Somatisation and eating disorders Flashcards
What is health anxiety
Excessive health-related concerns (e.g. ruminations on having an illness, suggestibility if one reads or hears about a disease, unrealistic fear of infection)
Somatic perceptions (eg preoccupation with bodily sensations or functioning)
Behaviours (eg repeated reassurance seeking, avoidance of medications or medical personnel)
What is somatisation disorder
process by which “psychological distress is expressed through physical symptoms and subsequent medical help-seeking”
There must be a history of at least 2 years complaints of multiple and variable physical symptoms that cannot be explained by any detectable physical disorder
Preoccupation with symptoms causes persistent distress
persistent refusal to accept medical reassurance
There must be a number of symptoms from at least 2 of the following systems:
GI Symptoms: Abdominal pain, nausea, feeling bloated, bad taste in mouth, complaints of vomiting, complaints of frequent loose bowel motions
Cardiovascular: breathlessness without exertion, chest pains
GU symptoms: dysuria, unpleasant sensation around the genitals, complaints of unusual or copious vaginal discharge
Skin and pain complaints: blotchiness, discoloration, pain in limbs, unpleasant numbness or tingling sensation
What is hypochondriasis
persistent belief, of at least 6 months, of the presence of a maximum of two serious physical diseases (of which at least one must be specifically named by the patient)
persistent preoccupation with a presumed deformity or disfigurement (body dysmorphic disorder)
Preoccupation with the belief and the symptoms causes persistent distress or interference with personal functioning in daily living, and leads the patient to seek medical treatment or investigation
Persistent refusal to accept medical reassurance that there is no physical cause for the symptoms or physical abnormality
What is factitious disorder?
Munchausen’s
Patient feigns or exaggerates symptoms for no obvious reason
Patient may even inflict self-harm in order to produce symptoms or signs
Internal motivation with aim of adopting the sick role
Munchausen syndrome by proxy - the patient imposes symptoms to other individuals (e.g. a child)
What is malingering
Conscious manufacturing or exaggerating of symptoms for a secondary gain e.g. benefits, housing, other than assuming the sick role
Epidemiology of somatisation
The female-to-male ratio has been estimated to be 10:1 for somatization disorder, from 2:1 to 5:1 for conversion disorder and from 2:1 for pain disorder.
Other epidemiology is hard to estimate
Normal illness behaviors
Adopt sick role
Expected to seek help
Expected to co-operate with treatment
Expected to wanting to get better
Abnormal illness behaviors
Taking too many tablets and using too many aids
Illness behavior continuing beyond appropriate timescale
Not wanting to get better
Denial of the problem
Not wanting to get medical advice
Going too doctors too often
3 types of health anxiety
Cognitive type (awareness and fear of disease) Somatising type (high symptom awareness and bodily occupation) Behavioral type (high disease conviction and avoidance)
Aetiology of health anxiety
Predisposing factors FH of OCD Family members with health anxiety Somatisation disorder among relatives Early life trauma (sexual trauma, violence)
Precipitating factors
Significant illness of a loved one
Personal experience of previous illness - misinterpret body signs
Perpetuating factors
Increase sensitivity in certain brain area (prefrontal cortex, anterior cingulate)
Somatosensory amplification (paying too much detail on minor body sensations)
Differentials for medically unexplained symptoms, and somatisation
Depression and anxiety disorders may present with somatic complaints
Personality disorders may complicate evaluation
Initial presentation of some organic syndromes:
MS, SLE, porphyrias
Dissociative disorders (the presence unconsciously produced symptoms that affect voluntary sensory or motor functions, suggesting a medical or neurological disorder)
psychosis or schizophrenia can also present with hypochondriacal delusion (very rarely)
What is dissociative disorder
Classically a traumatic event leads to a disruption of the usually integrated functions of consciousness, memory, identity or perception.
Patient may deny the impact of the traumatic event.
Presentation is variable:
amnesia
fugue (sudden, unexpected journey that may last a few months, together with memory loss, confusion about personal identity)
stupor
trance or possession disorders
motor disorders (like the case of Anna O. - paralysis of limbs)
anaesthesia/sensory loss
convulsions (“pseudo-seizures” or “psychogenic non-epileptic seizure”)
What is the role of investigations in medically unexplained symptoms
Limited.
Minimise unneccessary tests and treatments, because over-investigation/medication will reinforce anxiety.
But definitely perform the reasonable investigations
Bio-psychosocial approach to managing medically unexplained symptoms
Evidence for long-term efficacy is weak
SNRIs. SSRIs may be useful
In hypochondriacal delusion - antipsychotic
Avoid routine benzodiazepines
CBT (modify dysfunctional thoughts in response to symptoms and decrease problematic behaviors such as reassurance seeking and avoidance)
Psychoeducation
Encourage normal function (do not activities normal function)
Involve social network to improve emotional support
Prognosis of somatisation and hypochondriasis
Most respond well to medication, psychotherapy or both.
Anxiety and depression usually effectively treated with medication
May affect functioning if + chronic distress:
Mental health problems
Severe symptoms
Aetiology of eating disorder
Genetic
Neuro/endocrine changes (disturbance of hypothalamic function, increased serotonin levels, brain atrophy)
Many psychological factors:
Perfectionism
Low self-esteem (weight loss as a sense of achievement)
Sexual development (early development)
History of abuse (sexual, physical, psychological, neglect)
Personality disorder
Parental overprotection?
