Yr4 Psychiatry - Lectures Flashcards
Somatic Symptom and Related Disorders
- What is is characterised by?
- Symptoms?
- Changes from DSM-IV Criteria?
Somatic Symptom and Related Disorders
- SSRD characterised by distressed physical symptoms without clear medical explanation.
- Symptoms not intentionally produced and not fully explained by medical conditions.
- Overview of SSRD’s impact and classification under DSM-5.
- Is a new diagnosis in DSM-5.
- It involves physical symptoms with excessive thoughts, emotions, or behaviours related to the symptom.
- Symptoms may or may not have a medical explanation.
- Changes from DSM-IV criteria include eliminating the need for unexplained symptoms and adding psychobehavioral features.
- Previous disorders likely Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, and Pain Disorder are eliminated.
- These changes aim to make SSD more relevant and applicable in primary care settings.
Somatic Symptoms and Related Disorders
- Aetiology?
- Epidemiology?
SSD - Aetiology
- SSD stems from heightened awareness of bodily sensations.
- Individuals interpret these sensations as signs of medical illness.
- Unclear aetiology, but risk factors include childhood neglect, sexual abuse, chaotic lifestyle, alcohol/substance abuse.
- Severe somatisation linked to axis II personality disorders like avoidant, paranoid, self-defeating, and obsessive-compulsive disorder.
- Psychosocial stressors.
Somatic Symptoms and Related Disorders
- Pathophysiology?
- Differentials?
SSD - Pathophysiology
- Pathophysiology of SSD is unclear.
- Autonomic arousal from noradrenergic compounds may cause symptoms like tachycardia, gastric hypermotility, heightened arousal, muscle tension, and pain.
- Genetic component suggested by twin studies, with 7-21% contribution from genetic factors.
- Environmental factors also play a role in SSD. Single nucleotide polymorphisms associated with somatic symptoms in some studies.
Somatic Symptoms and Related Disorders
- Prognosis?
- Complications?
SSD - Prognosis
- Longitudinal studies indicate high chronicity, with up to 90% of SSD cases lasting over 5 years.
- Therapeutic interventions show small to moderate effect sizes based on systematic reviews and meta-analyses.
- Commonly observed outcomes include chronic limitation of general function, significant psychological disability and decreased quality of life.
Somatic Symptoms and Related Disorders
- What does the DSM-5 say?
- 3 Criteria?
- 3 things to specify?
- Mild, Moderate, Severe?
In DSM-5
- Focus on distressing somatic symptoms’ impact on daily functioning in SSD.
- Emphasis on symptoms and their effects rather than absence of medical explanations.
- Changes in duration requirement for SSD diagnosis in DSM-5.
- Reduction in duration criterion for adults and children.
- Removal of specific number of symptoms requirement, focusing on severity.
Illness Anxiety Disorder
- Formerly known as?
- 6 Criteria?
- 2 things to specify - 2 types?
= Formerly “Hypochondriasis”
What is the difference between Illness Anxiety Disorder (IAD) and Somatic Symptom Disorder (SSD)?
- The distinction between Illness Anxiety Disorder (IAD) and Somatic Symptom Disorder (SSD) lies in the source of distress.
- SSD individuals are distressed about their physical complaints.
- IAD individuals are primarily distressed by their anxiety about the meaning, significance, or cause of their physical complaints, not the complaints themselves.
Conversion Disorder (Functional Neurological Symptom Disorder)
- 4 Criteria?
- 2 Things to Specify?
Conversion Disorder (Functional Neurological Symptom Disorder)
* Inconsistent neurological symptoms not explained by medical conditions.
* Psychological factors associated with symptom onset or exacerbation.
Outline the Aetiology of Conversion Disorder.
Outline 3 Examples of Conversion Disorder.
Psychological Factors Affecting Other Medical Conditions
- 3 points?
Factitious Disorder
- What is a Malinger?
- 4 Points?
Factitious Disorder
* Distinction between psychological motives in Factitious Disorder and external incentives in Malingering.
* Malinger: pretend to be ill in order to escape duty or work.
