Psych

Question 1

Generalized Anxiety Disorder (GAD) definition, sx, criteria, tx

Answer 1

*5-9% lifetime prevalence, women > men (2:1)
*1/3 of risk for developing GAD is genetic

*sxs begin in childhood, median onset 30yo
*physical complaints (fatigue, muscle tension)

criteria
*excessive anxiety/worry (apprehensive expectation) about various events/activities lasting ≥6MO
*difficulty controlling the worry
Associated w/ 3+SXS: restlessness/feeling keyed up, fatigue, impaired concentration, irritability, muscle tension, insomnia
*only 1 symptom required in children

tx
Psychotherapy + pharmacotherapy = most effective
*CBT
*SSRIs (sertraline, citalopram), SNRIs (venlafaxine)
*+/- short-term BDZ course or augmentation w/ buspirone

Question 2

Panic Disorder definition, criteria, tx

Answer 2

*4% lifetime prevalence, median onset 20-24yo
*MC in females, 2:1
*up to 65% have comorbid MDD

RF: first-degree relative, childhood abuse

criteria
*2+ unexpected panic attacks w/o an identifiable trigger (4+SXS of panic attack)
*1+SXS for ≥1MO following attack
*concern about future attacks/consequences (e.g., losing control, heart attack, going crazy)
*significant maladaptive change in behavior (e.g., avoidance behavior)

tx
CBT + pharmacotherapy = most effective
*SSRIs first line (sertraline, citalopram, escitalopram)
*SNRIs (venlafaxine) also efficacious
*TCAs (clomipramine, imipramine) if above not effective
*BDZs until other medications reach full efficacy

Question 3

Specific Phobias definition, sx, criteria, tx

Answer 3

Specific Phobia: intense fear of object/situation leading to avoidance &/or anxiety endurance

*MC psychiatric d/o in women, 2nd MC psychiatric d/o in men (substance abuse is first)
*>10% lifetime prevalence, MC in women (2:1)
*mean onset 10yo

criteria
*≥6MO of persistent, excessive fear elicited by a specific situation or object which is out of proportion to any actual danger/threat
*exposure triggers IMMEDIATE response
*avoided when possible or tolerated w/ intense anxiety

Subtypes:
*animals (spiders, dogs, mice)
*situational (airplanes, elevators)
*natural environment (heights, thunder)
*blood-injection injury (needles, blood)

tx
*CBT TOC (exposure & desensitization therapy)
*short term BDZs or BBs in some pts

Question 4

Agoraphobia defintion, criteria, tx

Answer 4

*intense fear of being in public spaces where escape or obtaining help may be difficult
*avoidance behaviors may become as extreme as complete confinement to home
*often develops w/ panic disorder
*onset usually before 35yo

Risk Factors: genetic (60% heritability), onset often follows traumatic event

criteria
*intense fear/anxiety of 2+ SITUATIONS d/t concerns of difficulty escaping, obtaining help in case of panic, or other embarrassing sxs (e.g., falling/incontinence in elderly)
*outside home alone
*open spaces (e.g., bridges)
*enclosed spaces (e.g., stores)
*public transportation (e.g., trains, buses)
*crowds/lines
*agoraphobic situations always provoke fear/anxiety that is out of proportion to actual danger posed
*agoraphobic situations are avoided, require a companion, or endured w/ fear/anxiety
*lasting ≥6MO

tx: CBT + SSRIs

Question 5

Social Anxiety Disorder (Social Phobia) definition, criteria, tx

Answer 5

*fear of scrutiny or acting in embarrassing way
*phobic stimulus related to social scrutiny & negative evaluation

