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Health anxiety, somatisation, medically unexplained symptoms and eating disorders | Flashcards

1
Q

What is the definition of health anxiety?

What 3 things does it include?

A

An umbrella term that encompasses a wide range of:

  1. Excessive health-related concerns (e.g. ruminations on having an illness, suggestibility if one reads or hears about a disease, unrealistic fear of infection)
  2. Somatic perceptions (e.g. preoccupation with bodily sensations or functioning)
  3. Behaviours (e.g. repeated reassurance seeking, avoidance of medications or medical personnel)

This can also apply to a person with a medical illness. If this is the case, their reaction will be out of proportion with what would be expected

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2
Q

What is somatisation?

A

The process by which “psychological distress is expressed through physical symptoms and subsequent medical help-seeking”

Also known as medically unexplained symptoms

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3
Q

Health anxiety is not a term found in ICD-10, however it is linked to which conditions (6)?

A
  1. Hypochondriasis or hypochondriacal disorder (concerns about having a serious illness persists for at least six months despite medical assurance and these concerns cause clinically significant impairment or distress)
  2. Somatisation disorder
  3. OCD
  4. Body dysmorphic disorder
  5. Panic disorder
  6. Delusional disorder
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4
Q

What is the ICD-10 diagnoses of somatisation disorder?

A
  1. History of at least 2 years complaints of multiple and variable physical symptoms that cannot be explained by any detectable physical disorder
  2. Preoccupation with symptoms causes persistent distress and leads the patient to seek repeated consultations or sets of investigation with either primary care or specialist doctors; or persistent self-medication
  3. There is persistent refusal to accept medical reassurance that there is no adequate physical cause for the physical symptoms
  4. A number of symptoms from at least 2 separate groups from the following list:
    - GI Symptoms: Abdominal pain, nausea, feeling bloated, bad taste in mouth, complaints of vomiting, complaints of frequent loose bowel motions
    - Cardiovascular: breathlessness without exertion, chest pains
    - GU symptoms: dysuria, unpleasant sensation around the genitals, complaints of unusual or copious vaginal discharge
    - Skin and pain complaints: blotchiness, discoloration, pain in limbs, unpleasant numbness or tingling sensation
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5
Q

What is hypochondriacal disorder?

A
  1. Either of:
    a. Persistent belief, of at least 6 months, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient)
    b. Persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder)
  2. Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living, and leads the patient to seek medical treatment or investigation
  3. Persistent refusal to accept medical reassurance that there is no physical cause for the symptoms or physical abnormality
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6
Q

What is factitious disorder?

A
  1. Patient feigns or exaggerates symptoms for no obvious reason
  2. Patient may even inflict self-harm in order to produce symptoms or signs
  3. Internal motivation with aim of adopting the sick role
  4. Munchausen syndrome by proxy - the patient imposes symptoms to other individuals (e.g. a child)
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7
Q

What is malingering?

A

Conscious manufacturing or exaggerating of symptoms for a secondary gain e.g. benefits, housing, other than assuming the sick role

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8
Q

What are the 3 subtypes of health anxiety?

A
  1. Cognitive type
  2. Somatising type
  3. Behavioural type
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9
Q

What is cognitive type health anxiety?

A

Health anxiety with high cognitive awareness and more pronounced fear of disease

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10
Q

What is somatising type health anxiety?

A

Health anxiety with high symptom awareness and more pronounced bodily preoccupation

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11
Q

What is behavioural type health anxiety?

A

Health anxiety with high disease conviction and avoidance

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12
Q

What are predisposing factors for heath anxiety and somatisation?

A
  1. Family members with health anxiety
  2. Somatisation disorder among relatives
  3. Early life trauma (sexual trauma, violence, parental upheveal)
  4. Family history of OCD
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13
Q

What are precipitating factors for heath anxiety and somatisation?

A
  1. Personal experience of a previous illness - misinterpret bodily sensation, fear of relapse
  2. Significant illness of a loved one
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14
Q

What are perpetuating factors for health anxiety and somatisation?

