners over a lifetime for
men is 12 (not six) and for women, six (not two).
5. Ahomosexual orientationwas reported by 2.8 percent of men
and 1.4 percent ofwomen, with 9 percent of men and 5 percent
of women reporting that they had at least one homosexual
experience after puberty.
6. Vaginal intercourse is considered the most appealing type
of sexual experience by the majority of both men and
women.
7. Both men and women who as children had been sexually
abused by an adult were more likely as adults to have had
more than 10 sex partners, to engage in group sex, to report
a homosexual or bisexual identification, and to be unhappy.
8. About one man in four and one woman in 10 masturbates
at least once a week, and masturbation is less common (not
more common) among those 18 to 24 years of age than among
those 24 to 34 years old.
9. Three-quarters of the married women said “they usually
or always” had an orgasm during sexual intercourse compared
with 62 percent of single women. Among men, married
or single, 95 percent said they usually or always had an
orgasm.
34
Measures used to help differentiate organically caused
impotence from functional impotence include
A. monitoring of nocturnal penile tumescence
B. glucose tolerance tests
C. follicle-stimulating hormone (FSH) determinations
D. testosterone level tests
E. all of the above
The answer is E (all)
A variety of measures is used to differentiate organically caused
impotence from psychologically caused impotence. The monitoring
of nocturnal penile tumescence is a noninvasive procedure;
normally, erections occur during sleep and are associated
with rapid eyemovement (REM) sleep periods.Tumescence may
be determined with a simple strain gauge. In most cases in which
organic factors account for the impotence, the man has minimal
or no nocturnal erections. Conversely, in most cases of psychologically
caused or psychogenic impotence, erections do occur
during REM sleep.
Other diagnostic tests that delineate organic bases of impotence
include glucose tolerance tests, follicle stimulating hormone
(FSH) determinations, and testosterone level tests. The
glucose tolerance curve measures the metabolism of glucose
over a specific period and is useful in diagnosing diabetes, of
which impotence may be a symptom. FSH is a hormone produced
by the anterior pituitary, which stimulates the secretion of
estrogen from the ovarian follicle inwomen; it is also responsible
for the production of sperm from the testes in men. An abnormal
finding suggests an organic cause for impotence. Testosterone is
the male hormone produced by the interstitial cells of the testes.
In men, a low testosterone level produces a lack of desire as the
chief complaint, which may be associated with impotence. If the
measure of nocturnal penile tumescence is abnormal, indicating
the possibility of organic impotence, a measure of plasma
testosterone is indicated.
35
```
Psychiatric interventions used to assist the paraphilia patient
include
A. dynamic psychotherapy
B. external control
C. cognitive behavioral therapy
D. treatment of comorbid conditions
E. all of the above
```
The answer is E (all)
Five types of psychiatric interventions are used to assist the paraphilia
patient to rebalance internal control mechanisms, cease
victimization of others, and enhance the capacities to relate to
others: external control, reduction of sexual drives, treatment of
comorbid conditions, cognitive behavioral therapy, and dynamic
psychotherapy. The art of therapy is to select and modify these
various elements for the individual patient
36
```
Which of the following substances have been associated
with sexual dysfunction?
A. Cocaine
B. Trazodone
C. Amoxapine
D. Antihistamines
E. All of the above
```
The answer is E (all)
Intoxication with cocaine and alcohol, among other substances,
produces sexual dysfunction. Medications such as antihistamines,
antidepressants, and antiepileptics, among others, can
cause arousal and orgasmic disorders as well as decreased sexual
interest. Trazodone (Desyrel) is one of the substances associated
with priapism, and amoxapine (Asendin) is associated
with painful orgasm. Still other substances implicated in sexual
dysfunction include antihypertensives, antiparkinsonian agents,
anxiolytics, hypnotics, sedatives, amphetamines, and anabolic
steroids.
37
In the most severe forms of paraphilia,
A. persons never experience normal sexual behavior
with partners
B. the specific paraphilia imagery or activity is absolutely
necessary for any sexual function
C. the need for sexual behavior consumes so much
money, time, concentration, and energy that persons
describe themselves as out of control
D. orgasm does not produce satiety in the same way it
typically does for age mates
E. all of the above
The answer is E (all)
The DSM-IV-TR recognizes the paraphilias as consisting of recurrent,
intensely sexually arousing fantasies, sexual urges, or
sexual behaviors that involve nonhuman objects and the suffering
of the self, partner, children, or nonconsenting persons. To
qualify as a diagnosis, however, these patterns must have existed
for at least 6 months, and they have to cause clinically significant
distress or impairment in social; occupational; or some other
important area, such as sexual function.
The DSM-IV-TR specifies nine paraphiliac diagnoses: (1)
exhibitionism or genital exposure; (2) voyeurism, or clandestine observation of another person’s undressing, toileting, or sexual
behavior; (3) sadism, or causing suffering during sexual behavior;
(4) masochism or being humiliated during sexual behavior;
(5) pedophilia, or sexual behavior with prepubescent or peripubertal
children; (6) fetishism, or use of nonliving objects for
sexual behavior; frotteurism or rubbing against or touching a
nonconsenting person; (7) transvestic fetishism, or use of clothing
of the opposite sex for arousal; and (8) paraphilia NOS for
other observed atypical sexual patterns such as dressing in diapers,
requiring a partner who has an amputated limb, and others.
All paraphilia behaviors are rehearsed repeatedly in fantasy;
often these unusual fantasies have been present since childhood
or puberty. Some persons with paraphilias never experience any
sexual behavior with partners. The shame of the paraphilia interest
and the fear of negative consequences may contribute to a
lifelong avoidance of intimate contact.
In the most severe forms of paraphilia, the specific paraphiliac
imagery or activity is absolutely necessary for any sexual
function. The final parameter of severity is the degree of drive
to masturbate or act out the fantasy with a partner.
The most severe form of compulsivity is the loss of autonomy.
The loss of autonomy has three characteristics: (1) the need for
sexual behavior consumes so much money, time, concentration,
and energy that the patient describes himself as out of control; (2)
intrusive, unwanted paraphiliac thoughts prevent concentration
on other life demands and are the source of anxiety; and (3)
orgasm does not produce satiety in the way it typically does for
age mates.
38
```
A. Vaginismus
B. Sexual aversion disorder
C. Anorgasmia
D. Hypoactive sexual desire disorder
E. Dyspareunia
```
Avoidance of genital sexual contact with a sexual partner
b
Sexual aversion disorder is defined in the DSM-IV-TR as a “persistent
or recurrent and extreme aversion to, and avoidance of, all
or almost all, genital sexual contact with a sexual partner.” Some
researchers consider the line between hypoactive desire disorder
and sexual aversion disorder blurred, and in some cases, both diagnoses
are appropriate. Lowfrequency of sexual interaction is a
symptom common to both disorders. The clinician should think
of the words “repugnance” and “phobia” in relation to patients
with sexual aversion disorder.
