Health anxiety, somatisation, med unexplained sx and ED Flashcards
1
Q
Somataform Disorders
A
Patients remain agitated after examinations and tests show either:
a) no detectable structural or physical abnormalities
or
b)show abnormalities insufficient to explain the severity of response
- the distress and functional impairment caused are real
Most common:
- Somatisation Disorder
- hypochondrial Disorder
- Body dysmorphic Disorder
2
Q
Somatisation
A
multiple, recurrent and frequently changing physical sx with absence of physiological explanation
ICD-10:
- At least 2y of sx and no physiological explanation
- persistent refusalof reassurance from several doctors that there is no physical cause of sx
- some degree of impairment due to sx and resulting behaviour
3
Q
Somatisation example sx
A
GI
- N and V
- abdo pain
- constipation
- diarrhoaea
sexual
- loss of labido
- ED
- menorhogea
Urinary
- dysurea
- frequency
- retention
- incontinence
neuro
- paralysis
- parasthesia
- seizures
- difficulty swallowing
4
Q
Hypochondriacal Disorder
A
misinterpret normal bodily sensations and seek conformatory diagnosis as opposed to seeking relief/reassurance
5
Q
Body dysmorphic disorder
A
- preocupied with imagined or minor defect
- has to impair funtioning
- Overvalued idea and not delusion (somatic delusional disorder)
6
Q
functional, conversion and dissociative disorders
A
terms used interchangable where psychic pain is converted to somatic or physical sx
eg fibromyalgia, IBS, chronic cough, chronic back pain, atypical chest pain, ME, dissociative seizures, functional weakness and sensory distortians
7
Q
Factitious Disorder or Malingering
A
Factitious disorder
- aka munchausen syndrome
- focus is on primary gain of assuming sick role
- often a manifestaion of psychological distress
Malingering
- focus is on secondary gain
- eg avoiding military service, criminal justice prosecution, obtaining drugs or benefits etc
Munchausen syndrome by proxy
- form of abuse (classically parent and child)
8
Q
DDX
A
- undiagnosed unkown medical coditon
- udagnosed known medical condition
- functional (disociating/conversion) = usually clearly defined and isolated
- facticious disorxer
- malingering
- somataform disorder (somatisation, hypochondriacle, body dysmorphic disorder)
- other psychiatric disorder
9
Q
Other psychiatric disorder
A
- depression and panic disorder = sx episodic with this conditon and go with tx
- GAD = not limited to physical worries
- Difficult as half of smatisation have psychiatric disorder
10
Q
med unexplained thought process
A
- Physical disorder sufficient to cause sx excluded? (no? then more investigations)
- sx secondary to other psychiatric disorder?
- postive evidence of functional disorder? (hoover sign in neuro sx, pain relief on defaction in IBS, tnderness at specific pointsin fribromyalgia)
- abdnormal response to sz? ( undue concern of sx = somatisation, undue concern of presence of underlying disorder = hypochondriacle, and undue concern over appearance = body dysmorphic disorder)
- sx fabricated? (primary or secondary benefit?)
