EDs, PDs and MUS Flashcards
What are the types of eating disorders and who do they affect? What is the aetiology of EDs?
EDs:
- Anorexia (restriction of food intake and weight loss methods) - commonest in ED clinics, 16-22yo, 0.6% incidence
- Bulimia (restriction-> binge -> voiding e.g. purging/laxatives), 1% incidence
- BED - most common ED generally
Aetiology:
- > 90% are females [usually perfectionist, high-achieving women, low self-esteem/body fixation]
- > Often have co-morbid depression, substance misuse, OCD/dysmorphia
Anorexia:
Bio -> genetics (58% heritability), FHx of obesity, depression, substance misuse
Psychosocial -> perfectionism, low-self esteem, sociocultural (especially models, athletes, dancers), previous anorexia, parental overprotection
BN:
Bio -> 5-HT dysregulation, FHx of obesity, depression, substance misuse
Psychosocial -> perfectionism, low-self esteem, sociocultural (especially models, athletes, dancers), personal history of obesity, disturbed family dynamics, parental weight concern, high parental expectation
When would you immediately admit an ED patient (what is the high risk criteria)?
Admit if: [use MHA if needed]
- -> Based on MARSIPAN guidelines for admission but this includes:
- BMI low (<70% expected but not defined by NICE)
- WL >1kg/week
- Septic looking signs (low temperature, BP<80/50, cold peripheries, purpuric rash)
- HR <40 bpm and long QT
- Suicide risk!
How is AN diagnosed? What are some RFs? How may atypical AN present?
ICD10: Diagnosis must have all 3:
- BMI <17.5 or weight is = <15% than expected
- Deliberate weight loss (excessive exercise, laxatives, vomiting, appetite suppressants, restriction)
- Morbid fear of fatness
RFs = OCD, FHx, psychosocial factors, childhood feeding difficulties
Atypical:
- Sub-diagnostic features e.g. young boys losing weight for ‘6 pack’ but currently healthy weight
How may AN present? What are some signs and symptoms? What are some other DDx?
Sx:
- > Psych - intense fear of fatness and gaining weight/food, overexercising, body image issues
- > General = cold, lethargic, lanugo hair, Russel’s sign, cytopenias so infections/anaemia
- > CVS = low HR, postural hypotension, arrhythmias secondary to low K+
- > GI = Constipation, MW tears
- > Repro = amenorrhoea, loss of libido, infertility
- > MSK = proximal myopathy (squat test +), Hx of fractures, osteoporosis
- > Neuro = peripheral neuropathy, delirium/coma
DDx:
- > Organic causes of WL such as hyperthyroidism
- > Bulimia, EDNOS, body dysmorphic disorder
What Ix would you do in a patient with suspected AN?
Ix:
- Full Psych history + MSE (assess insight e.g. AN)
- Physical examination - weight, height, lanugo hair, Russel’s sign, dental hygeine, BP
- Bloods (exclude hyperthyroidism and other medical causes; U&Es, FBC, TFTs and LFTs main; results = low T4, ESR, glucose, Hb, electrolytes; high cortisol, cholesterol, carotenaemia, GH, glands (salivary), LFTs [‘raised G&Cs]
- Urine drug screen + assess hydration status
- ECG (bradycardia, arrhythmia, long-QT in BN)
- DEXA (osteoporosis risk, >2y history)
- Rating scale (eating attitudes test)
- Other bloods
How would you manage anorexia nervosa in terms of admission and referrals? How would you counsel them at their 1st visit at the GP?
Mx: [NO w&w - immediate referral]
-> Screen for immediate ADMISSION (Mx = MARSIPAN guidelines) but mostly managed as outpatients
OR
-> Immediate referral;
–> SEVERE = urgent referral to CEDS (community ED service) e.g. if BMI <15, rapid weight loss, evidence of systems failure
–> MODERATE = routine referral to CEDS e.g. if BMI 15-17, no evidence of systems failure
–> MILD = monitor/advice/support for 8w, BEAT for support e.g. pt BMI>17, no additional comorbidity but follow moderate referral to CEDS if failed to respond)
Mx upon 1st presentation to GP:
- > Engage and educate (stop laxative/diuretic/purging as doesn’t reduce calorie intake)
- > Signpost support (BEAT, MIND, NHS)
- > Treat cormorbid psychiatric illness if present
- > Plan for future with regular f/u and review (nutrition and weight gain e.g. 0.5-1kg/week*, CBT-ED, MANTRA or SSCM or family therapy if <18yo)
What is the management of AN in adults? How does this vary to management in children?