39
```
A. Vaginismus
B. Sexual aversion disorder
C. Anorgasmia
D. Hypoactive sexual desire disorder
E. Dyspareunia
```
Patient has few or no sexual thoughts or fantasies
d
Hypoactive sexual desire disorder is experienced by both
men and women; however, they may not be hampered by any
dysfunction after they are involved in the sex act. Conversely,
hypoactive desire may be used to mask another sexual dysfunction.
Lack of desire may be expressed by decreased frequency
of coitus, perception of the partner as unattractive, or overt complaints
of lack of desire. Upon questioning, the patient is found to
have few or no sexual thoughts or fantasies, a lack of awareness
of sexual cues, and little interest in initiating sexual experiences
40
```
A. Vaginismus
B. Sexual aversion disorder
C. Anorgasmia
D. Hypoactive sexual desire disorder
E. Dyspareunia
```
Recurrent and persistent inhibition of female orgasm
c
Female orgasmic disorder (also known as inhibited female
orgasm or anorgasmia) is defined as the recurrent and persistent
inhibition of the female orgasm, manifested by the absence or
delay of orgasm after a normal sexual excitement phase that the
clinician judges to be adequate in focus, intensity, and duration.
Women who can achieve orgasm with noncoital clitoral stimulation
but cannot experience it during coitus in the absence of
manual stimulation are not necessarily categorized as anorgasmic.
41
```
A. Vaginismus
B. Sexual aversion disorder
C. Anorgasmia
D. Hypoactive sexual desire disorder
E. Dyspareunia
```
Recurrent pain during intercourse
e
Dyspareunia refers to recurrent and persistent pain during
intercourse in either a man or a woman. In women, the dysfunction
is related to and often coincides with vaginismus. Repeated
episodes of vaginismus may lead to dyspareunia and vice versa,
but in either case, somatic causes must be ruled out. Dyspareunia
should not be diagnosed as such when a medical basis for
the pain is found or when (in a woman) it is associated with
vaginismus or with lack of lubrication.
42
```
A. Vaginismus
B. Sexual aversion disorder
C. Anorgasmia
D. Hypoactive sexual desire disorder
E. Dyspareunia
```
Involuntary and persistent constrictions of the outer onethird
of the vagina
a
Vaginismus is an involuntary and persistent constriction of
the outer third of the vagina that prevents penile insertion and
intercourse. The response may be demonstrated during a gynecological
examination when involuntary vaginal constriction
prevents introduction of the speculum into the vagina, although
some women only have vaginismus during coitus.
43
```
A. Fetishism
B. Voyeurism
C. Frotteurism
D. Exhibitionism
E. Sexual masochism
F. Sexual sadism
G. Transvestic fetishism
```
Rubbing up against a fully clothed woman to achieve
orgasm
c
44
```
A. Fetishism
B. Voyeurism
C. Frotteurism
D. Exhibitionism
E. Sexual masochism
F. Sexual sadism
G. Transvestic fetishism
```
Sexual urges by heterosexual men to dress in female
clothes for the purposes of arousal
g
45
```
A. Fetishism
B. Voyeurism
C. Frotteurism
D. Exhibitionism
E. Sexual masochism
F. Sexual sadism
G. Transvestic fetishism
```
Preoccupation with fantasies and acts that involve observing
people who are naked or engaging in sexual activity.
b
46
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
Vaginal lubrication
a
47
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
Orgasmic platform
b
48
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
Testes increase in size by 50 percent
a
49
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
Slight clouding of consciousness
b
50
A. Desire phase
B. Excitement phase
C. Orgasm phase
D. Resolution phase
Detumescence
b
51
A. Sexual identity
B. Gender identity
C. Sexual orientation
D. Sexual behavior
Sense of maleness or femaleness
b
Gender identity is a person’s sense of maleness or femaleness.
By the age of 2 or 3 years, almost everyone has a firm
conviction that “I am male” or “I am female.” Gender identity
results from an almost infinite series of clues derived from experiences
with family members, peers, and teachers and from
cultural phenomena. For instance, male infants tend to be handled
more vigorously, and female infants to be cuddled more
52
A. Sexual identity
B. Gender identity
C. Sexual orientation
D. Sexual behavior
The object of a person’s sexual impulses
c
Sexual orientation describes the object of a person’s sexual
impulses: heterosexual (opposite sex), homosexual (same sex),
or bisexual (both sexes).
53
A. Sexual identity
B. Gender identity
C. Sexual orientation
D. Sexual behavior
Chromosomes
a
Sexual identity is the pattern of a person’s biological sexual
characteristics: chromosomes, external and internal genitalia,
hormonal composition, gonads, and secondary sex characteristics.
In normal development, these characteristics form a cohesive
pattern that leaves persons in no doubt about his or
her sex.
54
A. Sexual identity
B. Gender identity
C. Sexual orientation
D. Sexual behavior
Gonads and secondary sex characteristics
a
55
A. Sexual identity
B. Gender identity
C. Sexual orientation
D. Sexual behavior
Desire and fantasies
d
56
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Interruption in production of testosterone
e
57
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Genotype is XXY
c
58
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Excess androgens in fetus with XX genotype
a
59
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Absence of second female sex chromosome (XO)
b
60
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Inability of tissues to respond to androgens
d
61
A. Virilizing adrenal hyperplasia (adrenogenital syndrome)
B. Turner’s syndrome
C. Klinefelter’s syndrome
D. Androgen insensitivity syndrome (testicular feminization
syndrome)
E. Enzymatic defects in XY genotype (e.g., 5-α-
redyctase deficiency, 17-hydroxy-steroid deficiency)
F. Hermaphroditism
Both testes and ovaries
F
62
Management of sexual victimisation
When sexual victimization of others has occurred, new external
controls should be instituted. Prison is an external control for
sexual crimes that usually does not contain a treatment element.
All relevant persons in the environment need to know what the
person has done and is capable of doing again under opportune
conditions. For intrafamilial abuse of children, for instance,
the adults and other children in the family are informed of the
abuse. The children in the family are not permitted to be alone
with the offender again as long as they are unable to adequately
protect themselves.
Psychiatrists need to consider the role of inadequately treated
comorbid states when planning to treat sexual compulsivity or
impulsivity. Alcohol and substance abuse, major depressive disorder,
grief, psychotic disorder, attention-deficit/hyperactivity
disorder, bipolar II disorder, and others may be the cofactor that
enables a compensated sexual pattern to deteriorate and come
to clinical attention.
It is frequently observed that sex offenders lack the social
skills necessary to live effectively and create nonproblematic
sexual relationships. Correcting some of these deficits is a goal
of most cognitive behavioral treatment programs for sexually offending
paraphiliac individuals. Each intervention is an aspect
of a therapy approach that assumes that a paraphiliac lifestyle
is learned and can be significantly modified. The specific techniques
can be implemented in individual or group settings.
