PSYCH 2: Personality Disorders, Delusional Disorders, Eating Disorders, Unexplained Symptoms

Question 1

What is the difference between personality traits and personality disorder?

Answer 1

Personality traits = fixed pattern of behaviour, ways of interacting w/environment. Cause no sig. distress or impaired function

Personality disorders = cause significant distress and/or impaired function, person unaware of disorder (lack insight)

Question 2

What are the 3 clusters of personality disorders and what are included within them?

Answer 2

Cluster A = ODD
- paranoid (distrust, projection)
- schizoid (voluntary social isolation, comfortable alone)
- schizotypal (odd beliefs, magical thinking but not delusions)

Cluster B = WILD
- antisocial (law breaking etc., need to have evidence of CD before 15yo)
- borderline/EUPD (unstable personal relationships, black and white thinking/splitting, self-harm)
- histrionic (enjoy attention, promiscuous, exoctic clothes etc.)
- narcissistic (grandiosity, lack of empathy, overreaction to criticism)

Cluster C = ANXIOUS
- avoidant (feel inadequate, afraid of not being liked)
- obsessive-compulsive (order and control, to do lists, behaviours they engage in help them achieve their goals)
- dependent (clingy, low self-esteem, depend on others etc.)

Question 3

What is the treatment of borderline personality disorder/EUPD?

Answer 3

Dialectical behaviour therapy (form of CBT) designed to treat chronic suicidality is now gold standard.

Discuss opposing view, patient and therapist meet weekly for 1-2yrs and discuss ways to look at world w/diff. perspective.

Question 4

What are different types of delusions?

Answer 4

Persecutory - going to be hurt
Somatic - tactile/feeling based
Grandiose - big ideas
Delusion of reference - after seeing something specific and relating it to themselves
Erotomaniac - thinks someone’s in love with them
Delusion of control - body or thoughts being controlled by something else

Question 5

What is Capgras delusion?

Answer 5

Friend, spouse, parent or another close family member or pet has been replaced by an identical imposter

NOTE: CAPgras (imposter wears a cap to hide himself/herself)

Question 6

What is a Fregoli delusion?

Answer 6

Different people are in fact a single person who changes appearance or is in disguise.

Often related to a brain lesion.

NOTE: F for faces (i.e. different faces = different masks = 1 person w/different faces)

Question 7

What is a Cotard delusion?

Answer 7

person is dead, does not exist, is putrefying and/or has lost blood and internal organs

nihilistic delusion, can refuse to eat due to belief of immortality so at risk of starvation

Question 8

What is an Ekbom delusion?

Answer 8

aka delusional parasitosis

Infested w/living or non-living pathogens like parasites, insects or bugs when no manifestation present

Tactile hallucinations known as formication.

Morgellons is subtype of this condition where individuals believe they have sores containing harmful strings/fibres

Question 9

What is anorexia nervosa?

Answer 9

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.

Question 10

Under what BMI do you have to hospitalise a patient?

Answer 10

<15 - increased mortality from malnutrition

Question 11

What are physiological effects of anorexia?

Answer 11

ENDOCRINE:
- amenorrhoea = functional hypothalamic amenorrhoea due to low caloric intake and generalised stress

ELECTROLYTES:
- hyponatraemia
- reduced GFR
- low creatinine
- hypokalaemia (due to purging)

MSK:
- bone density loss
- osteopenia -> osteoporosis -> bone fractures

HAEM:
- BM suppression -> pancytopenia

Question 12

How is anorexia investigated and how is it treated?

Answer 12

EXAMINATION FINDINGS = low BMI, bradycardia, hypotension, xerosis = dry, scaly skin, hair loss, lanugo hair growth

Rx = nutritional rehabilitation - structured meal w/observation and daily calorie goals + psychotherapy + SSRIs/SNRIs (olanzapine is often used)

Question 13

What is refeeding syndrome?

Answer 13

Low PO4 from poor nutrition -> feeding gives glucose -> insulin release -> futher decrease in PO4 from cellular uptake to make ATP -> lack of ATP leads to cardiac and resp failure

Most fatalities are cardiac - HF and arrhythmia

Hallmark = hypophosphatemia

Hence need slow refeeding

Question 14

What is bulimia nervosa?

Answer 14

Two types of behaviour:

BINGE-EATING = consuming massive amounts of calories in a short timeframe

COMPENSATION = inappropriate compensatory behaviours e.g. vomiting, laxatives, diuretics, excessive exercise etc.

Behaviour has to occur at least 1x/week for 3 months

Low urinary chloride = tell-tale sign

Question 15

How is bulimia investigated and how is it treated?

Answer 15

FINDINGS = parotid gland swelling/hypertrophy dubbed “sialadenosis”, increased serum amylase, erosion of dental enamel, Russells sign

Rx = nutritional rehabilitation + psychotherapy + SSRIs

Question 16

What is binge-eating disorder?

Answer 16

Compulsive overeating excessively large amounts of food

Feel lack of control + shame and embarrassment

Lack compensation behaviour hence not bulimia - high risk of T2DM

Rx = psychotherapy 1st line or CBT (RCT shows more effective than meds)

If meds to be considered = lisdexamfetamine (ADHD stimulant) and topiramate (seizure med)

Question 17

What is somatisation?

Answer 17

physical sx unexplained by a medical disease

Question 18

How is somatisation managed?

Answer 18

Do not challenge belief that symptoms are medical

Regular visits w/same physician to avoid different doctors reordering same tests.

Reassure patients that serious medical diseases are ruled out.

Set goals of functional improvement - mini goals

Psychotherapy

Question 19

What is somatic symptom disorder?

Answer 19

Somatic symptoms that cause distress

Persistent thoughts about seriousness of the symptoms cause anxiety

> 6mths

Sx are unintentional, motivation is unintentional

Question 20

What is illness anxiety disorder?

Answer 20

aka hypochondriasis

Preoccupation w/having undiagnosed illness w/mild or no somatic sx - anxiety about health w/ excessive health-related behaviours e.g. repeatedly checking HR or moles

Question 21

What is conversion disorder?

Answer 21

functional neurologic sx disorder

can be assoc. w/sudden onset following stressor

normal neurologic workup - classic feature = positive findings incompatible w/disease

la belle indifference can also be seen (not fussed by sx)

Question 22

What is factitious disorder?

Answer 22

On-self = Munchausen

Falsified medical or psychiatric sx done consciously out of desire for attention.

Pt might feign illness or may aggravate genuine illness, often willing to for tests/surgeries

Done for primary (internal) gain from illness -> pt feels better in sick roles e.g. if afraid of work or to be alone, feels better/happier in hospital setting

RFs = female gender, unmarried, prior or current healthcare worker

Question 23

What is munchausen by proxy?

Answer 23

Falsified medical sx by caregiver often a parent of sick child or caretaker of elderly

Question 24

What is malingering?

Answer 24

Consciously falsified medical symptoms​

Done for secondary (external) gain - allows patient to miss work but still get paid or obtain workman’s compensation​

Often involved musculoskeletal symptoms (easier to fake)​

Self-limited, will end as soon as the secondary gain is achieved VS Munchausen which often persists​