Mx: [Refer to CEDS]
1st line [any of below]:
- CBT-ED (1:1, 40 weekly sessions which address low self esteem, perfectionism, control issues]
- MANTRA (Maudsley anorexia treatment in adults, 20 sessions, focus on the cause of AN)
- SSCM (specialist supportive clinical management, 20 weekly sessions led by practitioner, explores problems of anorexia, education on nutrition and habits and a future beyond anorexia e..g getting back into work)
2nd line [if 1st line fails]:
- ED-focussed focal psychodynamic therapy (FTP)
- Adolescent focussed psychotherapy
- Motivational interviewing
- Family therapy (20 sessions over year, indicated in young-onset pts (<19) and short Hx of illness
- Interpersonal therapy (improves social functioning and interpersonal skills, indicated in longer Hx of illness, later onset AN)
Pharmacological management:
- Fluoxetine (especially helpful with food preoccupations and impulsivity control)
Children Mx:
1st line = Family therapy
2nd line = ED-CBT
What is refeeding syndrome? How does it present?
Important to consider in AN patients when in recovery
- Defined mainly by low phosphate
- Due to intracellular shift of already low levels of ions due to insulin release when refeeding
- Biochemistry = LOW K+ (arrhythmias)»_space; LOW PO4- (hypophosphataemic HF) and LOW Mg+
Sx - fatigue, weakness, confusion, high BP, seizures, arrhythmia, HF
What is the prognosis of anorexia and particularly bad prognostic factors? What are complications?
After 10y
- 50% recover
- 40% ongoing problems
- 10% die, 1/3 due to suicide
Complications:
- Osteoporosis
- Cardiac arrhythmia and failure
- Infertility
- Early death
Bad prognosis - very low weight, later onset, bulimic features, longer illness duration
How can you screen for EDs in your psychiatric history?
Initially screen with body image/weight perceptions e.g. negative thoughts about your body and weight?
SCOFF:
- Do you make yourself SICK because you feel uncomfortably full (+ ask laxatives/diet pills)
- Do you worry you have lost CONTROL over how much you eat?
- Have you recently lost weight (>ONE stone) recently in a 3m period?
- Do you believe yourself to be FAT when others say you are too thin?
- would you say FOOD dominates your life?
How is bulimia defined?
ICD10: must have all 3:
- Bingeing or a persistent preoccupation with eating and/or irresistible craving for food
- Purging behaviours (attempt to counteract binge) -> diuretics, laxatives, vomiting, insulin therapy, excessive exercise
- Psychopathology - morbid fear of fatness, loss of control, Hx of AN, set weight goal
How may patients with bulimia present? What are some differentials?
Sx:
- > Similar to AN but often at a normal body weight/less severe
- > Russel’s sign (rare), dental caries
- > Amenorrhoea in 50% despite a normal body weight
DDx:
- Upper GI disorder leading to vomiting
- Personality disorder
- Depressive disorder
how would you Ix bulimia?
Ix:
- Full Psych history + MSE (assess insight e.g. AN)
- Physical examination - weight, height, Russel’s sign, dental hygiene, BP
- Bloods (exclude hyperthyroidism and other medical causes; U&Es, FBC, TFTs and LFTs
- Urine drug screen + assess hydration status
- ECG (bradycardia, arrhythmia, long-QT in BN)
- DEXA (osteoporosis risk, >2y history)
- Rating scale (eating attitudes test)
- Other bloods
How would you manage bulimia? + In children?