Patients with the nonviolent paraphilias and the paraphiliarelated
disorders are often treated with traditional individual
or group therapies using a combination of supportive, growthpromoting
tactics. Such therapies aim at creating an evolving hypothesis
about the unique developmental origin of the patient’s
eroticism. The defensive function of the impulse to act out (the
anxiety reduction function) is defined so the person can deal
directly with the unpleasant feelings that trigger the impulses.
Dynamic psychotherapy approaches emphasize the importance
of the trusting relationship with the therapist to enable the work
to occur.
63
Virilizing adrenal hyperplasia
| (adrenogenital syndrome
Results from excess androgens in fetus with XX genotype; most common female intersex
disorder; associated with enlarged clitoris, fused labia, hirsutism in adolescence
64
Turners syndrome
Results from absence of second female sex chromosome (XO); associated with web neck,
dwarfism, cubitus valgus; no sex hormones produced; infertile; usually assigned as females
because of female-looking genitals
65
Klinefelters
Genotype is XXY; male habitus present with small penis and rudimentary testes because of
low androgen production; weak libido; usually assigned as male
66
Androgen insensitivity syndrome
Congenital X-linked recessive disorder that results in inability of tissues to respond to
androgens; external genitals look female, and cryptorchid testes present; assigned as
females even though they have XY genotype; in extreme form, patient has breasts, normal
external genitals, short blind vagina, and absence of pubic and axillary hair
67
Enzymatic defects in XY genotype (e.g.,
5-α-reductase deficiency,
17-hydroxysteroid deficiency)
Congenital interruption in production of testosterone that produces ambiguous genitals and
female habitus; usually assigned as female because of female-looking genitalia
68
Hermaphroditism
True hermaphrodite is rare and characterized by both testes and ovaries in same person (may
be 46 XX or 46 XY)
69
Pseudohermaphroditism
Usually the result of endocrine or enzymatic defect (e.g., adrenal hyperplasia) in persons with
normal chromosomes; female pseudohermaphrodites have masculine-looking genitals but
are XX; male pseudohermaphrodites have rudimentary testes and external genitals and are
XY; assigned as males or females, depending on morphology of genitals
70
Which of the following is true?
A. Girls with congenital virilizing adrenal hyperplasia
are less interested in dolls.
B. Polycystic ovaries has not been considered as associated
with transsexualism.
C. Mothers, more than fathers, give negative responses
to boys playing with dolls
D. Boys with gender identity disorders (GIDs) are more
likely to be right-handed than control boys.
E. Boys with GID generally tend to have more sisters
than brothers
The answer is A
Evidence for hormonal influence in gender identity disorder
(GID) derives from several sources. Girls with congenital virilizing adrenal hyperplasia overproduce adrenal androgen in
utero and, as girls, are less interested in dolls and more likely to
be considered tomboys than girls who do not have the disorder.
Reports describe polycystic ovaries as more common in femaleto-
male transsexuals than in the typical female population. In
social learning theories that focus on the differential reinforcement
of sex-typed behavior by parents, starting shortly after birth,
it has been noted that fathers, more than mothers, give negative
responses to boys playing with dolls. Handedness may relate to
prenatal sex steroid levels, and boys with GID are significantly
more likely to be left-handed than control boys. Similarly, boys
with GID have been reported to have significantly more brothers
than sisters.
71
```
In a patient with Turner’s syndrome, all of the following
are common findings except
A. atypical female sex identification
B. gonadal dysgenesis
C. female genitalia
D. small uterus
E. dyspareunia
```
The answer is A
Patients with Turner’s syndrome have typical female identification.
The majority report heterosexual identification, although
they tend to have fewer sexual relationships. During adolescence,
many patients have difficulties reading social cues and experience
social isolation and anxiety. Most patients with Turner’s
syndrome have gonadal dysgenesis and require exogenous estrogen
to complete growth and develop secondary sex characteristics.
However, in patients with 45,X0/46,XX mosaicism, spontaneous
menarche is common (40 percent), and in rare cases,
pregnancy is possible. These patients typically experience ovarian
failure at a later date. Patients with Turner’s syndrome have
female genitalia. The uterus may be small, but structural abnormalities
are not typical. The lack of estrogen may shorten the
vagina and contribute to dyspareunia.
72
Sex reassignment
A. is often the best solution in treating gender dysphoria
B. usually involves a full-time social transition to living
in the desired gender before hormonal treatment
C. includes daily doses of oral estrogen in persons born
male
D. may involve sex reassignment surgery
E. all of the above
The answer is E (all)
No drug treatment has been shown to be effective in reducing
cross-gender desire, and when gender dysphoria is severe and
intractable, sex reassignment may be the best solution. This involves
an extensive set of clinical management guidelines, and
many clinicians require that the patient begin the Real Life Test
or Real Life Experience before hormonal treatment. The Real
Life Test is typically 1 to 2 years of full-time cross-gender living,
including at least 1 year of employment in the desired gender
role and 1 year on high doses of cross-sex hormones. For biological
males, this includes high doses of oral estrogens; biological
women are treated with monthly or three weekly injections of
testosterone. Sex reassignment surgery is often the last stage in
the reassignment process.
73
Gender constancy
A. is a task of separation-individuation
B. has no age-related stage-like sequence because it is
inherent
C. includes a sense of “gender stability”
D. cannot be tested in the clinical situation
E. none of the above
The answer is C
Gender constancy is a Piagetian construct of the constancy
of gender and its possibility to change by altering superficial
characteristics. It is not described by Mahler in separation individuation.
It involves an age-related stage-like sequence, in
which children first self-categorize the gender of self and others,
“gender identity,” and then appreciate its invariance over time,
“gender stability.” Finally, it involves understanding that invariance
in the face of superficial transformations of gender, such
as changing sex-typed clothing or hair length. Although no psychological
test is diagnostic of gender identity disorder (GID) in
children, the It-Scale for Children and the Draw-A-Person test
have been used to assess GID in the clinical situation.
74
In patients born with ambiguous genitalia, which of the
following is the predominant factor by which assigned
sex is determined?
A. Wishes of the parents
B. Genetic phenotype and potential for reproduction
C. Extent of virilization
D. Surgical team capabilities
E. Wishes of the patient at the time of puberty
The answer is B
In patients born with ambiguous genitalia, the determination
of genetic phenotype and considerations for reproduction generally
dominates other factors in the designation of assigned
sex. Decision making in this area of pediatric urology is multifactorial,
requiring biological, surgical, and social factors to
be evaluated. Controversy surrounds pediatric sex assignment
because among many other factors, decisions are most often
made without patient or parent input. Some in the lay community
advocate waiting until puberty before making an assignment
to allow the patient to made the determination. Surgeons
tend to support earlier intervention, generally before 5 years of
age.
