Neurology: OCD; Anxiety; Eating Disorders Flashcards
What are the differences between obsessions and compulsions? [2]
Obsessions
- are unwanted and uncontrolled thoughts and intrusive images that the person finds it very difficult to ignore.
- Examples of this are an overwhelming fear of contamination with dirt or germs or violent or explicit images that keep appearing in their mind.
Compulsions
- are repetitive actions the person feels they must do, generating anxiety if they are not done.
- Often these compulsions are a way for the person to handle the obsessions.
- For example, checking that all electrical equipment is turned off to settle the anxiety of obsessing about the house burning down. This is a normal behaviour, but in OCD the person may check every plug in the house 10 times before being able to go to sleep or leave.
Describe the clinical features of OCD
Obsessive Themes:
* Contamination fears: Fear of becoming contaminated by germs, dirt, or harmful substances.
* Harm-related obsessions: Fear of causing harm to oneself or others due to negligence or unintentional actions.
* Unwanted sexual thoughts: Intrusive and distressing sexual thoughts or images involving inappropriate behaviours.
* Religious/moral obsessions: Excessive concern with religious or moral issues, also known as scrupulosity.
* Perfectionism/symmetry: Intense need for orderliness, symmetry, or exactness.
Compulsive Behaviors:
* Cleaning/washing: Excessive handwashing, showering, cleaning of objects, etc., in response to contamination fears.
* Checking rituals: Repeatedly checking doors, appliances, etc., to ensure safety and prevent harm.
* Counting/repeating rituals: Performing mental acts (e.g., counting) or repeating actions a specific number of times to reduce anxiety.
* Ordering/arranging behaviours: Arranging objects in a particular manner or following strict routines to achieve a sense of orderliness and control.
* Mental neutralizing strategies: Attempting to counteract intrusive thoughts with other thoughts (e.g., prayer) in an effort to alleviate distress.
Which assessment tools can be used to dx OCD? [2]
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS): A widely used clinician-administered scale that measures the severity of obsessions and compulsions.
Obsessive-Compulsive Inventory-Revised (OCI-R): A self-report questionnaire assessing the severity of various OCD symptoms.
OCD is strongly related to which other mental health issues? [5]
Anxiety
Depression
Eating disorders
Autistic spectrum disorder
Phobias
Describe the management of mild, moderate and severe OCD [+]
If functional impairment is mild
low-intensity psychological treatments:
* cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
* If this is insufficient or can’t engage in psychological therapy, then offer choice of either a course of an SSRI or more intensive CBT (including ERP)
If moderate functional impairment
* offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
If severe functional impairment
* offer combined treatment with an SSRI and CBT (including ERP)
NB: These notes are for adults
Describe how ERP works [2]
ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands).
- This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
How long is the tx for OCD for if effective? [1]
if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
- If SSRI ineffective or not tolerated try either another SSRI
How does NICE define anxiety? [1]
NICE define the central feature as an ‘excessive worry about a number of different events associated with heightened tension.’
What are medical causes of anxiety disorders? [3]
Hyperthyroidism
cardiac disease
medication-induced anxiety
- salbutamol
- theophylline
- corticosteroids
- antidepressants
- caffeine
NICE suggest a step-wise approach for treating GAD. What are the steps? [4]
step 1:
- education about GAD + active monitoring
step 2:
- low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3:
- high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4:
- highly specialist input e.g. Multi agency teams
What is the drug tx for GAD?
NICE suggest sertraline should be considered the first-line SSRI
- if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
- examples of SNRIs include duloxetine and venlafaxine
If the person cannot tolerate SSRIs or SNRIs
- consider offering pregabalin
- interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
- Weekly follow-up is recommended for the first month
NB - this is for adults
Describe the 5 step approach to the management of panic disorder? [5]
Again a stepwise approach:
step 1: recognition and diagnosis
step 2: treatment in primary care - see below
- NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line.
- If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered
step 3: review and consideration of alternative treatments
step 4: review and referral to specialist mental health services
step 5: care in specialist mental health services
Describe how you would explain panic attacks [2]
Panic attacks are acute episodes of intense fear or discomfort, often associated with physical and cognitive symptoms. They typically reach their peak within 10 minutes and usually last for about 20 to 30 minutes.