A
  1. Somatosenosry amplification - paying too much focus on minor body sensations
  2. Increase sensitivity in certain brain area (anterior cingulate, prefrontal cortex)
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15
Q

What are ddx for hypochondriasis, somatisation and medically unexplained symptoms?

A
  1. Depression and anxiety disorders
  2. Personality disorder
  3. Organic conditions
  4. Dissociative (conversion) disorders
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16
Q

What is dissociative (conversion) disorder?

A
  1. Classically a traumatic event leads to a disruption of the usually integrated functions of consciousness, memory, identity or perception
  2. Patient may deny the impact of the traumatic event
  3. They may also show a lack of concern for the disability
  4. Sometimes it is called conversion disorder - convert anxiety into more tolerable symptoms (primary gain) that attract benefits of the sick (secondary gain)
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17
Q

What are the different presentations of dissociative disorder?

A
  1. amnesia
  2. fugue (sudden, unexpected journey that may last a few months, together with memory loss, confusion about personal identity)
  3. stupor
  4. trance or possession disorders
  5. motor disorders
  6. anaesthesia/sensory loss
  7. convulsions (“pseudo-seizures” or “psychogenic non-epileptic seizure”)
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18
Q

What are the general principles of health anxiety/somatisation?

A
  1. Managed in primary care
  2. Rapport
    - Help them feel appreciated and understood, acknowledge patient’s symptoms are real and they don’t make these up
    - refocus treatment away from ‘cure’ and towards symptom management
  3. Investigations
    - minimise unnecessary tests and treatment - sometimes boundary is important. Over-investigations or over-medication can reinforce physical illness beliefs and further increase anxiety
    - do reasonable investigations and don’t assume everything is in the patient’s mind
  4. Interaction with patients
    - Scheduling of regular appointment independent from symptom status, preferably with the same healthcare professional to avoid doctor shopping
  5. Make the link between physical symptoms and psychological factors and broaden the agenda from a purely physical cause to include a psychological explanation
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19
Q

What is the biological management of health anxiety/somatisation?

A
  1. Evidence of the long-term efficacy of medications is weak
  2. Sometimes antidepressants (SSRI, SNRI) may be useful
  3. In the case of hypochondriacal delusion, antipsychotic may also be indicated
  4. Avoid routine benzodiazepine use
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20
Q

What is psychological management of the health anxiety/somatisation?

A
  1. CBT

2. Psychoeducation

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21
Q

What is the social management of health anxiety/somatisation?

A
  1. Encourage normal function - patient may avoid normal activities as they think these activities may exacerbate problems
  2. Involve social network to improve emotional support
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22
Q

What is the prognosis of somatisation or hypochondriasis?

A
  1. Some respond well to medication, psychotherapy, or both
  2. If the person has anxiety or depression that responds to treatment with medication, the prognosis can be quite good.
  3. In mild cases, the symptoms can be short-lived.
  4. If the symptoms are severe and the person has other mental health disorders, the person may be susceptible to chronic distress and problems functioning.
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23
Q

What is the biological aetiology of anorexia nervosa?

A

Unclear, but theories are:

  1. Monozygotic twin concordance significantly higher than dizygotic twin
  2. Neuro/endocrine changes (disturbance of hypothalamic function, increased serotonin levels, brain atrophy
  3. Changes in brain normalise when weight is restored through regular intake of balanced diet
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24
Q

What is the psychological aetiology of anorexia nervosa?

A
  1. Perfectionism
  2. Low self-esteem (weight loss as a sense of achievement)
  3. Sexual development (early development)
  4. History of abuse (sexual, physical, psychological, neglect)
  5. Personality disorder
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25
Q

What is the social aetiology of anorexia nervosa?

A
  1. Family: possible (research is being conducted at present)
  2. Theories include parental overprotection and family enmeshment. The young person with anorexia nervosa may be avoiding separation from family or becoming an independent sexual being.
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26
Q

What is the biological aetiology of bulimia nervosa?

A
  1. Changes in levels of serotonin

2. Monozygotic twin and dizygotic twin concordance rates broadly similar

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27
Q

What is the psychological aetiology of bulimia nervosa?