Somatic Symptoms and Related Disorders - Treatment
- Primary objective?
- Caution with what?
- What to avoid?
- What is recommended?
- Which meds?
Outline a biopsychosocial rehabilitation plan for the individual presentation of a somatic symptom disorder.
- 5 Implementation Steps?
- 2 Biological Interventions?
- 3 Psychological Interventions?
- 3 Social Interventions?
- 2 Interdisciplinary Care?
Implementation Steps:
1. Initial Assessment: Conduct a comprehensive assessment to understand the individual’s physical, psychological, and social needs.
2. Developing the Plan: Collaborate with the individual to develop a personalized rehabilitation plan based on the assessment.
3. Setting Goals: Establish short-term and long-term goals for the individual’s recovery and well-being.
4. Regular Follow-ups: Schedule regular follow-up appointments to monitor progress and make necessary adjustments to the plan.
5. Encouraging Adherence: Provide continuous support and encouragement to help the individual adhere to the rehabilitation plan.
What are 6 Risk Factors for Trauma having a greater impact?
- 7 PTSD Risk Factors?
Trauma has greater impact if it is:
1. Prolonged
2. Multiple
3. Early in life
4. Inflicted by humans (much worse than natural disasters)
5. Associated with dissociation
6. Associated with overwhelming powerlessness
PTSD Risk Factors
1. Psychiatric comorbidities
2. Lower socioeconomic status
3. Child or adolescent at the time of trauma
4. Lack of social support
5. Female sex
6. Prior traumatic exposure (including childhood experiences) and/or subsequent reminders
7. High perceived severity of the traumatic event
PTSD
- Epidemiology?
- Clinical features? (TRAUMMA)
- What are 6 features of PTSD?
- 3 Common comorbidities?
Acute stress disorder
- Occurs in up to 50% of individuals experiencing interpersonal violence (e.g., assault, rape)
- Occurs in up to ∼21% of individuals involved in motor vehicle accidents
PTSD
- Lifetime prevalence: 6–9%
- Sex: ♀ > ♂
Common comorbidities
1. Major depressive disorder
2. Substance use disorders
3. Somatic symptom disorder
PTSD
- 2 subtypes/variants?
- PTSD with delayed expression: a subtype of PTSD in which individuals first meet the full diagnostic criteria ≥ 6 months after the associated traumatic event(s)
- PTSD with dissociative symptoms: a subtype of PTSD in which individuals meet the diagnostic criteria for PTSD and concomitantly experience symptoms of either derealization or depersonalization
Note: DSM-5 criteria for stress disorders apply to individuals aged > 6 years.
List 11 Differential diagnoses of PTSD?
- Acute stress reaction
- Other trauma- and stressor-related disorders, e.g., adjustment disorder
- Anxiety disorders, e.g., generalized anxiety disorder, panic disorder
- Mood disorders, e.g., major depressive disorder, bipolar disorder
- Obsessive-compulsive disorder
- Dissociative disorders
- Psychotic disorders, e.g., schizophrenia
- Personality disorders
- Substance-related and addictive disorders
- Somatic symptom disorder
- Traumatic brain injury
What is the main study that looked at prevalence of trauma in childhood?
- 10 Areas of Trauma?
- Study results?
ACE STUDY
- Beginning in 1994, the “adverse childhood experiences” (ACE) Study, a partnership between the Centres for Disease Control (CDC) and Kaiser
Permanente assessed the relationship between adult health risk behaviours and childhood abuse and household dysfunction.
- Obtained baseline data for a total sample of 17,337 individuals.
What percentage of psychiatric conditions are attributed to an ACE?
- What effect does an ACE have on Chronic Disease development?
- What 6 effects does trauma have psychologically?
- What 3 effects does trauma have spiritually?
Psychological Effects of Trauma
1. Shame
2. Persistent fear
3. Helplessness and loss of control
4. Self loathing and self blame
5. Loss of self esteem
6. Loss of trust, the world is no a longer safe
Spiritual Effects of Trauma
1. Loss of meaning to life
2. Loss of faith
3. Punishment
Outline the pathophysiology of PTSD/the effect of trauma on the HPA?