*may develop d/t trauma encounter w/ stimulus
*avoidance results in functional impairment
*median onset 13yo, M = W

criteria
*fear/anxiety about 1+ SOCIAL SITUATIONS in which individual is exposed to possible scrutiny by others, lasting ≥6MO
*fears he/she will act in a way or show anxiety sxs that will be negatively evaluated (humiliating, embarrassing, rejection, offend others)
*social situation almost always provokes fear or anxiety that is out of proportion to actual threat posed
*social situations avoided or endured w/ intense fear/anxiety

tx
*CBT TOC
*SSRIs (sertraline, fluoxetine) or SNRIs (venlafaxine) first line pharmacotherapy if needed for debilitating symptoms
*BDZs (clonazepam, lorazepam) can be used
*beta blockers (propranolol) for performance-only/public speaking anxiety

Question 6

Selective Mutism definition, criteria, tx

Answer 6

*failure to speak in specific situations despite intact ability to comprehend/use language (rare)

*symptom-onset typically during childhood
*majority of pts suffer from anxiety (social)
*may remain silent or whisper

criteria
*consistent failure to speak in select social situations where speaking is expected (e.g., school) despite speaking in other situations lasting ≥1MO (not limited to first month of school)
*NOT attributable to language difficulty or communication disorder
*interferes w/ educational/occupational achievement or social communication

tx
*psychotherapy (CBT, family therapy)
*Medications: SSRIs (esp. w/ comorbid social anxiety disorder)

Question 7

Separation Anxiety Disorder definition, criteria, tx

Answer 7

Stranger Anxiety: begins ~6mo, peaks ~9mo

Separation Anxiety: emerges ~1y, peaks ~18mo
*considered pathological when anxiety becomes extreme or developmentally inappropriate
*may be preceded by stressful life event

criteria
*fear/anxiety/avoidance lasting ≥4WKS (children/adolescents) or ≥6MO (adults) that causes distress or impairment in important areas of functioning (social, academic, occupational, etc.)

FEAR/ANXIETY CONCERNING SEPARATION (3+):
*excessive distress when anticipating/experiencing separation from attachment figure
*worry about loss of/harm to attachment figure (illness, injury, disaster, death)
*worry about experiencing event causing separation (getting lost, kidnapped, accident, illness)
*reluctance/refusal to leave home, attend school or work, or go out d/t fear of separation
*fear of/reluctance about being alone
*reluctance/refusal to sleep alone/away from home
*nightmares about separation
*repeated physical complaints during separation (HA, N/V, stomachache, etc.)

tx
*psychotherapy (CBT, family therapy)
*medications: SSRIs can be effective as adjunct to therapy

Question 8

Conduct Disorder (CD) definition, criteria, tx

Answer 8

*most serious disruptive behaviors that violate the rights of other humans/animals
*inflict cruelty/harm through physical/sexual violence, lack remorse & empathy for victims

*9% lifetime prevalence, males > females
*high incidence of comorbid ADHD & ODD
*associated w/ antisocial personality disorder

criteria
Persistent pattern of violating basic rights of others/societal norms, manifested by 3+SXS in last 12MO AND 1+SXS in last 6MO:
AGGRESSION TO PEOPLE/ANIMALS: bullies/threatens/intimidates others, initiates physical fights, used a weapon w/ potential to seriously harm others (e.g., bat knife), physical cruelty to people or animals, robbery, rape
PROPERTY DESTRUCTION: fire setting, deliberately destroys another’s property
DECEITFULNESS/THEFT: burglary, lies to obtain goods/favors (i.e., “cons” others)
SERIOUS RULE VIOLATION: stays out late at night, runs away from home, truant from school before 13yo
*if ≥18yo, criteria not met for Antisocial Personality Disorder

Specifiers:
*Childhood-onset type: begins before 10yo
*Adolescent-onset type: begins after 10yo

tx
*multimodal: behavior modification, family & community involvement
*Parent Management Training (PMT) can help w/ setting limits & enforcing consistent rules

*medications used to target comorbid symptoms & aggression (SSRIs, guanfacine, propranolol, mood stabilizers, antipsychotics)