- From a medical perspective, panic attacks can be viewed as an exaggerated response of the body’s ‘fight or flight’ system - a survival mechanism that prepares the body to respond to perceived threats. This involves activation of the sympathetic nervous system, leading to physiological changes such as increased heart rate, rapid breathing (hyperventilation), sweating and trembling.
Describe presentation of anorexia nervosa [+]
Features of anorexia nervosa include:
- Weight loss (e.g., 15% below expected or BMI less than 17.5)
- Amenorrhoea (absent periods)
- Lanugo hair (fine, soft hair across most of the body)
- Hypotension (low blood pressure)
- Hypothermia (low body temperature)
- Mood changes, including anxiety and depression
- Amenorrhea (absence of periods) occurs due to disruption of the hypothalamic-pituitary-gonadal axis. There is a lack of gonadotrophins (LH and FSH) from the pituitary, leading to reduced activity of the ovaries (hypogonadism).
- Cardiac complications include arrhythmia, cardiac atrophy and sudden cardiac death.
- Low bone mineral density is another complication.
Describe the physiological abnormalities seen in anorexia nervosa [+]
- hypokalaemia
- low FSH, LH, oestrogens and testosterone
- raised cortisol and growth hormone
- impaired glucose tolerance
- hypercholesterolaemia
- hypercarotinaemia
- low T3
Describe the dx of AN [
Diagnosis is now based on the DSM 5 criteria. Note that BMI and amenorrhoea are no longer specifically mentioned:
1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
2. Intense fear of gaining weight or becoming fat, even though underweight.
3. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.
What is the treatment plans for children / YAs [2] and adults [2] for anorexia
In children and young people
- NICE recommend ‘anorexia focused family therapy’ as the first-line treatment.
- The second-line treatment is cognitive behavioural therapy.
For adults with anorexia nervosa, NICE recommend we consider one of:
- individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
- Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
- specialist supportive clinical management (SSCM).
What are the cardiac complications of anorexia? [4]
bradycardia
hypotension
prolonged QT interval, increasing the risk of sudden cardiac death
Mitral valve prolapse may also occur.
Describe the endocrine abnormalities see in anorexia [4]
Endocrine abnormalities:
* Amenorrhoea is common due to hypothalamic dysfunction.
* Other endocrine disturbances include thyroid dysfunction (hypothyroidism) growth hormone resistance, cortisol excess and insulin resistance.
Describe the GII abnormalities see in anorexia [4]
Gastroparesis, constipation, and liver dysfunction are frequently observed. Superior mesenteric artery syndrome may also develop.
What is the prognosis of anorexia?
AN has the highest mortality rate among psychiatric disorders. The standardised mortality ratio is estimated to be around 5.86, indicating that individuals with AN are almost six times more likely to die prematurely than those without.
About 50% of individuals with AN achieve full recovery while around 20-30% remain chronically ill. The remaining patients may experience partial recovery but continue to struggle with body image issues or disordered eating patterns.
Describe the clinical features of bulimia nervosa [+]
Features of bulimia nervosa include:
* Erosion of teeth
* Swollen salivary glands
* Mouth ulcers
* Gastro-oesophageal reflux
* Calluses on the knuckles where they have been scraped across the teeth (called Russell’s sign)
Alkalosis can occur after repeated vomiting of hydrochloric acid from the stomach.
TOM TIP: Unique examination findings in bulimia make it a popular spot diagnosis in exams. A teenage girl with an average body weight that presents with swelling to the face or under the jaw (salivary glands), calluses on the knuckles and alkalosis on a blood gas may indicate bulimia.
What are the two types of bulimia? [2]
Purging Type:
- This subtype is characterised by regular engagement in self-induced vomiting or misuse of laxatives, diuretics, or enemas during the current episode.
Non-Purging Type:
- In this subtype, the individual employs other inappropriate compensatory behaviours, such as fasting or excessive exercise, but does not regularly engage in self-induced vomiting or misuse of laxatives, diuretics, or enemas.