*Lots of sx in young think somatisation
11
Q
Somatisation RF
A
Femal
childhood sex abuse
growing up with general stress
12
Q
somatisation prognosis
A
- chronic episodic course with waxing/waning sx often excerbated by stress
- bettwe outcome if abrupt onset, mild and absence of comorbitdity
13
Q
mx
A
Body DD
- CBT (+ERP)
- SSRIs if mod-severe
somatisation/hypochondriacal
-CBT to decrease Sx
Treat comorbid conditions
14
Q
somatisation GP role
A
- regular fixed intervals
- increased support at times of stress
- take seriously and encourage to talk about emotions
- limit medications to and investigations to absolutely necessary
- teach coping mechanisms and consider psychiatrist
- high threshold for specialist referal and investigations
15
Q
Explanation and advice for dissociative functional disorder
A
- state what is wrong (you have functional seizures
- state what is not wronge ( you don’t have epilepsy)
- describe mechanism (body not damaged by not working properly)
- try metaphor (software not hardware)
- explain diagnosis (share results)
- state you believe (don’t think you are making up sx)
- emphasize common and others suffer
- emphasize its gets better as there is no damage
- emphasize self help - there are things YOU can do
16
Q
Anorexia Nervosa ICD-10
A
all of:
- low body weight: 15% below expected (BMI < 17.5KG/M2 in adults)
- self induced weight loss (decrease intake, vomitting, exercise)
- Overvalued idea: dread of fatness, self perception of being too fat and low target weight
- endocrine disturbance (hypothalamic - pituitary - gonadal axis, resulting in amenorhoea, raised cortisol, growth hormone, loss of labido and impotency in men)
- prepubertal failure to make expected weights and delayed pubertal events
17
Q
Bulimia Nervosa ICD-10
A
all of:
- binge eating
- strong cravings of food
- methods to counteract weight (vomitting, laxitives, fasting, exercise)
- overvalued idea: dread of fatness, self perception of being fat and low target weight
18
Q
ED assessment
A
- first build report and ask about background, family, friends, stress, functiong
- then later focus on weight and eating w/o alienating . . . normalise it for interview:
- body weight very important to some people . . . .a common way of losing weight is . . .. .sometimes when you lose weight periods xxxx . . . . sometimes people feel unconfortable after eating lots and vomit . . sometimes people use drugs to contol weight
19
Q
ED physical sx
A
hx should include:
- menstrual hx
- episodes of syncope/presyncope
- palpitations
- tiredness
- muscle weakness
- sensitivity to cold
20
Q
ED complications
A
related to starvation
- cardiomyopathy
- abdo pain
- cold intolerence
- bradycardia/ hypotension
- lanuago hair
- peripheral oedema
- osteoprosis
- muscle wasting
- seizures
- depression
- decreased concentration
- emaciation
- amenorhea
relating to vomitting
- dental erosion
- enlarged salivary glands
- calasus on back of hands
- oesophageal tears
21
Q
ED lab tests
A
- normocytic anaemia
- leukopenia
- aki (if dehydrated)
- increase transaminases
- hypoglycaemia
- increase cortisol, GH, serum amylase
- decrease T3, FSH, LH, Na, Mg+ , PO4+, cholesterol
22
Q
ED exam
A
SKIN -lanugo hair -loss of head hair -russels sign (hand calluses) DENTITION -abrasions -tooth decay CARDIO -lying/standing BP and pulse ABDO -constipation MSK -wasting -sit up test -stand squat test -pathological fractures OTHER -core temperature -mucous membranes -facial glands
23
Q
ED investigations
A
- ECG
- U and E s
- RBCs
- LFTs
- Serum glucose and lipids
- TFTs
- amylase
24
Q
Weight loss DDX
A
Medical -malignancies -GI disease - endocrine (DM, hypothyroidism) -chronic infections -chronic inflamattory conditions Alcohol and substance misue dementia psychotic disorders depression OCD A nervose B nervosa Binge eating disorder
25
AN mx
Adult
-1st line = one of CBT-ED, MANTRA or SSCM
-2nd line = another 1st line or psychodynamic therapy
Young
-1st line = Family therapy with anorexia focus
2nd line = CBT-ED or psychotherapy (adolescence anorexia focus)
Hospital?
- BMI < 13.5 KG/M2
- rapid weight loss
- severe electrolyte abnormality
- syncope
- risk of suicide
Remember to assess refeeding syndrome
26
refeeding syndrome
```
if >5 dayss starvation
sx
-muscle weakness (phosphates)
-seizures (potassium)
-arythmias (na+)
-hypotension (metablic acidosis)
-delirum ( thiamine def)
```
tx
-electrolyte replacement
prevention
- refeed gradually
- monitor u and es
- thiamine replacement
Hypophosphateamia is key
27
Bulimia nervosa mx
ADULT
- 1st line = guided self help (CBT informed)
- 2nd line = CBT-ED
Young
- 1st line = guided self help (bulimia focused)
- 2nd line = CBT-ED
depression/anxiety unlikely to be result of starvation unlike AN
-specialist services of suicide/self harm risk or electrolyte abnormalities
28
ED prognosis
AN - complete remission at 5 years 1/4 get BN, 1/5 remain very unwell and rest relapsing course. 6x increase of death (1/5 suicide and rest starvation related). poor markers:
- onset pre puberty or >17
- male
- v low weight
- binge purge sx
- personality difficulties
- familty relationship difficulties
```
BN50-70% full/partial reovery at 5 years
2x increase of death
-severe bing/purgeing
-low weight
-co morbid depression
```