75
A boy with gender identity disorder
A. usually begins to display signs of the disorder after
age 9 years
B. experiences sexual excitement when he cross-dresses
C. has boys as his preferred playmates
D. is treated with testosterone
E. may say that his penis or testes are disgusting
The answer is E
A boy with gender identity disorder (GID) may say that his penis
or testes are disgusting and that he would be better off without
them. Persons with this disorder usually begin to display signs of
the disorder before age 4 years (not after age 9 years), although
it may present at any age. Cross-dressing may be part of the
disorder, but boys do not experience sexual excitement when
they cross-dress.Aboy with a GID is generally preoccupied with
female stereotypical activities and usually has girls (not boys) as
his preferred playmates. Patients with GID are not treated with
testosterone.
76
Girls with gender identity disorder in childhood
A. regularly has male companions
B. may refuse to urinate in a sitting position
C. may assert that she has or will grow a penis
D. may give up masculine behavior by adolescence
E. all of the above
The answer is E (all)
Girls with gender identity disorder (GID) in childhood regularly
have male companions and an avid interest in sports and
rough-and-tumble play; they show no interest in dolls and playing
house. In a few cases, a girl with this disorder may refuse
to urinate in a sitting position, may assert that she has or
will grow a penis, does not want to grow breasts or menstruate,
and says that she will grow up to become a man. Girls
with GID in childhood may give up masculine behavior by
adolescence.
77
In biological men undertaking estrogen hormone treatment,
all of the following side effects are common except
A. testicular atrophy
B. change in pitch of voice
C. diminished erectile capacity
D. breast enlargement
E. decrease in density of body hair
The answer is B
The pitch of the male voice is determined primarily by the resonance
and volume of the chest and not affected by estrogen
treatment. Speech therapy can be undertaken to achieve a more
feminine pitch, and laryngeal surgery is an option, although the
range may be decreased by the procedure. Biological men undergoing
hormonal treatment with daily doses of estrogen can
expect the enlargement of breast tissue, testicular atrophy, decreased
libido, diminished erectile tissue, and decreased body
hair. Facial hair most often requires electrolysis. Maximal breast
tissue development is generally achieved within 2 years of hormonal
treatment, and surgical augmentation may be required to
achieve aesthetic goals. In addition to estrogen, a variety of antiandrogenic
compounds (cyproterone acetate, flutamide, spironolactone)
and gonadectomy can be used to counter the effects of
testosterone.
78
True statements about the epidemiology of gender identity
disorders include
A. As many as five boys are referred for each girl referred.
B. Among a sample of 4- to 5-year-old boys referred for
a range of clinical problems, the reported desire to be
the opposite sex was 15 percent.
C. Most parents of children with gender identity disorder
report that cross-gender behaviors were apparent
before age 3 years.
D. The prevalence rate of transsexualism is estimated to
be about one case per 10,000 males.
E. All of the above
The answer is E (all)
The prevalence of the gender identity disorder (GID) of childhood
can only be estimated because no epidemiological studies
have been published. A rough estimate can be obtained from
two items on Thomas Achenbach’s Child Behavior Checklist
that are consistent with components of the diagnosis: behaves
like opposite sex and wishes to be of opposite sex. In one study,
among a sample of 4- to 5-year-old boys referred for a range
of clinical problems, the reported desire to be of the opposite
sex was 15 percent. Among 4- to 5-year-old boys not referred
for behavioral problems, it was only 1 percent. For ages 6 to 7
years, the rates were 2.7 and 0 percent; for ages 8 to 9 years, 5.1
and 0 percent; and for ages 10 to 11 years, 1.1 and 2.3 percent.
For clinically referred girls, there was more uniformity across
the ages, with the highest being 8 percent at age 9 and the lowest
being 4 percent for other ages. For nonreferred girls, the highest
rate was 5 percent at ages 4 to 5 years and less than 3 percent for
other ages.
As many as five boys are referred for each girl referred, for
which several explanations are possible. First, there is greater
parental concern with sissiness than with tomboyishness, and
greater peer group stigma attaches to substantial cross-gender
behavior in boys. Thus, there may be an equal prevalence of GID
in boys and girls but a differential referral rate. Another possibility
is that a genuine disparity results from males’ more perilous
developmental course. The fundamental mammalian state is female.
No sex hormones are required for prenatal female anatomical
development(XOchildren with gonadal dysgenesis [Turner’s
syndrome] appear female at birth). However, sex hormones are
required at critical developmental times for male anatomical differentiation.
If the mechanisms of behavioral development track
anatomical development, the masculine behavioral system requires
adequate levels of hormones at the appropriate time for
normative expression. Finally, the psychodynamic developmental
model explaining the disparate referral rates views both boys
and girls as initially identifying with the female parent, with only
boys needing to make the developmental shift for later normative
male identification.
Most children with a GID are referred for clinical evaluation
in early grade school. Parents typically report that cross-gender
behaviors were apparent before age 3 years.
79
Which of the following statements does not apply to the
treatment of gender identity disorder?
A. Adult patients generally enter psychotherapy to learn
how to deal with their disorder, not to alter it.
B. Before sex-reassignment surgery, patients must go
through a trial of cross-gender living for at least 3
months.
C. A one-to-one play relationship is used with boys in
which adults’ role model masculine behavior.
D. Hormonal therapy is not required as a preceding event
in sex-reassignment surgery.
E. During hormonal treatments, both males and females
need to be watched for hepatic dysfunction and
thromboembolic phenomena.
The answer is D
Hormone treatment is required and must be received by patients
for about 1 year before sex-reassignment surgery, with estradiol
and progesterone in male-to-female changes and testosterone in
female-to-male changes. Many transsexuals like the changes in
their bodies that occur as a result of that treatment, and some
stop at that point, not progressing to surgery. Another requirement
before sex-reassignment surgery is that patients must go
through a trial of cross-gender living for at least 3 months and
in many cases up to 1 year. Adult patients generally enter psychotherapy
to learn how to deal with their condition, not to alter
it. In boys with gender identity disorder, a one-to-one play relationship
is used, in which adults or peers role model masculine
behavior. During hormonal treatments, both males and females
need to be watched for hepatic dysfunction and thromboembolic
phenomena.
80
```
A. Klinefelter’s syndrome
B. Turner’s syndrome
C. Congenital virilizing adrenal hyperplasia
D. True hermaphroditism
E. Androgen insensitivity syndrome
```
A 17-year-old girl presented to a clinic with primary
amenorrhea and no development of secondary sex characteristics.
She was short in stature and had a webbed
neck.
The answer is B
81
```
A. Klinefelter’s syndrome
B. Turner’s syndrome
C. Congenital virilizing adrenal hyperplasia
D. True hermaphroditism
E. Androgen insensitivity syndrome
```
A baby was born with ambiguous external genitalia. Further
evaluation revealed that both ovaries and testes were
present
D
82
```
A. Klinefelter’s syndrome
B. Turner’s syndrome
C. Congenital virilizing adrenal hyperplasia
D. True hermaphroditism
E. Androgen insensitivity syndrome
```
A baby was born with ambiguous external genitalia. Further
evaluation revealed that ovaries, a vagina, and a
uterus were normal and intact
C
83
```
A. Klinefelter’s syndrome
B. Turner’s syndrome
C. Congenital virilizing adrenal hyperplasia
D. True hermaphroditism
E. Androgen insensitivity syndrome
```
A buccal smear from a phenotypically female patient revealed
that the patient was XY. A further workup revealed
undescended testes
E
84
```
A. Klinefelter’s syndrome
B. Turner’s syndrome
C. Congenital virilizing adrenal hyperplasia
D. True hermaphroditism
E. Androgen insensitivity syndrome
```
A tall, thin man presented for infertility problems was
found to be XXY.