A
  1. Low self esteem
  2. History of abuse (sexual, physical, psychological, neglect)
  3. history of self harm
  4. impulsive personality traits
  5. personality disorder
  6. High value placed on food and eating behaviour (either personally or within the family culture)
  7. History of being over-weight (factual or perceived)
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28
Q

What is the social aetiology of bulimia nervosa?

A
  1. Exposure to culture of dieting

2. Family/ social culture of categorizing food as good or bad, healthy or naughty treat

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29
Q

What are important elements of the history of an eating disorder?

A
  1. Eating behaviour
  2. Medical history
  3. Personal and social history
  4. Psychiatric history

Also need to do:

  1. Mental state
  2. Risk assessment
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30
Q

What specific qs do you need to ask in a history about eating behaviour in someone with a possible eating disorder (4)?

A
  1. Methods of weight loss: diet, weight control (exercise, vomiting, medications)
  2. Typical day, intake (fluid and solids)
  3. Relationship with body image (past and present)
  4. Any binge eating and/or compensatory behaviours
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31
Q

What specific qs do you need to ask in a history about medical history in someone with a possible eating disorder (4)?

A
  1. Menstrual history (female) / sexual dysfunction (male +/- female)
  2. Complications of starvation
  3. Digestive complications
  4. Known physical illness
32
Q

What specific qs do you need to ask in a history about personal and social history in someone with a possible eating disorder (5)?

A
  1. Past abuse, physical, sexual, neglect. Context to this
  2. Bullying, nature of this
  3. Loss of loved one
  4. Major change in situation, home, school, work etc
  5. Effect of eating behaviour and associated weight loss on elements of social life:
    - Education
    - Career
    - Relationships
    - Home life
    - Socializing
    - Hobbies/interests
33
Q

What specific qs would you ask about regarding affects of eating behaviour and associated weight loss on social life (6)?

A
  1. Education
  2. Career
  3. Relationships
  4. Home life
  5. Socializing
  6. Hobbies/interests
34
Q

What specific qs do you need to ask in a history about psychiatric history in someone with a possible eating disorder (3)?

A

Comorbidity:

  1. Anxiety
  2. Depression
  3. Self-harm
35
Q

What body systems can anorexia affect/cause symptoms in (7)?

A
  1. Hair and skin
  2. Head/CNS
  3. Heart
  4. Bones
  5. Reproductive system
  6. Muscles
  7. Feet and ankles
  8. Metabolic
  9. Haematological
  10. Temperature control
  11. Infections
36
Q

What are the hair and skin symptoms of anorexia (3)?

A
  1. Hair and skin can become dry and brittle
  2. Hair can thin and drop out
  3. Lanugo hair may grow over the skin on face and body aiming to aid warmth
37
Q

What are the head/CNS symptoms of anorexia (6)?

A
  1. Thinking becomes inflexible, difficult to make a decision
  2. Poor concentration
  3. Obsessions, difficulty being spontaneous
  4. Interest becomes centered around food, for example cookery books and programs. Interest in other topics declines
  5. Irritated mood
  6. ‘Flattened effect’, little variance in mood.
38
Q

What are the cardiac symptoms of anorexia (4)?

A
  1. BP drops
  2. Pulse declines
  3. Increased risk of heart arrhythmias
  4. Risk of heart failure
39
Q

What are the bone symptoms of anorexia (1)?

A

Osteopenia/ Osteoporosis

40
Q

What are the symptoms of anorexia relating to the reproductive system (5)?

A
  1. Lack of sex drive
  2. Reproductive system ceases to function
  3. Amenorrhoea in females
  4. Low testosterone in males
  5. Often function will return with weight restoration and regular eating
41
Q

What are the symptoms of anorexia relating to the muscles (4)?

A
  1. Muscle wastage
  2. Muscle cramp
  3. Sit up and squat test can assess this
  4. If muscle is wasted around the body it is likely the heart is also smaller and weaker
42
Q

What are the symptoms of anorexia relating to the feet and ankles (3)?