Mx: [NO w&w - immediate referral]
-> Screen for immediate ADMISSION (Mx = MARSIPAN guidelines) but mostly managed in community
OR
-> Immediate referral;
–> SEVERE = if daily purging, significant electrolyte imbalance, comorbidity. Mx = URGENT referral to CEDS (community ED service)
–> MODERATE = frequent bingeing and purging (>2x a week, some medical consequences like chest pain). Mx = guided self-help, recommend BEAT charity support and monitor for 8w. Routine referral to CEDS if failed to respond
–> MILD = infrequent bingeing <2x/week routine. Mx = guided self-help, recommend BEAT charity support and monitor for 12w. Referral to CEDS if failed to respond
Mx upon 1st presentation to GP:
- > Engage and educate (explain Dx, stop laxative/diuretic/purging as doesn’t reduce calorie intake)
- > Signpost support (BEAT, MIND, NHS)
- > Treat medical complications e.g. dental review (had any tooth pains etc?)
- > Treat co-morbid psychiatric illness if present
- > Moderate to severe –> high dose SSRIs e.g. 60mg fluoxetine to help with impulses of bingeing and purging
- > Plan for future with regular f/u and review
Children:
1st line = BN-focussed family therapy
Adults:
1st line = Guided self help programme (Bulimia focussed)
2nd line = [if 1st line ineffective for 4w/declined] then try CBT-ED
- Also consider high dose SSRI
PACES:
- Explain Dx + causes (low self esteem, body image/relationship issues)
- Explain complications (teeth, heart, gum and GI problems)
- Education on support, guided self help and monitoring
- Referral if persistent sx - can use talking therapies (CBT-ED and family therapy if younger)
- Pharmacological options (fluoxetine)
What is the prognosis of bulimia? What are bad prognostic indicators?
After 10y:
- 70% recover
- 1% die
Bad prognostic indicators:
- V low weight
- Severe bingeing and purging
- Co-morbid depression
- Biochemical changes such as hypokalaemia from vomiting and hypocalcaemia
What must personality disorders be, to be diagnosed?
Must be:
- Pervasive (occurs in all/most areas of life)
- Persistent (evident in adolescence, but not Dx until 18+, and continues through adulthood)
- Pathological (causes distress to self or others, impairs function)
How has the ICD10 categorisations of PD’s different to ICD11?
ICD10 - 3 clusters:
[A] - ‘odd or eccentric’ –> paranoid, schizoid and schizotypal
[B] - ‘dramatic/emotional’ –> EUPD, dissociate, histrionic and narcissistic
[C] - ‘anxious and fearful’ –> anapaestic, anxious-avoidant and dependent
ICD-11 focuses on severity (mild/moderate/severe) with added traits of dissociality etc
What is the ‘REPORT’ criteria for personality disorders? What is the epidemiology and aetiology of them?
PDs must be: R - relationships affected E - enduring (persistent) P - Pervasive O - onset in childhood/adolescence R - result in distress T - trouble in occupational/social performance
Overall M»_space;> F (M more in cluster A, anakastic, dissocial types, F>M in EUPD, histrionic)
Affects 10% population (2% have EUPD - commonest seen in practice). Long-term 10% suicide risk
Aetiology:
Bio - strong genetics and FHx association
Psychosocial - childhood temperament (>3yo), childhood experiences such as attachment and trauma, cognitive theories (e.g. confirmation bias - if you are negative, then spark ‘negativity’ others = what you thought), psychological defences such as projection, splitting etc
How may patients with each PD present? [Cluster A]
Must present with REPORT and at least 3 of the following features (ICD10):
[A] ‘Odd or Eccentric’
- > Paranoid PD - (SUSPECT = sensitive, unforgiving, suspicious, possessive and jealous of partners, excessive self-importance, conspiracy theories and tenacious set of rights)
- > Schizoid PD - (ALLALONE = just negative schizophrenia symptoms = anhedonic, limited emotional range, little sexual interest, apparent indifference to praise/critique, lacks close relationships, one-player activities, normal social conventions ignored and excessive fantasy world)
- > Schizotypal PD - some positive symptoms also such as paranoid/bizarre ideas along with cold/inappropriate affect and social withdrawal
How may patients with each PD present? [Cluster B]
Must present with REPORT and at least 3 of the following features (ICD10):
[B] - ‘Dramatic/emotional’
- > EUPD = AEIOU = affective instability, explosive behaviour, impulsive (inc SH tendencies), outbursts of anger and unable to plan/consider consequences.