A
85
```
Anorexia nervosa has a mortality rate of up to approximately
A. 1 percent
B. 18 percent
C. 30 percent
D. 42 percent
E. 50 percent
```
B
The answer is B
Most studies show that anorexia nervosa has a range of mortality
rates from 5 percent to 18 percent. Indicators of a favorable
outcome are admission of hunger, lessening of denial and immaturity,
and improved self-esteem. Such factors as childhood neuroticism,
parental conflict, bulimia nervosa, vomiting, laxative
abuse, and various behavioral manifestations (e.g., obsessivecompulsive,
hysterical, depressive, psychosomatic, neurotic, and
denial symptoms) have been related to poor outcome in some
studies but not in others.
86
Characteristic results in anorexia nervosa include
A. decreased serum cholesterol levels
B. decreased serum salivary amylase concentrations
C. ST-segment and T-wave changes on electrocardiography
D. increased fasting serum glucose concentrations
E. all of the above
The answer is C
No laboratory tests can provide a diagnosis of anorexia nervosa.
The medical phenomena present in this disorder result from the
starvation or purging behaviors. However, several relevant laboratory
tests should be obtained in these patients. A complete
blood count often reveals leukopenia with a relative lymphocytosis
in emaciated anorexia nervosa patients. If binge eating and
purging are present, serum electrolytes will reveal hypokalemic
alkalosis. Fasting serum glucose concentrations are often low
(not increased) during the emaciated phase, and serum salivary
amylase concentrations are often elevated (not decreased) if the patient is vomiting. An electrocardiogram may show STsegment
and T-wave changes, which are usually secondary to
electrolyte disturbances; emaciated patients will have hypotension
and bradycardia. Adolescents may have an elevated (not
decreased) serum cholesterol level. All of these values revert to
normal with nutritional rehabilitation and cessation of purging
behaviors. Endocrine changes that occur, such as amenorrhea,
mild hypothyroidism, and hypersecretion of corticotrophinreleasing
hormone, are attributable to the underweight condition
and revert to normal with weight gain
87
Features associated with anorexia nervosa include
A. onset between the ages of 10 and 30 years
B. mortality rates of 20 to 25 percent
C. the fact that 7 to 9 percent of those affected are
male
D. normal hair structure and distribution
E. all of the above
The answer is A
Features associated with anorexia nervosa include onset between
the ages of 10 and 30 years; lanugo (neonatal-like body hair),
not normal hair structure and distribution; mortality rates of 5 to
18 percent (not 20 to 25 percent); and the fact that 4 to 6 percent
(not 7 to 9 percent) of those affected are male.
88
Which of the following is the most common comorbid
disorder associated with anorexia nervosa?
A. Body dysmorphic disorder
B. Bulimia
C. Depression
D. Obsessive-compulsive disorder
E. Social phobia
The answer is C
The diagnostic challenges of eating disorders are only partly addressed
when a specific eating disorder is identified because in
the large majority of cases, comorbid psychiatric disorders accompany
the eating disorder, with two to four separate additional
diagnoses on Axis I or II of the text revision of the fourth edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR) commonly seen. Anorexia nervosa is associated
with depression in 65 percent of cases, social phobia in 34 percent
of cases, and obsessive-compulsive disorder in 26 percent of
cases. There is also a high comorbidity of anorexia nervosa with
body dysmorphic disorder—estimated at 20 percent—in which
patients additionally have obsessional preoccupations regarding
specific body parts not related to weight or shape in particular
89
Which of the following percentages below expected
weight does an anorexic patient generally fall before being
recommended for inpatient hospitalization?
A. 20 percent
B. 40 percent
C. 60 percent
D. 80 percent
E. None of the above
The answer is A
In general, anorexia nervosa patients who are 20 percent below
the expected weight for their height are recommended for inpatient
hospital programs, and patients who are 30 percent below
their expected weight require psychiatric hospitalization for 2 to
6 months. The decision to hospitalize a patient is based on the
patient’s medical condition and the amount of structure needed
to ensure patient cooperation. The first consideration in the treatment
of anorexia nervosa is to restore patients’ nutritional state;
dehydration, starvation, and electrolyte imbalances can seriously
compromise health and, in some cases, lead to death.
90
```
Treatments that have shownsome success in ameliorating
anorexia nervosa include
A. cyproheptadine
B. electroconvulsive therapy
C. chlorpromazine
D. fluoxetine
E. all of the above
```
The answer is E (all)
Medications can be useful adjuncts in the treatment of anorexia
nervosa. The first drug used in treating anorexic patients was
chlorpromazine (Thorazine). This medication is particularly
helpful for severely ill patients who are overwhelmed with constant
thoughts of losing weight and behavioral rituals for losing
weight. There are few double-blind controlled studies to definitively
prove this drug’s effectiveness for calming such patients
and inducing needed weight gain. Cyproheptadine (Periactin) in
high dosages (up to 28 mg a day) can facilitate weight gain in
anorectic restrictors and also has an antidepressant effect. Some
recent studies indicate that fluoxetine (Prozac) may be effective
in preventing relapse in patients with anorexia nervosa. Amitriptyline (Elavil) has been reported to have some benefit
in patients with anorexia nervosa, as have imipramine (Tofranil)
and desipramine (Norpramin). There is some evidence that electroconvulsive
therapy (ECT) is beneficial in certain cases of
anorexia nervosa associated with major depressive disorder
91
A young woman who weighed about 10 percent above
the average weight but was otherwise healthy, functioning
well, and working hard as a university student joined
a track team. She started training for hours a day, more
than her teammates, and began to perceive herself as fat
and thought that her performance would be enhanced if
she lost weight. She started to diet and reduced her weight
to 87 percent of the “ideal weight” for her age according
to standard tables. She started to feel apathetic and
morbidly afraid of becoming fat. Her food intake became
restricted, and she stopped eating anything containing fat.
Her menstrual periods became skimpy and infrequent but
did not cease, and she was not taking oral contraceptives.