- Which system in the brain does it have a significant impact on?
- Effect on the Amydala?
- Effect on the Hippocampus?
- Trauma is also a “physioneurosis”.
- This is based on the persistence of biological emergency responses.
- The fight of flight stress response does not return to baseline.
- Trauma also has a significant impact on the development and functioning of the limbic system.
6 Differential diagnoses of trauma and stressor related disorders:
- Symptoms?
- Triggers?
- Features?
- Duration of symptoms?
- Social functioning?
Management of PTSD
- Approach?
- Psychotherapy?
- Pharmacological treatment?
Approach
- Provide education about the broad range of expected reactions to traumatic situations, the natural course of the disorder, and treatment options.
- For patients with suicidal ideation or at risk of self-harm, refer to psychiatry and consider hospitalization.
- Early trauma-focused psychotherapy prevents progression to PTSD in patients with acute stress disorder.
- What are 2 behaviours that trauma may result in?
- What are the 2 aims of a consult when seeing a patient with PTSD?
- What are 9 reactions a patient may have once trauma is triggered?
- What are the 7 aims in good clinical interaction with patients with PTSD?
- What are 6 ways drs can respond to trauma reactions?
- How should trauma-informed care be delivered?
1 - Dissociation
- Dissociation is a protective defense at the time of trauma.
- It always indicates past trauma.
- It can continue to occur with even minor triggers.
- It can be very subtle.
2 - Episodes of High Arousal
- Trauma may also result in the loss of the ability to soothe and lead to episodes of high arousal.
- Lack of a secure attachment through trauma impedes the ability of the child to learn to self soothe, to settle their own distress, to be able to be alone and not panic.
Explain the dysregulation of the hypothalamic-pituitary-adrenal axis in PTSD vs. depression?
- Hypothalamic-pituitary-adrenal (HPA) axis in the physiological state, in major depression, and in post-traumatic stress disorder (PTSD).
- Left: Physiologically, further cortisol release is reduced via a negative feedback mechanism.
- Center: In patients with major depression, the HPA axis is typically hyperactive, with increased cortisol levels at reduced feedback sensitivity. A potential underlying mechanism is a decreased function or number of glucocorticoid receptors.
- Right: In patients with PTSD, cortisol levels are reduced, despite constantly elevated CRH levels. Persistently increased CRH stimulation in the pituitary gland leads to a downregulation of CRH receptors and thus to reduced ACTH production and cortisol release. Also, increased feedback sensitivity further leads to decreased ACTH production. In contrast to depression, the function or number of glucocorticoid receptors is increased.
What is a Personality Trait?
What are the Big 5 Dimensions of Personality? (OCEAN)
Personality trait: a stable, repetitive pattern of thoughts, feelings, and behaviors characteristics of a particular individual as expressed in a wide range of social and personal contexts.
The Big Five dimensions of personality
- The most widely recognized personality model that maps personality according to five distinct dimensions, namely the degree of conscientiousness, agreeableness, neuroticism, openness to experience, and extraversion expressed by an individual.
- The dimensions are equally determined by genetic and environmental factors and remain stable throughout adulthood.
- Each dimension is the sum of several factors or characteristics and should not be assessed in binary categories of presence and absence but rather as traits on a spectrum.
Personality Disorders
- Definition?
- Age of onset?
- Gender epidemiology?
- Classification as per DSM-5?
Personality disorders
- Definition: pervasive, inflexible, and maladaptive personality patterns that lead to significant distress and/or functional impairment
Epidemiology
- Age of onset: late childhood or adolescence
- Antisocial and narcissistic personality disorders are more commonly diagnosed in male individuals.
- Histrionic and borderline personality disorders are more commonly diagnosed in female individuals.
Aetiology
- Multifactorial
- Caused by a combination of hereditary (e.g., personality disorders in parents) and psychosocial factors (e.g., child neglect, abuse)
Classification:
- The DSM-5 divides personality disorders into three clusters (A, B, and C).