- > Histrionic = ACTORS = attention-seeking, concerned with appearance, theatrical, open to suggestion, racy and seductive, shallow affect
- > Dissocial = FIGHTS = forms but cannot maintain relationships, irresponsible, guiltless, heartless, temper easily lost and someone else fault
How may patients with each PD present? [Cluster C]
Must present with REPORT and at least 3 of the following features (ICD10):
- > Anakastic = DETAILED = doubtful, excessive detail, tasks not completed, adheres to rules, inflexible, likes own way, excludes pleasure and relationships and dominated by intrusive thoughts
- > Anxious-avoidant = AFRAID = avoids social contact, fear rejection/critisism, restricted lifestyle, apprehensive, inferiority and doesn’t get involved unless sure of acceptance
- > Dependent = SUFFER = subordinate, undemanding, fears abandonment, feels helpless when alone, encourages others to make decisions and reassurance needed
What are the following ego defences and general defence mechanisms seen in PD patients? Avoidance Splitting Projection Dissociation Reaction formation Regression Sublimation Identification Displacement
Avoidance - denial/pretending a problem doesn’t exist
Splitting - an immature response where a person cannot reconcile the good/bad in someone and can only view someone as all-good or all-bad, therefore can’t maintain relationships (EUPD/BPD)
Dissociation - immature ego defence where one assumes a different identify to deal with a situation
Sublimation - mature ego defence where one takes an unacceptable personality trait and uses it positively e.g. anger issues -> boxing
Reaction formation - immature ego defence where one suppresses unacceptable emotions and replaces with the opposite e.g. man with homoerotic desires -> champion of anti-homosexual policy
Regression - revert to an immature behaviour in stressful situation (e.g. banging desk)
Identification - modelling behaviour of someone else e.g. abused becoming an abuser, older brother playing with dead younger brothers toys
Displacement - defence mechanism where someone takes out emotions on a neutral person/unlikely to respond
Projection - person assumes an innocent/neutral character is responsible or as guilty as the patient for the patients actions
How would you Ix PD? What are your other DDx?
Ix:
- > Second interview (+ collateral Hx) - check for REPORT criteria
- > Specific questionnaires for each cluster/type
DDx depend on type but include OCD (anakastic), depression/delusional disorder, mania/BPAD (histrionic)
How would you Mx PDs?
Biopsychosocial approach:
–> 1st line = make a crisis plan (crisis team contact numbers/Samaritans, sedative antihistamines)
Biological:
- > Antipsychotics - reduce impulsivity and aggression (Cluster B)
- > Antidepressants (SSRIs) - reduce impulsively and anxiety (Cluster B, C)
- > Anticonvulsants (Li) - useful for labile affect (Cluster B)
Psychological:
[EUPD]
-> 1st fine for EUPD = Dialectical behavioural therapy (sub-type of CBT)
- focuses on factors leading to EU and introduces 2 concepts - validation (emotions are acceptable) and dialectics (showing things are rarely B&W, enabling openness)
-> Mentalisation therapy - integrative psychotherapy, teaching how to think about thinking and others viewpoints
Others:
- > Group CBT = 1st line for disssocial PD (other CBT also available for other PDs, focussing on interaction between thoughts, feelings, behaviours)
- > Cognitive analytical therapy (CAT) - focusses on specific issues
- > Psychodynamic psychotherapy
Social:
-> Therapeutic community - programme to teach social skills to groups with complex psychological needs
What is Dissociative (Conversion) disorder? Acute vs Chronic?