The diagnosis of anorexia nervosa can be made for the
above patient because
A. she did not reach less than 85 percent of “expected
weight”
B. she restricted her food intake
C. she retained some menstrual functioning
D. she joined the track team
E. she started out 10 percent above the average weight
The answer is B
Most experienced eating disorder clinicians would diagnosis the
patient above with anorexia nervosa, restrictor subtype, because
she restricted her food intake and she pushed herself hard in
her training, even harder than her teammates on the track team,
because she feared she was becoming fat and her performance
on the track team was in jeopardy. She does not meet the strict
“letter of the law” for anorexia nervosa, but she does meet all
of the core clinical psychopathological and behavioral criteria
for anorexia nervosa. However, under strict DSM-IV-TR criteria,
this patient would be diagnosed as having an eating disorder
not otherwise specified because she did not reach less than
85 percent of “expected weight” and still retain some menstrual
functioning.
92
```
Patients with “atypical anorexia nervosa”
A. have a distorted body image
B. recognize their thinness
C. respond poorly to treatment
D. have less favorable outcomes
E. none of the above
```
The answer is B
The term atypical anorexia has been applied to patients who recognize
their thinness, in contrast to those with typical anorexia
nervosa, who insist that their body image distortions represent
objective fact. Prognostically, those with recognition of their
extreme thinness have better (not poorer) responses to treatment
and more (not less) favorable outcomes because they are
not constantly fighting an inaccurate view of themselves as being
heavy. In most patients, body weight is tightly tied to selfesteem.
93
Which of the following features can be associated with
bulimia nervosa?
A. Undeveloped breasts
B. Abnormal insulin secretion
C. Widespread endocrine disorder
D. A previous episode of anorexia nervosa
E. Body weight at least 15 percent below normal
The answer is D
A previous episode of anorexia nervosa is often associated with
bulimia nervosa. This episode may have been fully or only moderately
expressed.
Undeveloped and underdeveloped breasts, abnormal insulin
secretion, widespread endocrine disorder, and body weight at
least 15 percent below normal are all associated with anorexia
nervosa, not bulimia nervosa
94
Which of the following is not an endocrine or structural
change noted as a result of starvation?
A. Thyroid suppression
B. Increased total brain volume
C. Hypercortisolemia
D. Gonadotropin-releasing hormone suppression
E. Enlarged ventricles
The answer is B
Endogenous opiates may contribute to the denial of hunger
in patients with anorexia nervosa. Preliminary studies show
dramatic weight gains in some patients given opiate antagonists.
Starvation results in many biochemical changes, some of
which are also present in depression, such as hypercortisolemia
and nonsuppression by dexamethasone. Thyroid function is
suppressed as well. These abnormalities are corrected by realimentation.
Starvation produces amenorrhea, which reflects
lowered hormonal levels (luteinizing, follicle-stimulating, and
gonadotropin-releasing hormones). Some anorexia nervosa patients,
however, become amenorrheic before significant weight
loss. Several computed tomography studies reveal enlarged cerebrospinal
fluid spaces (enlarged sulci and ventricles) in anorectic
patients during starvation, a finding that is reversed by
weight gain. Although decreases in total brain volume and increases
in brain ventricular size are usually seen, normal brain structural studies may also be seen in some very malnourished
patients.
95
Biological complications of eating disorders may include
A. salivary gland and pancreatic inflammation
B. gastric or esophageal tearing or rupture
C. cardiac arrhythmias, loss of cardiac muscle, and cardiomyopathy
D. leukopenia
E. all of the above
The answer is E (all)
Most of the physiological and metabolic changes in anorexia
nervosa are secondary to the starvation state or purging behaviors.
These changes usually revert to normal with nutritional
rehabilitation or cessation of the purging behavior
96
Medical complications of eating disorders related to
weight loss include all of the following except
A. abnormal taste sensation
B. bradycardia
C. constipation and delayed gastric emptying
D. erosion of dental enamel with corresponding decay
E. osteoporosis
The answer is D
Erosion of dental enamel with corresponding decay is associated
with the purging behavior of eating disorders, not to the weight
loss of eating disorders. Table 22.1 lists medical complications
related to weight loss and purging in eating disorders. Among
these complications are bradycardia, delayed gastric emptying,
disturbed taste sensation, and osteoporosis
97
```
Patients who binge eat but do not compensate in any way
afterward are most likely to have
A. anorexia nervosa
B. bulimia nervosa
C. binge eating disorder
D. obesity
E. night eating syndrome
```
The answer is C
Patients who binge eat but do not compensate in any way after
binge eating meet the criteria for binge eating disorder, an eating
disorder subtype considered a research diagnosis within “atypical”
eating disorder not otherwise specified. These patients are
often medically overweight or obese, generally somewhat older
(30s to 50s), and are almost as likely to be male as female. Patients
are not fixated on body shape and weight
98
Pickwickian syndrome is
A. when persons eat excessively after they have had their
evening meal
B. binge eating without the inappropriate compensatory
behaviors
C. when a person is 100 percent over desirable weight
with cardiorespiratory pathology
D. when persons feel their bodies are grotesque and
loathsome
E. sudden, compulsive ingestion of very large amounts
of food in a short time
The answer is C
Pickwickian syndrome is said to exist when a person is 100
percent over desirable weight and has associated respiratory
and cardiovascular pathology. Night eating syndrome is one in
which persons eat excessively after they have had their evening
meal; it seems to be precipitated by stressful life circumstances.
Binge-eating disorder is recurrent episodes of binge eating in
the absence of the inappropriate compensatory behaviors characteristic
of bulimia nervosa; these patients are not fixated on
their body shape and weight. Body dysmorphic disorder is when
some persons believe that a specific aspect of their bodies is
grotesque. The binge-eating syndrome (bulimia) is characterized
by sudden, compulsive ingestion of very large amounts of
food in a short time.
99
```
Ipecac intoxication is associated with
A. pericardial pain and cardiac failure
B. dyspnea
C. generalized muscle weakness
D. hypotension
E. all of the above
```
The answer is E (all)
Bulimia nervosa patients who engage in self-induced vomiting
and who abuse purgative or diuretic medications are susceptible
to the same complications as patients with anorexia nervosa involved
in this behavior. Exposure to gastric juices through vomiting
can cause severe erosion of the teeth, pathological pulp exposures,
diminished masticatory ability, and an unaesthetic facial
appearance. Parotid gland enlargement is associated with elevated
serum amylase concentrations and is commonly observed
in patients who binge and vomit. Acute dilatation of the stomach
is a rare emergency condition for patients who binge eat, and
esophageal tears can occur in the process of self-induced vomiting.
Severe abdominal pain in a patient with bulimia nervosa
should alert the physician to a diagnosis of gastric dilatation and the need for nasal gastric suction, radiographs, and surgical consultation.
Cardiac failure caused by cardiomyopathy from ipecac
toxication is a medical emergency that usually results in death.
Symptoms of pericardial pain, dyspnea, and generalized muscle
weakness associated with hypotension, tachycardia, and electrocardiogram
(ECG) abnormalities should alert medical personnel
to possible ipecac intoxication
100
Which of the following is true of eating disorders in relation
to obesity?
A. Binge eating disorder is more common than bulimia
nervosa in obese patients.
B. All bulimic persons are obese.
C. Patients with bulimia nervosa have lower rates of psychopathology
than obese patients.