- For the general character of each cluster, remember WWW: Weird (A), Wild (B), Worried (C)
Personality Disorders
- What are 6 key features of all personality disorders?
- Diagnostic Criteria?
Key Features of all Personality Disorders
1. Deviates markedly from the expectations of the individual’s culture
2. Is inflexible and pervasive across a broad range of personal and social situations
3. Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
4. Is stable and of long duration, with onset able to be traced back at least to adolescence or early adulthood
5. Is not the result of another mental disorder, drug or physical condition
6. Affected individuals consider their symptoms normal and nonproblematic.
Cluster A Personality Disorders
- General description?
- List 3 types and their characterstic features & Additional distinguishing features?
Cluster A personality
- THESE are individuals with longstanding difficulties in relating to others, ranging from distrust to detachment to social deficits
Cluster A - Paranoid Personality Disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Paranoid personality disorder
- Paranoid personality disorder is characterised by pervasive distrust and suspiciousness and a tendency to interpret others as malevolent in some way.
- These individuals may be preoccupied with unspecified doubts about the motives of others and are reluctant to confide, as they fear information will be used maliciously against them.
- Some paranoid individuals have recurrent suspicions about a spouse or partner
Cluster A - Schizoid Personality disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Schizoid Personality Disorder
- The essential feature of schizoid personality disorder is detachment from social relations and a restricted range of expression of emotions in interpersonal settings.
- Schizoid individuals appear to lack a desire for intimacy and do not seem to enjoy close relationships.
- This clinical picture clearly develops with some features of pervasive developmental disorders and may sometimes be a precursor of schizophrenia
Cluster A - Schizotypal Personality disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Schizotypal Personality disorder
- Schizotypal personality disorder refers to a pattern of reduced capacity for interpersonal relatedness with cognitive distortions and eccentricities of behaviour.
- Individuals with schizotypal personality disorder often have ideas of reference, that is, they incorrectly interpret external events as having unusual and specific meaning for them.
- Schizotypal individuals may be interested in the paranormal and have a range of beliefs about their own mental powers
Cluster B Personality Disorders
- List 4 types, their Characteristic features and their Additional distinguishing features?
Cluster B - Antisocial Personality Disorder
- Description?
- Epidemiology?
- Diagnostic Criteria?
- Differentials?
- Treatment?
Cluster B - Antisocial Personality Disorder
- ANTISOCIAL personality disorder refers to a pervasive pattern of disregard for the rights of others and has been previously known as psyochopathy or sociopathy.
- Antisocial individuals frequently have a history of childhood maltreatment and behavioural disturbances, including aggression from an early age.
- Some antisocial individuals are superficially charming and confident and can be successful in exploiting others
Cluster B - Antisocial Personality Disorder
- Description?
- Epidemiology?
- Diagnostic Criteria?
- Differentials?
- Treatment?
Borderline personality disorder
- Identity and self-image
- Control of feelings and impulses
- Interpersonal functioning
- They have difficulty tolerating negative- feeling states and can turn to substance use and risk-taking behaviours to avoid intense emotional experiences
Cluster B - Histrionic Personality Disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Cluster B - Histrionic Personality Disorder
- Histrionic personality disorder involves a pattern of excessive emotionality and attention-seeking behaviour.
- These individuals are often dramatic in style and demand to be the centre of attention.
- Histrionic individuals are prone to exaggeration and are highly suggestible.
Outline Normal Human Responses to Stress
- 5 Physiological?
- 3 Emotional?
- 3 Behavioural?
Outline Abnormal Human Responses to Stress
- 2 Physiological?
- 4 Emotional?
- 5 Behavioural?
List 4 Factors Influencing Stress Responses?
Factors Influencing Stress Responses
1. Genetics: Some individuals may be more predisposed to developing abnormal stress responses due to genetic factors.
2. Environment: Exposure to chronic stressors, such as a high-stress job or a traumatic event, can influence how a person responds to stress.
3. Personality: Certain personality traits, such as resilience and optimism, can affect an individual’s ability to cope with stress.
