Psychiatry in GI

Question 1

What is a globus sensation and what can cause it?

Answer 1

Sensation of a lump in the throat.

Causes: Foreign body, GORD, Pharyngeal pouch, cancer, pollen/oral allergy.

Question 2

What is globus?

Answer 2

Diagnosis of exclusion for globus sensation (functional)

Experienced with intense emotional expirience/nerveousness

Question 3

How is globus managed?

Answer 3

Reassurance
Stop smoking
Antacid treatment
Refer to Speech and language
Stress treatment

Question 4

What is functional dysphagia?

Answer 4

Sensation of solid or food sticking on the way down oesophagus (diagnosis of exclusion)

Question 5

How is functional dysphagia managed?

Answer 5

Reassurance
Dietary avoidance including food which triggers dysphagia
Carefully chewing food.

Question 6

What are some psychotic symptoms in GI and how are they managed?

Answer 6

Belief of poisoning 
Dead gut
Tracking device in bowel
Olfactory hallucinations. 
Go with their story/open questions and refer to psychiatry as it can be caused by lots of different causes. (Mood disorders, Schizophrenia, drug induced, organic (Dementia, delerium, brain tumours)

Question 7

What is the criteria for IBS diagnosis?

Answer 7

Abdominal pain or discomfort that is:
- relieved by daefication
- associated with altered bowel frequency or stool form
AND at least two of the following:
1) Altered stool passage (straining, urgency, incomplete evaculation)
2) abdominal bloating, tenderness, distention, hardness
3) Symptoms made worse by eating
4) Passage of mucus
Symptoms for at least 6 months

Question 8

What are common stimuli for IBS?

Answer 8

Acute gasteroenteritis

Emotional stress or abuse

Question 9

What symptoms are seen in IDB but NOT is IBS?

Answer 9

Ulceration of bowel
Bleeding PR/dark stool
Increased risk of chron’s, UC or colon cancer

Question 10

What is the typical demographic for IBS?

Answer 10

Female, western, 20-30s

Changes with menstruation.

Question 11

What percentage of IBS is linked to trauma in the past?

Answer 11

30-40% (physical/sexual abuse, neglect, bereavement)

Question 12

What is the management for IBS?

Answer 12

Diet modifications (low FODMAP diet)
Exercise
Reduce stress
Medication
Antispasmodics, laxatives, antimotility agents, low dose antidepressants
STOP opioid analgesics.
Psychological treatment eg CBT (common comorbidites include depression)

Question 13

Medically unexplained symptoms accounts for ~20% of GP appointments. What percentage of these people have an underlying psychiatric disorder?

Answer 13

30% (10-80%)

Question 14

What is the management for medically unexplained symptoms?

Answer 14

Good communication 
Take patient seriously
Don't over simplify to one life event
Reassure that this is common but don't normalise.
Don't over investigate

Question 15

Somethings we see can make us feel sick, ill or funny. Which part of the brain is interpreting this?

Answer 15

Visual cortex and Amygdala

Question 16

What is a Malingering disorder?

Answer 16

Making up or exaggerating symptoms for external gain (court case, aviod work, increase benefits, access drugs)

Question 17

What is a Factitious disorder?

Answer 17

Making up or exaggerating symptoms to occupy the sick role- not for purpose of secondary gain.
Want medication, oer investigation so they feel better. Common in women with chronic pelvic pain

Question 18

What are the criteria for diagnosis of anorexia nervosa?

Answer 18

1) Significant weight loss (BMI<17.5)
2) Weight loss is self induced
3) Core psychopathology (fear of fattness, slimness represents success and control, body image distortion)
4) Widespread endocrine abnormality (Amenorrhea, osteoporosis, arrhythmias, decrease Na,K, Mg, PO4, Insulina dn glucose, thyroid. Elevated Cortisol/cholesterol

Question 19

What is the difference between the restricting and binge eating/purging anorexia nervosa?

Answer 19

Restricting- no evidence of binge eating and purging

Binge eating and purging- either or both present.

Question 20

What is Bulimia Nervosa?

Answer 20

COre psychopathology identical to anorexia.
Atemts to restrict intake fail =? binges
Low/normal/increased weight
No endocrine abnormalities
30% past history of annorexia.

Question 21

What are the systemic signs of bulimia Nervosa?

Answer 21

Russels sign- calices on knuckles

Bad teeth from acid attack.

Question 22

What percentage of anorexia nervosa patients have additional psychiatric symptoms and what are these?

Answer 22

80%
1) Depressive symptoms
Low mood, low energy, social withdrawal, insomnia, concentration difficulties
2) Obsessive compulsive symptoms: food, cleaning
3) Personality disorder

Question 23

Prevalence of anorexia and bulimia in young women/adolecents?

Answer 23

Anorecia =1%

Bulimia =3%

Question 24

What are the causes of eating disorders?

Answer 24

Socio-cultural pressures
Family dysfunction
Personal vunrabilit factors- low self esteem
Conflicts in sexual maturity- sexual abuse
Biological vunerability- 7% have an effected 1st degree relative

Question 25

What is the treatment for eating disorders?

Answer 25

Weight gain: obsessional features and depression
Establish a therapeutic alliance: self esteem, perfectionism and alternative strategies for stress.
Psychological interventions eg CBT

Question 26

What are the indications for in patient treatment of eating disorders?

Answer 26

High suicidicity
Chronicty >5 years
Comorbidity- OCD or depression
Family dysfunction 
Social isolation 
Failure of out patient treatment.

Question 27

What drugs can be used in eating disorders?

Answer 27

Antidepressants (weight gain side effect) Fluoxetine 60mg

Antipsychotics have NO impact.

Question 28

What are the outcomes for eating disorders?

Answer 28

50% return to normal weight
40% develop normal eating behaviour
Mortality is 20% after 20 years of illness 
Suicide accounts for 50% of deaths. 
Earlier onset => worse outcome