Question 9

Oppositional Defiant Disorder (ODD) definition, criteria, tx

Answer 9

*maladaptive pattern of irritability/anger, defiance, or vindictiveness causing dysfunction or distress in patient/those affected

*3% prevalence
*onset usually in preschool years
*seen more often in boys before adolescence
*↑ comorbidity substance use & ADHD
*often precedes CD, but most don’t develop CD

criteria
4+SXS from any of the following categories, occurring w/ 1+ non-sibling, lasting ≥6MO:

ANGRY/IRRITABLE: loses temper frequently, is touchy or easily annoyed, often angry/resentful
ARGUMENTATIVE/DEFIANT: breaks rules, blames others, argues w/ authority figures, deliberately annoys others
VINDICTIVE: has been spiteful/vindictive ≥2x in past 6mo

tx
*behavior modification, conflict management training, improving problem-solving skills
*Parent Management Training (PMT) can help w/ setting limits & enforcing consistent rules
*medications for comorbid conditions (ADHD)

Question 10

Intermittent Explosive Disorder definition, sx, criteria, tx

Answer 10

*men > women
*onset usually in late childhood or adolescence

sx
HX: injury not adequately explained or inconsistent w/ hx given
*bruises, lacerations, soft tissue swelling, dislocations/fx, spiral fx
*burns (doughnut-shaped, stocking-glove, symmetrically round)
*bruises/injuries w/ regular patterns on face, back, buttocks, thighs
*internal hemorrhages, abdominal injuries, bite marks, injury w/ shape of instrument used

Other manifestations: anxiety, aggression/violence, PTSD, depression/suicide, substance abuse, poor self-esteem, dissociative disorders, paranoid ideation, FTT

DX: careful hx obtained & documented from all caregivers separately, complete head-to-toe PE

*Hx from child, if <14y 🡪 forensically informed manner w/o asking leading questions
*Rape kit within 72h of assault
*Labs to assess for bleeding disorders

Radiographic skeletal survey: all children w/ suspicious injuries up to 2y

CT/MRI: all children <6mo, children >1y if neuro changes

tx
FIRST: care for any immediate injuries

Providers required to report any suspicions of abuse to CPS; report to law enforcement for suspected physical/sexual abuse
Involve social worker
Safe disposition plan prior to DC

Question 11

Suicide about, RF, and tx

Answer 11

Women attempt more
Men more successful

Evaluation: includes assessment of ideation, method, plan, & intent
- PHQ-9
- Beck Hopelessness Scale

Risk Factors: “SAD PERSONS”
S – sex (male)
A – age: <19 or >60
D – depression

P – previous attempt
E – ETOH/substance abuse
R – rational thinking loss
S – suicide in family
O – organized plan
N – no spouse
S – sickness

tx
- hospitalization
- antidepressants
- psychotherapy

Question 12

Attention-Deficit- Hyperactivity Disorder (ADHD) definition, types and associations

Answer 12

Characterized by persistent inattention, hyperactivity, & impulsivity inconsistent w/ patient’s developmental age

3 Subcategories: predominantly inattentive type, predominantly hyperactive/impulsive type, combined type
*5% of children, 2.5% of adults
*Males > females, 2:1
*females present more often w/ inattention

Etiology is multifactorial: first-degree relative, low birth weight, smoking when pregnant, childhood abuse/neglect, neurotoxin/alcohol exposure

Stable through adolescence, many continue to have sxs as adults (inattentive > hyperactive)
*high incidence comorbid ODD, CD, & specific LD

Question 13

Attention-Deficit- Hyperactivity Disorder (ADHD) criteria inattentive vs hyperactive

Answer 13

ONSET BEFORE AGE 12, SXS ≥6MO, IN 2+ SETTINGS

INATTENTIVE (6+):
*no attention to details or careless mistakes
*difficulty sustaining attention
*does not appear to listen when spoken to
*struggles to follow instructions & fails to finish assignments
*unorganized
*avoids/dislikes tasks requiring sustained mental effort
*misplaces/loses things often
*easily distracted
*forgetful