4. Support System: Having a strong support system can buffer against the negative effects of stress.
Cluster B - Narcissistic Personality Disorder
- Description?
- Diagnostic Criteria?
- 3 Classifications?
- Differentials?
Narcissistic personality disorder
- Individuals with narcissistic personality disorder are grandiose, with a need for admiration
- They often have a sense of self-importance and overestimate their abilities and accomplishments
- They have a limited capacity to understand the feelings or experiences of other people and can be hurtful and inconsiderate
Cluster C Personality Disorders
- List 3 types, their Characteristic features, and their Additional distinguishing features?
Cluster C - Avoidant Personality Disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Avoidant personality disorder
- Socially inhibited and hypersensitive to the negative evaluation of others
Adjustment Disorder
- Definition?
- Epidemiology?
- Aetiology?
- Diagnostic Criteria?
- 3 Differentials?
- Treatment & Prognosis?
Definition: A maladaptive emotional (e.g., anxiety) or behavioral (e.g., outburst) response to a stressor, lasting ≤ 6 months following resolution of the stressor.
Epidemiology
- Occurs in ∼ 5–20% of individuals undergoing outpatient mental health treatment.
- Up to one-third of patients with a cancer diagnosis develop this disorder.
Aetiology: A combination of intrinsic and extrinsic stressors (e.g., divorce, losing a job, academic failure, difficulties with a peer group, illness)
Cluster C - Dependent Personality Disorder
- Description?
- Diagnostic Criteria?
- Differentials?
Dependent Personality Disorder
- Dependent personality disorderrefers to a pervasive and excessive need to be taken care of that leads to clinging behaviour with others and a fear of separation
- These individuals experience ongoing difficulty in making decisions and taking initiative and responsibility in their lives
- They are at risk of being dominated and exploited by others and may acquiesce to unreasonable demands rather than risk disagreement or potential abandonment
Cluster C - Obsessive-compulsive Personality Disorder
- Description?
- Diagnostic Criteria?
- Difference to OCD?
- Differentials?
Obsessive–compulsive personality disorder
- Obsessive–compulsive personality disorder describes individuals who are preoccupied with order and control and are seen as perfectionists and rigid in thinking and behaviour
- They tend to be focused on minutiae and rules,pay excessive attention to detail and have difficulties in task completion
- The perfectionism and self-imposed high standards of performance cause significant dysfunction and distress and impact negatively in interpersonal relationships and activities
- List 6 Causes of Personality Disorders?
- 6 Consequences of Personality Disorders?
- Treatment for Personality Disorders?
Causes of Personality Disorders
1. Neurotoxic effects of cortisol - Dysregulation of the developing HPA axis and ongoing vulnerability to stress
2. Disruption of limbic system regulation
3. Effects on neurotransmitter systems
4. Attachment challenges
5. Trauma
6. Genetic
Consequences of Personality Disorders
1. Social exclusion
2. Poverty
3. Drug and alcohol use
4. Criminal conviction
5. Self-harm
6. Completed suicide
- 2 Principles of management of a Personality Disorder?
- 4 Stages of treatment of a personality disorder?
- 4 Stages of self-awareness?
Principles of Management
1. Negative attitudes by the clinician towards treatment and a false belief that personality disorder is not treatable.
2. Being overly controlling and giving direct advice can result in either dependency or chronic rejection of all suggestions
Stages of treatment of a personality disorder
- Four major stages in the treatment of personality disorders, beginning with the common entry point of crisis management and stabilisation
- Cloninger’s model does not assume that all individuals will be able to undergo major personality change.
- It does suggest that the initial clinical response should be on stabilisation and establishing a working alliance with the patient if they can accept ongoing support.
How can you Risk Assess for Personality Disorders? (6)
Risk assessment
1. Identifies potential triggers that could lead to a crisis
2. Specifies self-management strategies likely to be effective
3. Establishes how to assess crisis services if needed
- Outline an approach to the management of a personality disorder? (6 points)
- Role of medications in the management of personality disorders? (NICE guidelines)
- Short term psychotropic use for stabilisation of personality disorder?