A
  1. Swollen feet and ankles
  2. Cold extremities
  3. Broken skin
43
Q

What are the metabolic symptoms of anorexia (6)?

A
  1. Hypoglycaemia
  2. Hyponatraemia
  3. Hypokalemia
  4. Vitamin deficiency
  5. Hypercholesterolaemia
  6. Deranged liver function
44
Q

What are the haematological symptoms of anorexia (3)?

A
  1. Iron deficiency anaemia
  2. Leucopenia
  3. Thrombocytopenia
45
Q

What are the symptoms of anorexia regarding temperature control (1)?

A

Hypothermia

46
Q

What body systems can bulimia nervosa affect (8)?

A
  1. Head/CNS
  2. Mouth and teeth
  3. Heart
  4. Abdomen
  5. Hand
  6. Feet and ankles
  7. Metabolic
  8. Muscles
47
Q

What are the symptoms of bulimia regarding the head/CNS (3)?

A
  1. Poor concentration
  2. Irritability
  3. Seizure secondary to electrolytes imbalance
48
Q

What are the symptoms of bulimia regarding the mouth and teeth (4)?

A
  1. Tooth decay, erosion
  2. Horse voice
  3. Bleeding from mouth or throat
  4. Swollen parotid glands (“chipmunk” faces)
49
Q

What are the symptoms of bulimia regarding the heart?

A

Potassium is crucial to heart function.
Hypokalemia can cause cardiac arrhythmias and can be potentially fatal, caused through the use of diuretics, diarrhoea, vomiting and excessive use of laxatives

50
Q

What are the symptoms of bulimia regarding the abdomen (7)?

A
  1. Swollen stomach
  2. Stomach pain
  3. Constipation
  4. Delayed gastric emptying
  5. Oesophageal tears/Oesophagitis
  6. Rectal prolapse
  7. Renal failure, UTI
51
Q

What is a symptom on the hand in bulimia?

A

Russell sign - callosities, scarring and abrasion on the dorsal surface of index and long fingers as a result of repeated self-induced vomiting

52
Q

What is a symptom in the feet and ankles in bulimia (2)?

A
  1. Swollen feet and ankles

2. Cold extremities

53
Q

What are the metabolic symptoms of bulimia (2)?

A
  1. Dehydration

2. Electrolytes imbalance

54
Q

What is a symptom of the muscles in bulimia?

A

Muscle paralysis

55
Q

What is the DSM-5 diagnostic criteria of anorexia nervosa?

A
  1. BMI <17.5
  2. Persistent restriction of energy intake leading to significantly low body weight
  3. Either an intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain
  4. Disturbance in the way one’s body weight or shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
56
Q

What are the 2 subtypes of anorexia nervosa?

A
  1. Restricting type

2. Binge-eating/ purging type

57
Q

What is the DSM-5 criteria for bulimia nervosa?

A
  1. Recurrent episodes of binge eating, characterised by eating more than most would in a certain amount of time e.g. 2 hours or a sense of lack of control during an eating episode, unable to stop or to switch behaviour
  2. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting or excessive exercise
  3. Binge eating and compensatory behaviours occur, on average, at least one a week for 3 months
  4. Self-evaluation is unduly influenced by body shape and weight
  5. The disturbance does not occur exclusively during episodes of anorexia nervosa
58
Q

What are 5 ddx of anorexia?

A
  1. Hyperthyroidism -> weight loss
  2. Depression -> reduced intake and pleasure from food
  3. OCD -> excessive energy expenditure
  4. Body dysmorphic disorder -> a refusal to gain weight and extreme dissatisfaction with appearance
  5. Psychosis -> Food refusal as they believe it is poisoned etc
59
Q

What are some comorbidities within bulimia nervosa (3)?

A
  1. Alcohol misuse
  2. Illicit substances misuse
  3. Self-harm
60
Q

What is the biological treatment of anorexia?

A
  1. Weight restoration is key
  2. Regular weight monitoring, frequency depends on severity
  3. Regular blood monitoring, frequency depends on severity
  4. Dexa bone density scan if indicated
  5. ECG
  6. Admission to a general medical ward if results of blood tests are severely out of range
  7. Specialist dietician
61
Q

What do you need to be careful of in weight restoration of a patient with anorexia?

