Neurotic disorders Flashcards
What are the features of anorexia nervosa? (4)
Markedly low weight: BMI< 17.5
Weight loss self induced by: restriction, exercise, vomiting
Cognitive distortions: “too fat”, fear of fatness
Endocrine disturbance: Amennorrhoea, Loss of libido
Define OCD. (2)
Obsessive compulsive disorder is an anxiety disorder in which the patient suffers from time-consuming obsessions and compulsions that interfere with everyday life.
Name 2 other psychiatric disorders that are associated with OCD. (2)
Anankastic personality disorder
Depression
Tourettes syndrome
Describe 3 features of the compulsions and obsessions experienced in OCD. (3)
Acknowledged as originating in the mind persistent, repetitive and intrusive patient tries to resist them Not intrinsically pleasurable Cause distress and interfere with functioning
Define compulsions. (2)
Stereotyped acts, recognised as excessive, unreasonable or exaggerated. If patient tries to resist there is a sense of mounting tension that is immediately relieved by performing compulsion.
What is the management of OCD? (2)
CBT
Clomipramine or SSRIs
Define obsession. (2)
Persistent thoughts, images, doubts or impulses. Common content include contamination, bodily fears, aggression, orderliness/symmetry.
What supplementary questions should be asked in a psychiatric history relating to eating disorders? (4)
Weight - current weight - how often do you weigh yourself - what has your weight been like in the past (high and low) Eating - What do you eat on a normal day - Are you dieting at the moment? - Do you ever binge eat? - Do you think about food a lot? - Do you try any other methods of losing weight? - Do you ever make yourself sick? - Do you take laxative/diuretics? Body image - How do you see yourself? - Do you feel fat? - What would your ideal weight be? - Are you dissatisfied with particular parts of your body? Physical problems associated with weight loss - Are your periods regular? - Are you interested in sex? - Do you feel tired and weak? - Do you suffer from dizziness?
What are the diagnostic criteria for anorexia nervosa? (4)
Low body weight: ->15% below expected / BMI < 17.5 -Weight loss self induced -Avoidance of eating -Vomiting -Purging -Excessive exercise -Use of appetite suppressants, diuretics, laxatives Body image distortion -Over-valued idea of fatness, fear of being fat Endocrine disorders -Amenorrhoea -Reduced libido -Raised GH levels, raised cortisol, altered TFTs, abnormal insulin secretion -Delayed or arrested puberty.
Name 3 predisposing/precipitating factors for anorexia nervosa. (3)
Bio
Genetics (65% concordance in MZ twins)
Psycho
Family: over-protectiveness, lack of conflict resolution, weak generational boundaries
Individual: disturbed body image due to dietary problems in early life, parents’ preoccupation with food, lack of sense of identity, low self-esteem
Social Pressure from peers Occupation: ballet dancers or models Higher socio-economic groups Western caucasians
Name 6 physical consequences of anorexia. (6)
Oral: dental caries
CV: hypotension, prolonged QT, arrhythmias, cardiomyopathy
GI: prolonged GI transit, constipation
Endo: hypokalaemia, hyponatraemia, hypoglycaemia, hypothermia, altered thyroid function, hypercortisolaemia, amenorrhoea, arrested growth, delayed puberty, osteoporosis
Renal: Calculi
Repro: infertility
Derm: dry skin, brittle hair, lanugo (fine body hair)
Neuro: peripheral neuropathy, loss of brain volume, ventricular enlargement, cerebral atrophy
Haem: anaemia, leucopenia, thrombocytopenia
Name 4 investigations you would perform in a girl diagnosed with anorexia. (4)
ECG
BMI
FBC – anaemia, leucopenia, thrombocytopenia
ESR – normal or reduced (if elevated look for organic cause)
U&Es – high U&Cr if dehydrated, hyponatraemia from excessive water intake or SIADH, metabolic alkalosis from vomiting, metabolic acidosis from laxative abuse.
Glucose – low (prolonged starvation, low glycogen stores)
LFTs – minimal elevation
TFTs – low T3, T4, sick euthyroid syndrome
Cholesterol – may be dramatically elevated (starvation)
Endocrine – hypercortisolaemia, high GH levels, low LHRH/LH/FSH/oestrogens/progesterone
Name 3 differentials for anorexia. (3)
Organic -Brain tumour -GI disorder: Crohns, malabsorption syndrome -Loss of appetite eg side effects of SSRIs (Psychotic- none) Mood disorder -Depression Neurotic disorder -OCD (Personality disorder- none)
What is the management for anorexia? (3)
Pharmacological:
Fluoxetine
Feeding
Psychological:
Family therapy
Individual therapy eg CBT
Education
Nutritional education can challenge over valued ideas
What are the criteria for hospitalisation in anorexics? (3)
Extremely rapid or excessive weight loss Severe electrolyte imbalance Serious physiological complications Cardiac complications Marked change in mental status Psychosis or risk of suicide Failure of outpatient treatment
What is the main risk of re-feeding and how can it be avoided? (3)
Risk of cardiac decompensation
- Myocardium cannot withstand stress of increased metabolic demand
- Symptoms: excessive bloating, oedema and CCF
Minimise risk:
- Measure U&Es and correct imbalance before feeding
- Recheck every 3 days for first 7 days and then weekly
- Increase caloric intake slowly by 200-300kcal every 3-5 days until sustained weight gain of 1-2lb/week
- Monitor regularly for tachycardia or oedema.
What is the prognosis for anorexia? (2)
Untreated – 10-15% mortality Treated – rule of thirds 1/3 full recovery 1/3 partial recovery 1/3 chronic problems
Name 3 poor prognostic features for anorexia. (3)
Late age of onset Bulimic features Poor parental relationships Males Excessive weight loss Anxiety when eating with others
What is bulimia nervosa? (2)
Characterised by recurrent episodes of binge eating, with compensatory behaviours and overvalued ideas about “ideal” body shape and weight.
Often may have history of anorexia nervosa or obesity and body weight may be normal.
What are the diagnostic criteria for bulimia nervosa? (3)
Persistent preoccupation with eating
Irresistible craving for food
“Binges” – episodes of overeating
Attempts to counter the fattening effects of food
Self-induced vomiting, purgatives, starvation, use of drugs
Morbid dread of fatness with imposed low weight threshold.
What are the differentials for bulimia? (3)
Organic: -Upper GI disorder -Brain tumour -Drug related increased appetite Psychotic - none Mood -Depressive disorder Neurotic -OCD Personality disorder
What is the management for bulimia? (3)
Pharmacological
SSRIs – Fluoxetine
Psychological
CBT best evidence
Guided self help
Interpersonal psychotherapy
What are the SCOFF questions? (5)
Screening tool for eating disorders in primary care
2 yes answers indicates need for detailed history
Do you make yourself Sick when you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than One stone in a 3 month period?
Do you believe yourself to be too Fat when others say you are too thin?
Would you say that Food dominates your life?
Name 3 complications of anorexia. (3)
Osteoporosis cardiac arrhythmias Renal failure Pancreatitis Hepatitis Seizures Peripheral neuropathies Suicide