D. All of the above
E. None of the above
The answer is A
Two eating disorders can be associated with obesity: bulimia
nervosa and binge eating disorder. Binge eating disorder is more
common than bulimia nervosa in obese patients and is associated
with more comorbid psychiatric illness, such as major depression.
It is important to note that not all patients with bulimia
nervosa are obese; they may be overweight or of normal weight.
More males are affected by binge eating disorder than bulimia
nervosa. Bulimia nervosa has an earlier age of onset (15.7 vs.
17.2 years). Although patients with bulimia nervosa have higher
rates of psychopathology compared with patients with binge eating
disorder, patients with binge eating disorder have higher (not
lower) rates of psychopathology compared with obese patients
without binge eating disorder.
101
A 17-year-old young woman presents to clinic reporting
anhedonia, decreased energy, and hopeless feelings for
the past 2 years. She denies drinking, smoking, or use of
recreational drugs. Her physical examination results are
normal, and she denies suicidal ideations. After some
consideration, her psychiatrist decides to prescribe her
bupropion. Of the following, which is a contraindication
for usage of bupropion?
A. Smoking
B. Dysthymia
C. Chronic fatigue syndrome
D. Bulimia
E. None of the above
The answer is D
Bupropion may induce seizures in patients with eating disorders
such as bulimia. Bulimic patients may have electrolyte abnormalities
due to vomiting, diuretics, or laxative usage. Smoking
is not a contraindication for the use of bupropion. It is used to
facilitate smoking cessation.
Bupropion may be used to relieve depressive symptoms in
patients with dysthymia and chronic fatigue syndrome and is
therefore not contraindicated for treatment of patients with these
conditions.
102
A. Anorexia nervosa, food-restricting type
B. Anorexia nervosa, binge eating and purging type
Social isolation
both
103
A. Anorexia nervosa, food-restricting type
B. Anorexia nervosa, binge eating and purging type
Tend to have family members who are obese
b
104
A. Anorexia nervosa, food-restricting type
B. Anorexia nervosa, binge eating and purging type
Calorie consumption is usually below 500 calories per
day
a
105
A. Anorexia nervosa, food-restricting type
B. Anorexia nervosa, binge eating and purging type
Overexercising
both
106
A. Anorexia nervosa, food-restricting type
B. Anorexia nervosa, binge eating and purging type
Has similar features to bulimia nervosa without anorexia
nervosa
b
107
A. Anorexia nervosa
B. Bulimia nervosa
Severe weight loss and amenorrhea
a
108
A. Anorexia nervosa
B. Bulimia nervosa
Visual agnosia, compulsive licking and biting, hypersexuality
neither
109
A. Anorexia nervosa
B. Bulimia nervosa
After 5 to 10 years, at least 50 percent will be markedly
improved
both
110
A. Anorexia nervosa
B. Bulimia nervosa
Higher fatality rate
a
111
A. Anorexia nervosa
B. Bulimia nervosa
Family therapy is not widely used
b
112
A. Anorexia nervosa
B. Bulimia nervosa
Cognitive behavioral therapy is the benchmark, first-line
treatment
b
Cognitive behavioral therapy should be considered the
benchmark, first-line treatment for bulimia nervosa. It has been
found to be the most effective treatment in more than 35 controlled
psychosocial studies. About 40 to 50 percent of patients
are abstinent from both binge eating and purging at the end of
treatment (16 to 20 weeks). Altogether, improvement by a reduction
in binge eating and purging occurred in a range from 70
to 95 percent of patients.
113
A. Anorexia nervosa
B. Bulimia nervosa
Decreased appetite only occurs in the most severe stages
a
114
A. Anorexia nervosa
B. Bulimia nervosa
Body weight of less than 85 percent of the patient’s expected
weight
a
115
A. Bulimia nervosa
B. Binge eating disorder
Patients are almost as likely to be male as female.
b
116
A. Bulimia nervosa
B. Binge eating disorder
Binges include high carbohydrates and sugars.
a
117
A. Bulimia nervosa
B. Binge eating disorder
Binge eating begins before dieting.
b
118
A. Bulimia nervosa
B. Binge eating disorder
Eating is in response to unpleasant emotions.
b
119
Criteria for AN
Restriction of energy
Low weight
Intense fear or behaviours to avoid weight gain despite being underweight
Disturbance in experience of body weight or shape, or undue influence of body shape of self evaluation, or denial of seriousness
Types: restricting eating, purge/binge
120
Criteria for bulimia
```
Recurrent binge eating, defined time, more than most
Sense of lack of control
Recurrent compensatory
Undue influence of body
At least twice per week over 3months
Not exclusively in anorexia
```
121
Binge eating disorder
Recurrent binge eating episode (time and amount)
Sense of lack of control
Episodes are associated with three or more
Eating more rapidly
Eating until uncomfortably full
Large amounts when not physically hungry
Eating alone because of embarrassments
Feeling disgusting with oneself, depressed or very guilty afterwards
122
Poor prognostic factors in anorexia
BMI <17
Onset in adulthood rather than adolescence
Co existing mental illness or personality disorder
Rapid weight loss
Purging
Family dysfunction
Long duration Of illness
123
What are the principles of management of AN
```
Risk of physical complications
Location of treatment
Restore patient to health weight
Psycheducation
CBT
Family therapy
Pharmacotherapy
Treat comorbidyt
Relapse prevention
```
124
Cardiovascular complications in AN
Bradycardia
Hypotension
Sudden death
Mitral valve dysfunction
Arrhythmia- more common with bingeing and purging
Cardiac failure- more common with binging and purging
125
ELectrolyte abnormalities with eating disorders
```
Hypokalemia
Hyponatremia
Hypochloremia
Metabolic acidosis with laxatives
Metabolic alkalosis with purging
Hypomag, hypophos
Hypocalcemia
```
126
List the endocrine and metabolic abnormalities in eating disorders
```
Occur mainly in AN
Amenorrhea
Low LHRH, FH, FSH
Low estrogen and progesterone
Low T3
High cortisol
High fasting GH
Hypercholesterolemia
Hypercarotenemia
Impaired glucose tolerance
```
127
Haematological abnormalities in eating disorders
Leucopenia
Thrombocytopenia
Low eSR
Reduced serum complement
128
Git side effects of eating disorders
```
Parotid swelling
Referring pancreatitis
Delayed gastric emptying
Nutritional hepatitis
Constipation
```
Esophageal erosion
Gastric and duodenal ulcers
Pancreatitis
129
Prevalence of eating disorders rs
n the general population, lifetime prevalence of anorexia nervosa is around 1% in women and < 0.5% in men, bulimia nervosa around 2% in women and 0.5% in men, and binge eating disorder around 3.5% in women and 2.0% in men
130
Aetiology of eating disorders
Socio-cultural, biological and psychological factors all contribute to the aetiology of eating disorders (Mitchison and Hay, 2014; Smink et al., 2012; Stice, 2002). The strongest socio- demographic risk factor for having an eating disorder continues to be being of female gender and being from the developed world where the ‘thin ideal’ prevails. Migrants from the developing world seem to be at particular risk. Also at risk are those living in urban areas and undertaking life pursuits where body image concerns predominate, for example, competitive gymnastics and fashion modelling.