Family enmeshment
When becoming an independent sexual being
Aetiology of bulimia nervosa
Changes in serotonin levels
Less of a genetic factor
Low self esteem
History of abuse (sexual, physical, psychological, neglect)
history of self harm
impulsive personality traits
personality disorder
High value placed on food and eating behaviour (either personally or within the family culture)
History of being over-weight (factual or perceived)
Exposure to culture of dieting
Family/ social culture of categorizing food as good or bad, healthy or naughty treat
important questions in a possible eating disorder
EATING BEHAVIOR
Methods of weight loss: diet, weight control (exercise, vomiting, medications)
Typical day, intake (fluid and solids)
Relationship with body image (past and present)
Any binge eating and/or compensatory behaviours
PMH Menstrual history (female) / sexual dysfunction (male +/- female) Complications of starvation Digestive complications Known physical illness
Past abuse, physical, sexual, neglect. Context to this
Bullying, nature of this
Loss of loved one
Major change in situation, home, school, work etc
Effect of eating behaviour and associated weight loss on elements of social life:
Education
Career
Relationships
Home life
Socializing
Hobbies/interests
Co-morbidity:
Anxiety
Depression
Self-harm
Physical consequences of eating disorders
Skin and hair thin and brittle. Lanugo hair to insulate heat (on chest, arms, back, face).
BP drops
Pulse declines
Increased risk of arrhythmias
Risk of heart failure
Muscle wastage/cramp (assess with sit up/squat test)
It likely means that the heart is small and wasted
Reduced sex drive
Amenorrhoea in females
Low testosterone in males
Often function returns with weight restoration
hypothermia
infections
metabolic disturbance (hypoglycaemia, hyponatraemia, hypokalemia, vitamin deficiency, hypercholesterolaemia, deranged liver function)
haematological (iron deficiency anaemia, leucopenia and thrombocytopenia)
Psychological consequences of eating disorders
Thinking is difficult (eg. decisions) Poor concentration Obsessions Unspontaneous Interest becomes around food (eg. cooking) Irritated affect Flattened mood
Physical complications of bulimia nervosa
Dehydration (cold extremities)
Electrolyte imbalance (may cause seizures or arrhythmias)
Muscle paralysis
Tooth decay
Hoarse voice
Bleeding from mouth or throat
Swollen parotid glands
Hypokalaemia can cause arrhythmias and be fatal
Swollen stomach
Stomach pain
Constipation
Delayed gastric emptying
Russel sign on hand (callosities of knuckles)
Swollen feet and ankles
Psychological consequences of bulimia nervosa
Poor concentration
Irritability
DSM5 criteria of anorexia nervosa
BMI <17.5
Persistent restriction of energy intake leading to significantly low body weight.
Either an intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain
Disturbance in the way one’s body weight or shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of current low body weight
DSM5 criteria of bulimia nervosa
Recurrent episodes of binge eating, characterised by eating more than most would in a certain amount of time e.g. 2 hours or a sense of lack of control during an eating episode, unable to stop or to switch behaviour
Recurrent inappropriate compensatory behaviour:as self-induced vomiting
misuse of laxatives, diuretics, or other medications
fasting
excessive exercise
These at least once a week for 1 month
Self-evaluation by body shape and weight.
The disturbance does not occur exclusively during episodes of anorexia nervosa
Differentals of eating disorders
Hyperthyroidism Depression (anhedonia) OCD Body dysmorphic disorder Psychosis (eg. food is poisoned)
Comorbidities with eating disorders
Alcohol misuse
Illicit substances misuse
Self-harm
Prevalence of eating disorders
Prevalence of Anorexia Nervosa 0.6-1%
Prevalence of Bulimia Nervosa ~1%
Bio treatment of anorexia nervosa (tip - lot of investigations)
WEIGHT restoration!
Regular weight and blood monitoring:
BMI >16: FBC, U&E, LFT & glucose
BMI <15: above and also phosphate, magnesium, calcium, creatinine kinase, zinc, B12 and folate
Dexa bone density scan if indicated
ECG, looking for QTc prolongation, rate<50, heart block or other arrhythmias
Admit to general ward if really out of range (eg. BMI <13)
Psychological and social approach to anorexia nervosa
motivational interviewing CBT Interpersonal therapy Mindfullness Arts psychotherapy, such as dance movement, art and drama
Family therapy if under 18
Therapeutic relationship is the most important factor
Advise to inform a loved one for extra support
Carer support
Increased flexibility with and participation in social plans and lifestyle goals such as hobbies or vocation related goals
Biological approach to bulimia nervosa
SSRI most commonly fluoxetine
Advise to stop laxative use
Advise cessation of excessive alcohol, planned and controlled reduction if physical dependence has occurred
Regular weight monitoring
Regular blood monitoring, frequency depends on severity.
Most essential blood test is U&E, particularly to check for hypokalaemia, which can lead to severe effects on the heart, nerves and muscles
Psychological and social approach to bulimia nervosa
Psychoeducation for coping
Specialist services doing 20 therapies of CBT (NICE)
IPT
Compassion focused therapy
Arts psychotherapy (dance, art, drama)
Therapeutic relationship is most important
Dietician input for psychoeducation on balanced eating
Advise to inform a loved one for extra support
Carer support
Focus on encouraging regular intake, cessation of restrict, binge, purge cycle
Increased involvement with social plans and lifestyle goals such as hobbies or vocation related goals
Prognosis of anorexia nervosa
Slow recovery rates
30% take 3 years
30% take 6 years
Recovery unlikely after 15 years
After 10 years, 50% recovered, 10% mortality (1/3 due to suicide), 40% with ongoing eating problem (many cross-over to BN)
What are poor prognostic indicators in anorexia nervosa
very low weight bulimic features family difficulties personality difficulties longer illness duration
Prognosis of bulimia nervosa
70% recover in 10 years
1% mortality
Poor prognostic indicators:
low body weight
comorbid depression