HYPERACTIVE/IMPULSIVE (6+):
*fidgets w/ hands/feet or squirms in chair
*difficulty remaining seated
*runs about/climbs excessively in childhood (extreme restlessness in adults)
*difficulty engaging in activities quietly
*“on the go” or “driven by a motor”
*talks excessively
*blurts out answers before questions completed
*difficulty waiting his/her turn
*interrupts/intrudes on others

Question 14

Attention-Deficit- Hyperactivity Disorder (ADHD) tx

Answer 14

Multimodal: medications most effective for ↓ core sxs, but should be used in conjunction w/ educational & behavioral interventions

Pharmacological:
*First line: stimulants (methylphenidate, dextroamphetamine, etc.)
*Second line: Atomoxetine
*Alpha2-Agonists (clonidine, guanfacine) can be used instead of or as adjunct to stimulants

Nonpharmacological:
*behavior modification techniques & social skills training
*educational interventions (classroom modifications)
*parental psychoeducation

Question 15

Autism Spectrum Disorder (ASD) definition and etiology

Answer 15

Characterized by impairments in social communication/interaction & restrictive, repetitive behaviors/interests
*encompasses spectrum of symptomatology formerly diagnosed as autism, Asperger’s, childhood disintegrative disorder, & pervasive developmental disorder

*1% of population
*4:1 male to female ratio
*typically recognized between 12-24mo, but varies based on severity

Etiology is multifactorial:
*prenatal neurological insults (infection, drugs), advanced paternal age, low birth weight
*15% associated w/ known genetic mutation, Fragile X MC known single gene cause of ASD
*Down Syndrome, Rett Syndrome, & TSC are other genetic causes
*high comorbidity w/ ID, associated w/ epilepsy

Question 16

Autism Spectrum Disorder (ASD) dx criteria

Answer 16

SOCIAL COMMUNICATION/INTERACTION DEFICITS (ALL REQUIRED):
*social-emotional reciprocity deficits
*nonverbal communicative behavior deficits
*developing, maintaining, & understanding relationships deficits

RESTRICTED/REPETITIVE BEHAVIOR/INTERESTS (2+):
*stereotyped/repetitive motor movements, use of objects, or speech (echolalia, idiosyncratic phrases)
*insistence on sameness, inflexible adherence to routines, ritualized verbal/nonverbal behavior
*highly restricted/fixated interests of abnormal intensity
*hyper/hyporeactivity to sensory input or unusual interest in sensory aspects of environment (sounds, textures, pain)

Other signs: failure to develop social relationships, no parental preference over other adults, unusual sensitivity, unusual attachments, savantism (unusual talents)

Question 17

Autism Spectrum Disorder (ASD) tx

Answer 17

Chronic condition, prognosis variable

2 most important predictors of adult outcome: level of intellectual functioning & language impairment

TX for sxs management & improvement of basic social, communicative, & cognitive skills:
*early intervention
*remedial education
*behavioral therapy
*psychoeducation
*low-dose atypical antipsychotic (Risperidone, Aripiprazole) may help reduce disruptive behavior, aggression, & irritability

Question 18

Major Depressive Disorder (MDD) definition

Answer 18

*marked by episodes of depressed mood associated w/ loss of interest in daily activities
*+/- somatic sxs (fatigue, HA, abdominal pain, muscle tension, etc.)