The severity of Bulimia nervosa is also categorised based on the frequency of inappropriate compensatory behaviours (as per DSM-5):
What determines mild, moderate, severe and extreme bulimia? [4]
Mild: An average of 1-3 episodes per week.
Moderate: An average of 4-7 episodes per week.
Severe: An average of 8-13 episodes per week.
Extreme: An average of 14 or more episodes per week.
Describe the electrolyte disturbances seen in BN [+]
Electrolyte imbalances:
- Chronic purging by vomiting or laxative abuse can lead to hypokalaemia (low potassium levels), hyponatraemia (low sodium levels), and hypochloraemia (low chloride levels). These imbalances can have serious cardiovascular and neuromuscular consequences.
Metabolic alkalosis due to vomiting, and metabolic acidosis due to laxative abuse may occur. Hypomagnesaemia (low magnesium levels) may also be seen.
Describe the investigations used for BN
Psychological Assessment
- Semi-structured interviews: The Eating Disorder Examination (EDE) is considered the gold standard for diagnosing eating disorders including BN.
- Self-report questionnaires: Tools such as the Bulimia Test-Revised (BULIT-R) or Eating Disorders Inventory (EDI) can be used to supplement clinical interviews and provide additional information about symptom severity and related psychological features.
Laboratory Investigations
* FBC: anaemia or infection
* U&Es: hypokalaemia; AKIs
* LFTS: malnutrition or alcohol abuse
Radiological Investigations (not routine)
- DEXA scan
- Gastrointestinal imaging
ECG
Describe the dx of BN
The diagnostic criteria for Bulimia Nervosa, as per the ICD-10 and DSM-5, are outlined below. It’s imperative to note that these criteria are not exhaustive and should be used in conjunction with clinical judgement.
ICD-10 Criteria:
* A persistent preoccupation with eating, and an irresistible craving for food; the patient succumbs to episodes of overeating in which large amounts of food are consumed in short periods of time.
* The patient attempts to counteract the ‘fattening’ effects of food by induced vomiting, purgative abuse, alternating periods of starvation, or use of drugs such as appetite suppressants.
* If the disorder occurs in diabetic patients they may choose to neglect their insulin treatment.
DSM-5 Criteria:
* Recurrent episodes of binge eating characterised by both consuming an amount of food that is definitely larger than most people would eat during a similar period under similar circumstances and a sense of lack of control over eating during the episode.
* Recurrent inappropriate compensatory behaviours to** prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.**
* The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for three months.
* Self-evaluation is unduly influenced by body shape and weight.
How does BN differentiate from binge eating disorders (BED) [1]
In BED, binge-eating episodes are not followed by inappropriate compensatory behaviours such as purging or excessive exercise which are hallmark features of BN.
Describe the management of BN [+]
Psychotherapy:
* Offer CBT-ED to adults with BN as it has been shown to reduce binge-eating and purging behaviours.
* If CBT-ED is not available or the patient declines, consider other forms of psychological therapy such as interpersonal psychotherapy or dialectical behaviour therapy.
Pharmacotherapy:
* Selective serotonin reuptake inhibitors (SSRIs), specifically fluoxetine, have been approved by the Food and Drug Administration for BN treatment. However, they should be used in conjunction with psychotherapy rather than standalone treatment.
* If SSRIs are contraindicated or not tolerated, consider other types of antidepressants like tricyclics or monoamine oxidase inhibitors after discussing potential side effects and monitoring requirements.
Dietetic Support:
* A registered dietitian can provide valuable input regarding meal planning and nutritional rehabilitation. They can also help address any distorted beliefs about food and weight.
Physical Health Monitoring:
* Routine monitoring of vital signs and electrolytes is crucial due to the risk of complications associated with purging behaviours. Electrocardiogram may be required in some cases.
Inpatient or Day Patient Care:
* Consider inpatient care for patients who are medically unstable or for whom outpatient treatment has failed. The goal should be to stabilise the patient’s physical health while continuing with psychotherapeutic interventions.
BN suffer which cardiac complication than those without? [1]
Mitral valve prolapse: This is a heart condition that affects the mitral valve’s function. It has been observed more frequently in individuals with bulimia nervosa than in those without.