In all eating disorders there is an increased genetic heritability and frequency of a family history. A family history of ‘leanness’ may be associated with anorexia nervosa and a personal or family history of obesity with bulimic eating disorders. Early menarche (controlling for body weight) also increases risk. Also likely important are epigenetic changes to DNA structure that are not encoded by the DNA sequence itself but which nonetheless result in enduring changes in gene expression and which are transmitted to subsequent generations. These can occur following periods of food deprivation (e.g. the Dutch starvation in World War 2), food repletion, or severe environmental stress (Campbell et al., 2011).
Psychological factors include a ‘milieu’ of weight concern in formative developmental years and specific personality traits, mostly notably low self-esteem (all eating disorders) and high levels of clinical perfectionism for those with anorexia nervosa, and impulsivity for bulimic disorders. Adverse experiences including emotional and sexual child abuse increase personal vulnerability, most likely through impeding a robust sense of self-worth and adaptive coping. The eating disorder then provides a sense of improved self-esteem and self-control for the individual (Stice, 2002).
131
Important history in eating disorders
: dietary restriction; weight loss; inability to restore weight; body image disturbance; fears about weight gain; binging; purging; excessive exercise; early satiety; constipation; and the use of laxatives, diuretics, or medications to lose or maintain low weight (APA, 2013). Other symptoms may include disturbed eating behaviours, e.g. eating apart from others and ritualistic patterns of eating such as prolonged meal times and division of food into very small pieces (Wilson et al., 1985). It is important to accurately assess nutritional and fluid intake, with specific enquiries made as to the adequacy of main meals and snacks consumed. Where possible, collateral sources such as family members and other clinicians involved in the person’s care should be utilised. The perspective of others is especially important given that symptom minimisation, poor insight or genuinely poor understandings of the seriousness of symptoms are common aspects of anorexia nervosa
The assessment should also include any history of fainting, light- headedness, palpitations, chest pain, shortness of breath, ankle swelling, weakness, tiredness and amenorrhoea or irregular menses
132
Cognitive changes in anorexia
•• Assessing cognitive changes due to starvation such as slowed thought processing, impaired short-term memory, reduced cognitive flexibility and concentration and attention difficulties (Hatch et al., 2010). Whilst brain imaging is not routine, these problems reflect consistent findings of reduced grey matter volumes that often do not reverse following weight recovery (Phillipou et al., 2014).
133
Treatment of anorexia
Assessment of adults with anorexia nervosa
• Be person-centred and culturally informed in assessment practices.
• Involve family and significant others unless there are clear
contraindications.
• Take a multidisciplinary approach.
• Use a dimensional approach to the illness, i.e. tailor management
based on stage of illness severity and symptom profile.
• Conduct detailed assessments of core symptomatology including
restriction methods, psychological symptoms related to fear of weight gain, weight loss, drive for thinness, and body image disturbance/ dissatisfaction, establishing both severity and (where possible) duration of illness.
• Conduct detailed evaluations for any comorbid psychiatric diagnoses.
• Conduct detailed physical, medical, and laboratory examinations,
thereby setting priorities for any specific medical interventions.
Treatment of adults with anorexia nervosa
• Treat in the least restrictive environment possible. Many people can be treated in outpatient care (EBR II).
• Provide ‘stepped and seamless care’ options, with smooth transition between services (including between primary care, general hospital settings and other community services).
• Admit to hospital when indicated for those at high risk of life- threatening medical complications, extremely low weights, and other uncontrolled symptoms.
• Use refeeding and weight gain regimes that minimise the risk of refeeding syndrome, ‘underfeeding’ and other medical complications arising from increased nutritional intake.
• Take a multi-axial approach to assessing treatment progress, including considering nutritional, medical and psychological aspects.
• Provide psychoeducation, support and a therapeutic relationship at all stages of treatment and initiate more intense psychological therapies after the person is sufficiently medically stabilised and cognitively improved from the effects of starvation.
• Initiate longer-term follow-up as recovery rates are low and relapse rates are high. This will limit the need for re-intensified treatment.
Specific pharmacological treatments
• There is only weak evidence for pharmacological treatment of anorexia nervosa. Low-dose antipsychotics such as olanzapine may be useful in reducing anxiety and obsessive thinking, but results of trials are mixed and such individuals are at greater risk of adverse side effects (EBR I). Exercise caution in prescribing psychotropic medication
for severe comorbid conditions/symptoms until it is clear that such symptoms are not secondary to starvation.
Specific psychological treatments
• Psychological therapy is considered essential, but there is limited high quality evidence to direct the best choice of therapy modality.
• There is modest evidence that family based therapies are effective for younger people (up to the age of 18) living with families.
• Specialist therapist-led manualised based approaches show the most promising evidence base, and as such should be first-line options.
134
Which antidepressant has the best evidence of bulimia
High dose fluoxetine has the strongest evidence base for bulimia nervosa; other selective serotonin reuptake inhibitors are also effective in both bulimia nervosa and binge eating disorder.
135
NHMRC levels of evidence
EBR I
A systematic review of level II studies
A systematic review of level II studies
EBR II
A randomised controlled trial
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive persons with a defined clinical presentation
EBR III-1
A pseudo-randomised controlled trial (i.e. alternate allocation or some other method)
A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among non- consecutive persons with a defined clinical presentation
EBR III-2
A comparative study with concurrent controls: • Non-randomised, experimental trial
• Cohort study
• Case-control study
• Interrupted time series with a control group
A comparison with reference standard that does not meet the criteria required for level II and III-1 evidence
EBR III-3
A comparative study without concurrent controls:
• Historical control study
• Two or more single arm studies
• Interrupted time series without a parallel control group
Diagnostic case-control study
EBR IV
Case series with either post-test or pre-test/post-test outcomes
Study of diagnostic yield (no reference standard)
136
Symptoms and management of refeeding
Severely malnourished
Hypophosphatemia hypomagnesemia
Hypocalcemia and fluid retention
```
Symptoms
Dyspnea
General weakness
Fatigues
Peripheral Edelman
Seizures
Coma
Parasthesias
Auditory hallucination
Sudden death
```
```
Treatment:
Best rest
iV fluids
Multivitamin
Suspend nutrient intake or reduce significantly
```
Prevention:
Monitor serum levels of phosphate, magnesium and calcium for 5 days of refeeding and every other day for several weeks
137
Reverse anorexia or muscle dysmorphophobia
| Eating disorders in males
Occurs exclusively in males
Perception of thinness despite being highly muscular
Higher rates of premorbid obesity
Higher rate of homosexuality
HPA axis dysfunction reflected by loss of sex drive