A

Re-feeding syndrome
-need input from specialist dietician to monitor increased intake to avoid re-feeding syndrome
-It is characterised by deranged phosphate, potassium and magnesium balance within the
body
-Leads to metabolic acidosis, ketoacidosis and hyperosmolar states. Also can lead to cardiac decompensation, pre-renal failure with metabolic acidosis and sudden death

62
Q

What bloods monitoring would you do for treatment of anorexia in:
BMI >16
BMI <15

A

BMI >16: FBC, U&E, LFT & glucose

BMI <15: above and also phosphate, magnesium, calcium, creatinine kinase, zinc, B12 and folate

63
Q

What are you looking for on an ECG in a patient with anorexia (4)?

A
  1. QTc prolongation
  2. Rate<50
  3. Heart block
  4. Other arrhythmias
64
Q

What are the psychological treatments of anorexia nervosa?

A
  1. Evidence suggests therapeutic relationship is most important factor in recovery
  2. Formal psychological therapy unlikely to be effective if below BMI 13
  3. Specialist services providing different types of psychological therapies and integrative supportive individualised care plan
  4. Family therapy commonly used if patient is under 18 years of age
65
Q

What types of specialist psychological therapies are there for anorexia nervosa (6)?

A
  1. Motivational Interviewing
  2. CBT
  3. Interpersonal therapy
  4. Compassion Focused Therapy
  5. Mindfulness
  6. Arts Psychotherapy such as Dance Movement, Art and Drama and Cognitive Analytical Therapy
66
Q

What is the social management of anorexia (3)?

A
  1. Advise to inform a loved one for extra support
  2. Carer support
  3. Increased flexibility with and participation in social plans and lifestyle goals such as hobbies or vocation related goals
67
Q

What is the biological treatment of bulimia (5)?

A
  1. Anti-depressant medication, SSRI, usually Fluoxetine
  2. Advise cessation of laxative use
  3. Advise cessation of excessive alcohol
  4. Regular weight monitoring, frequency depends on severity
  5. Regular blood monitoring, frequency depends on severity
68
Q

What is the most important blood test for those with bulimia (5)?

A

U&Es to check for hypokalaemia -> severe effects on heart, nerves and muscles

69
Q

What is the psychological treatment of bulimia nervosa (5)?

A
  1. Psycho-education regarding coping mechanisms
  2. Specialist services providing psychological therapy, 20 sessions of CBT recommended by NICE
  3. Other specialist services: Interpersonal Therapy, Compassion Focused Therapy, Mindfulness, Arts Psychotherapy such as Dance Movement, Art and Drama and Cognitive Analytical Therapy
  4. Evidence suggests therapeutic relationship being the most important factor in recovery
  5. Input from Specialist Dietician to give psycho-education on balanced eating
70
Q

What is the social treatment of bulimia (4)?

A
  1. Advise to inform a loved one for extra support
  2. Carer support
  3. Focus on encouraging regular intake, cessation of restrict, binge, purge cycle
  4. Increased involvement with social plans and lifestyle goals such as hobbies or vocation related goals
71
Q

What is the prognosis of anorexia nervosa?

A

Slow recovery rates:

  1. A third up to 3 years
  2. Another third 3-6 years
  3. Recovery less likely after 15 years
72
Q

For anorexia, after 10 years, what % are:

  1. Recovered
  2. Mortality
  3. Have an ongoing problem?
A
  1. 50%
  2. 10% - 1/3 due to suicide
  3. 40%
73
Q

What are poor prognostic indicators for recovery from anorexia (5)?

A
  1. Very low weight
  2. Bulimic features
  3. Family difficulties
  4. Personality difficulties
  5. Longer illness duration
74
Q

What is the prognosis of bulimia?

A
  1. 70% recover in 10 years

2. 1% mortality rate

75
Q

What are poor prognostic indicators for recover from bulimia (2)?

A
  1. Low body weight

2. Comorbid depression

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