*12% lifetime prevalence worldwide
*onset peaks in 20s, but can be any age
*1.5-2x as prevalent in reproductive ♀︎
*up to 15% of pts eventually die by suicide

RF: adverse childhood events, family hx (2-4x more likely if first-degree relative w/ MDD)

Etiology: HPA overactivity, dysfunctional neuronal connectivity, 5HT, DA, NE, GABA

Question 19

Major Depressive Disorder (MDD) criteria

Answer 19

≥2WKS, 5+SXS *1 symptom must be 1) depressed mood or 2) loss of interest or pleasure (anhedonia)
S sleep (insomnia or hypersomnia)
I interest (loss of interest or pleasure in activities i.e., anhedonia)
G guilt (excessive or inappropriate guilt; feelings of worthlessness)
E energy (loss of energy or fatigue)
C concentration (diminished concentration or indecisiveness)
A appetite (decrease or increase in appetite; weight loss or gain)
P psychomotor agitation/retardation (i.e., restlessness or slowness)
S suicide (recurrent thoughts of death, SI/SA)

Specifiers:
*w/ melancholic features: anhedonia, early morning awakening, depression worse in morning, psychomotor agitation/retardation (i.e., restlessness or slowness), excessive guilt, anorexia
*w/ atypical features: hypersomnia, hyperphagia, mood reactivity (i.e., mood ↑ in response to actual or potential positive events), leaden paralysis (i.e., heavy feeling in limbs, weighed down), rejection sensitivity
*w/ mixed features: ≥3SXS of DIGFAST present during depressive episode
w/ catatonia: catalepsy (immobility), purposeless motor activity, extreme negativism or mutism, bizarre postures, echolalia (esp. responsive to ECT)
*w/ psychotic features: presence of delusions &/or hallucinations
*w/ anxious distress: feeling keyed up/tense, restlessness, concentration difficulty, fear of something bad happening, feelings of loss of control
*w/ peripartum onset: occurs during pregnancy or within 4wks postpartum
*w/ seasonal pattern: relationship of MDE onset w/ time of year (winter MC but can be any season)

Question 20

Major Depressive Disorder (MDD) tx

Answer 20

sychopharmacologic: SSRIs/SNRIs first-line
*evaluate response q3-4wks
*once therapeutic effect achieved, continue ≥6mo

Therapy: CBT
*combo of meds + CBT = most success

Treatment-Resistant: TCAs, MAOIs, atypical APs, stimulants, carbamazepine, ECT

Pharm: should give drug ≥6wks at maximum dose before switching

Question 21

Persistent Depressive Disorder (Dysthymia) defintion, criteria, tx

Answer 21

DSM V combined dysthymia & chronic major depressive disorder into PDD
*criteria for MDD may be continuously present for 2yrs

*2% 12mo prevalence
*more common in women
*onset often in childhood, adolescence, & early adulthood

criteria
*Depressed mood majority of the day on most days lasting ≥2YRS (1y in children/adolescents)
*never been without symptoms >2MO at a time
*never had manic/hypomanic episode

2+SXS:
1) poor appetite or overeating 2) insomnia or hypersomnia
3) low energy or fatigue 4) low self-esteem
5) poor concentration or indecisiveness
6) feelings of hopelessness

tx
*combo treatment w/ psychotherapy & pharmacology more efficacious than either alone

Pharmacotherapy: SSRIs, SNRIs, TCAs, MAOIs
Psychotherapy: interpersonal, cognitive, insight-oriented

Question 22

Disruptive Mood Dysregulation Disorder (DMDD) definition, criteria, tx

Answer 22

*core feature of DMDD is chronic severe, persistent irritability occurring in childhood & adolescence
*irritability: frequent temper outbursts + persistent irritable or angry mood between outbursts

criteria
Occurs ≥3X/WK for ≥12MO + NO PERIOD ≥3MO W/O SXS, PRESENT IN 2+ SETTINGS
*Recurrent temper outbursts manifested verbally (e.g., verbal rages) &/or behaviorally (e.g., physical aggression) that are out of proportion to situation/provocation & inconsistent w/ developmental level
*Mood between outbursts is persistently irritable or angry & observable by others
*Symptoms began BEFORE AGE 10 (not diagnosed before 6yo or after 18yo)

tx
*psychotherapy (parent management training) first line
*medications for symptom control & comorbidities (stimulants, SSRIs, mood stabilizers, second-generation antipsychotics)