A form of MUS (physical complaint in the absence of underlying organic cause) –> loss of physical function
ICD10 - partial or complete loss of the normal integration between memories of the past, awareness of identity and sensations and control of body movements
= DISORDERS OF PHYSICAL FUNCTIONS UNDER VOLUNTARY CONTROL AND LOSS OF SENSATION [affects physical functions]
Acute - tend to remit after few weeks/months especially if onset associated with traumatic life event
Chronic (i.e. paralyses) if onset associated with chronic problems or interpersonal difficulties
What are some categories of dissociative/conversion disorder? [amnesia, fugue, stupor, trance+possession, convulsions, motor disorder and anaesthesia]
Dissociative amnesia - loss of memory (too great to be attributed to ordinary forgetfulness)
Dissociative fugue - dissociative amnesia and purposeful travel beyond normal everyday range
Dissociative stupor - lack of voluntary movement/normal responses to external stimuli (light, noise, touch); evidence of stress from recent event
Trance and possession disorders - temporary loss of personal identity and full sense awareness of surroundings
Dissociative motor disorders - loss of ability to move a whole/part of a limb (like ataxia/apraxia…)
Dissociative convulsions - mimic epileptic seizures but tongue-biting, bruising and incontinence is rare. Consciousness maintained or replaced by state of stupor or trance.
Dissociative anaesthesia - areas of anaesthesia which DONT follow normal dermotomal distribution
How would conversion disorder present? What are some RFs?
RFs = traumatic events, intolerable problems, disturbed relationships
Onset = acute, specific, dramatic, follows sudden stress or conflict
Sx:
- Paralysis
- Aphonia (can’t speak)
- Psychogenic amnesia (loss of all memories, including own identity)
- Fugue (loss of memory entirely and wander away from home)
- May show a relative lack of concern despite worrying symptoms
- Blindness, seizures, stupor
How would you Ix conversion disorder?
Ix:
- Exclude organic cause
- Full psych Hx, collateral if possible and MSE [screen for depression + cognition]
- Bloods - prolactin is usually raised after a real seizure, normal after a dissociative convulsion
- Identify and treat any comorbid depression
How would you manage conversion disorder?
Mx:
- Self limiting spontaneous recovery (75%) return to normal
- Supportive therapy - encourage return to normal activity, avoid reinforcing behaviour (i.e. wheelchair for stupor/motor disorders), address physical stressors rather than physical manifestations
What is somatisation? Who does it tend to affect [RFs, other co-morbid conditions patients may have]
Form of MUS
ICD10 - multiple, recurrent and frequently life changing physical symptoms of at least 2y duration
- Many pts have complicated history of contact with medical care, many negative Ix carried out
- Chronic and fluctuating disorder; disruption of social, interpersonal and family behaviour
- 10x more females affected
- Co-morbid background = anxiety, depression, substance and alcohol abuse, histrionic and dissocial PD
What sub-types of somatisation disorder are there?
- Undifferentiated somatoform disorder = multiple, varying and persistent complaints of <2y duration (i.e. not full definition)
- Hypochondrial disorder = persistent preoccupation with idea of having serious/progressive physical disorder (often CANCER). Normal sensations interpreted as abnormal - despite being fine, patient maintains overvalued idea
Somatoform autonomic dysfunction - symptoms presented as if due to physical disorder of system/organ largely or completely under the control of the ANS (CVS/GI/resp) - objective autonomic arousal (palpitations, sweating, tremor, flushing) and the subjective non-specific (fleeting aches/pains, burning sensation, bloating)
Persistent somatoform disorder - persistent, severe and distressing pain, not otherwise explained. Evidence of emotional conflict or psychosocial problems
How would a patient present with somatisation disorder?
Sx:
- Multiple, recurrent and frequently changing physical symptoms (>2y)
- Hx of interactions with HCPs without successful outcomes
- Co-morbid conditions = depression, anxiety, substance and alcohol abuse, histrionic and dissociate PD
What Ix would you carry out for somatisation disorder?
Ix:
- Full history and examination (physical and MSE)
- Exclude organic causes e.g. stroke
- Exclude co-morbid conditions e.g. HADS for depression
How would you manage somatisation disorder?
Mx:
- Mostly counselling during interview
- Ensuring continuity of care (seen by same Dr each time)
- 1st line = explain and reassure
- -> broaden to just physical cause, to physical and psychological cause
- -> be clear about negative clinical findings, and LINK the symptoms to psychological causes, acknowledge psychosocial distress, elicit childhood experience of illness
- -> explain you will NOT do any further investigations and state why you’re stopping
- -> emotional support, encourage coping strategies and letting go of an inappropriate sick role, involve family and encourage normal function
2nd line = CBT
+ Treat co-morbid conditions