Question 23

Premenstrual Dysphoric Disorder (PMDD) definition, criteria, tx

Answer 23

PMS: cluster of physical, behavioral, & mood changes w/ cyclical occurrence during the luteal phase of the menstrual cycle

Premenstrual Dysphoric Disorder (PMDD): severe PMS w/ FUNCTIONAL IMPAIRMENT

*PRESENT week BEFORE MENSES ONSET, IMPROVE after a few days of onset, MINIMAL/ABSENT week AFTER MENSES ENDS

*must be confirmed by recording of AT LEAST 2 CYCLES

criteria
1+SXS from (A) AND 1+SXS from (B) to equal 5+SXS TOTAL
(A) 1+SXS:
*affective lability (e.g., mood swings, suddenly tearful, more sensitive)
*irritability, anger, or increased interpersonal conflict
*depressed mood, feelings of hopelessness, or self-deprecating thoughts
*anxiety, tension, &/or feelings of being keyed up or on edge
(B) 1+SXS:
*decreased interest in usual activities
*subjective concentration difficulty
*lethargy, easily fatigued, or lack of energy
*change in appetite, overeating, or specific cravings
*hypersomnia or insomnia
*feeling overwhelmed or out of control
*physical sxs (breast tenderness/swelling, joint/muscle pain, bloating, weight gain)

tx
*underlying cause must be ruled out w/ TSH, hCG, CBC, FSH

Lifestyle modifications: stress reduction + exercise, limit caffeine, alcohol, cigarettes, & salt, NSAIDs, vitamin B6 & E

*SSRIs first line for emotional sxs w/ dysfunction
*Fluoxetine, Sertraline, Citalopram
*OCPs: drospirenone-containing
*Spironolactone: improves sxs of bloating & tender breasts

Question 24

Anorexia Nervosa definition

Answer 24

LOW WEIGHT + CALORIE INTAKE RESTRICTED

Patients w/ anorexia nervosa are preoccupied w/ their weight, body image, & health; often associated w/ obsessive-compulsive personality traits

2 SUBTYPES:
1) Restricting Type: has not regularly engaged in binge-eating or purging behavior, weight loss achieved through diet, fasting, &/or excessive exercise
2) Binge-Eating/Purging Type: eating binges followed by self-induced vomiting &/or use of laxatives, enemas, or diuretics; some individuals purge after eating small amounts of food w/o binging

*10:1 female to male ratio, 0.4% 12mo prevalence in young females
*BIMODAL ONSET AGE
*13-14 (hormonal influences)
*17-18 (environmental influences)
*↑ in industrialized countries w/ abundant food & thin body ideal
*↑ in sports involving thinness, revealing attire, subjective judging, & weight classes (e.g., running, ballet, wrestling, diving, cheerleading, figure skating)

Question 25

Anorexia Nervosa sx

Answer 25

A) Restriction of energy intake relative to requirements leading to significantly LOW body weight (defined as less than minimally normal/expected)
B) Intense FEAR of gaining weight or becoming fat, or persistent behaviors that PREVENT weight gain
C) Disturbed body image, undue influence of weight or shape on self-evaluation, or denial of seriousness of current low body weight

S/SXS: amenorrhea, cold intolerance/hypothermia, hypotension (esp. orthostasis), bradycardia, arrhythmia, ACS, cardiomyopathy, MVP, constipation, edema, dehydration, peripheral neuropathy, hypothyroidism, osteopenia, osteoporosis

*lanugo (fine, soft body hair usually found on newborn)
*alopecia

+/- Russel’s sign: callouses on the dorsum of the hand from self-induced vomiting

Severity Classification:
*Mild: BMI ≥17kg/m2
*Moderate: BMI 16-16.99kg/m2
*Severe: BMI 15-15.99kg/m2
*Extreme: BMI <15kg/m2

Question 26

Anorexia Nervosa dx

Answer 26

*hyponatremia
*hypochloremic hypokalemic alkalosis
*IF vomiting
*leukopenia, hypothyroidism
*anemia (normocytic, normochromic)
*hypoglycemia, hypercholesterolemia
*transaminitis

↓ FSH/LH, estrogen/testosterone
↑ BUN, growth hormone, cortisol

Other findings: arrhythmias (QT prolongation), osteopenia

Prognosis:
*variable course: compete recovery, fluctuation/relapses, progressive deterioration; most remit within 5y
*5% mortality per decade d/t starvation, suicide, or heart failure
*suicide rate 12/100,000/year

Question 27

Anorexia Nervosa tx

Answer 27

*FOOD IS THE BEST MEDICINE

TX: CBT, family therapy (Maudsley Approach), supervised weight-gain programs

Maudsley Approach: gold standard for treating teenagers
*3 phases: weight restoration, returning control over eating to the adolescent, establishing healthy identity

*SSRIs have not been effective, but may be used for comorbid anxiety or depression
*antipsychotics (Olanzapine) can treat preoccupation w/ weight/food or independently promote weight gain (little evidence)
*some consensus that a premeal anxiolytic (alprazolam) can encourage eating by ↑ anticipatory anxiety
*BUPROPRION CONTRAINDICATED (SEIZURES)

Indications for Supervised Refeeding & Hospitalization: >20-25% below ideal body weight, serious medical or psychiatric complications

*LOOK OUT FOR REFEEDING SYNDROME

Question 28

Bulimia Nervosa definition

Answer 28

NORMAL OR OVERWEIGHT + NO INTAKE RESTRICTION

Involves binge eating combined w/ behaviors intended to counteract weight gain (e.g., vomiting, laxatives, enemas, diuretics, fasting, excessive exercise); ↑ prevalence of borderline personality disorder
*embarrassed by binging, overly concerned w/ weight
*usually maintain NORMAL WEIGHT (may be overweight)

↑ RISK: childhood obesity, early pubertal maturation

*10:1 female to male ratio, 1-1.5% 12mo prevalence in young females
*onset in late adolescence or early adulthood
*high incidence of comorbid mood disorders, anxiety disorders, impulse control disorders, substance use, prior physical/sexual abuse

Question 29

Bulimia Nervosa sx

Answer 29

A) Recurrent episodes of binge eating (requires both):
*eating extreme amount of food within 2h
*lack of control over eating
B) Recurrent inappropriate compensatory behaviors to prevent weight gain (self-induced vomiting, laxative or diuretic misuse, fasting, excessive exercise)
C) ≥1x/wk for ≥3mo
D) Unduly influence of shape/weight over self-evaluation

S/SXS: dental erosions/caries, petechiae, peripheral edema, aspiration
*salivary gland enlargement (sialadenosis)

+/- Russel’s sign: callouses on the dorsum of the hand from self-induced vomiting

Severity Classification: # of compensatory behaviors per week (1-3 mild, 4-7 mod., 8-13 severe, ≥14 extreme)

Question 30

Bulimia Nervosa dx and tx

Answer 30

*hypochloremic hypokalemic alkalosis
*metabolic acidosis (laxative abuse)
*hypernatremia, esophagitis
*altered thyroid hormone
*cortisol homeostasis

↑ bicarb, BUN, amylase

Prognosis:
*chronic, relapsing
*better prognosis than anorexia
*exacerbated during stress
*half recover fully w/ tx
*2% mortality rate per decade
*elevated suicide risk compared to general population

tx
*SSRIs + therapy = first line
*Fluoxetine (60-80mg/d) only FDA-approved medication for bulimia

*nutritional counseling & education
*therapy: CBT (most efficacy), interpersonal psychotherapy, group therapy, family therapy

*BUPROPRION CONTRAINDICATED (SEIZURES)