The role of medications
- It is not uncommon for a variety of psychotropic medications to be trialled in patients with severe personality disorder, usually aimed at specific symptoms or with the goal of relieving subjective distress
- There is little evidence to support the use of antipsychotic drugs in the medium- and long-term treatment of personality disorder and little support for the use of novel antipsychotics for emotional instability, transient psychotic symptoms and aggression
- The NICE guidelines suggest that short-term use of sedative medication may be considered cautiously as part of crisis management, but should not be maintained for more than one week
Role of the following medications in the management of Personality Disorders:
- Antidepressants?
- Mood stabilisers/Anxiolytic agents?
- Antipsychotic agents?
Dialectic Behavioural Therapy
- Definition of Dialectics?
- Role in therapy?
- What is emotional regulation? (4)
- Why is it important to understand emotion dysregulation?
- Provide a Biosocial model of emotion dysregulation?
Dialectics
- Definition: The concept of ‘dialectics’ means that two opposites can coexist and be reconciled. In DBT, the dialectic usually addressed is the tension between acceptance and change.
- Role in therapy: In DBT, therapists and clients work together to balance the need for acceptance with the need for change in their therapeutic relationship and in their daily lives.
- Core dialectic: balancing Acceptance and Change
- Main goal = Building a life worth living
Dialectical Behavioural Therapy
- Overview of DBT components?
- What is it?
- What can it help with?
- 5 Benefits?
- 4 Skills DBT can teach?
Overview of DBT Components
- Individual Therapy: One-on-one sessions between client and therapist focused on improving problem behaviors.
- Group Skills Training: Usually taught in a group setting, this is where clients learn and practice behavioral skills.
- Phone Coaching: Provides in-the-moment support to help clients apply the skills in their everyday lives.
- Therapist Consultation Team: Aids therapists in managing their own responses to challenging client issues and staying motivated.
What are the normal human responses to bereavement?
- 4 Emotional?
- 3 Cognitive?
- 4 Physical?
- 4 Behavioural?
What are the abnormal human responses to bereavement?
- Prolonged Grief Disorder? 4 Emotional?
- 3 Cognitive?
- 4 Physical?
- 4 Behavioural?
Prolonged Grief Disorder (PGD):
1. Persistent Intense Grief: Severe, debilitating grief lasting more than six months.
2. Impairment: Significant impairment in personal, social, and occupational functioning.
3. Preoccupation with the Deceased: Constant longing and yearning for the deceased.
4. Emotional Numbness: Inability to experience joy or engage in life activities.
Complicated Grief:
1. Chronic Symptoms: Symptoms of acute grief that persist without improvement over time.
2. Maladaptive Behaviours: Behaviours such as avoidance of reminders of the deceased or an inability to accept the death.
3. Severe Depression: Major depressive episodes that are pervasive and persistent.
List 4 Factors Influencing Bereavement Responses?
- 4 Healthy coping strategies?
- 3 Unhealthy coping strategies?
Factors Influencing Bereavement Responses
1. Relationship with the Deceased: The closeness of the relationship can impact the intensity and duration of grief.
2. Circumstances of Death: Sudden or traumatic deaths often lead to more complicated grief reactions.
3. Previous Mental Health: Individuals with a history of mental health issues may experience more severe grief responses.
4. Social Support: Access to a strong support network can help mitigate the severity of grief reactions.
Develop a comprehensive biopsychosocial management plan for a patient with borderline personality disorder presenting in crisis.
- Biological Interventions?
- Psychological Interventions?
- Social Interventions
3. Social Interventions
Support Systems:
* Family Involvement: Educate family members about BPD and involve them in the treatment process when appropriate.
* Peer Support Groups: Encourage participation in support groups for individuals with BPD.
Environmental Modifications:
* Stable Living Situation: Assist in finding a stable and supportive living environment.
* Work/School Support: Provide support for maintaining employment or continuing education, which may include accommodations or vocational training.
Social Skills Training:
* Assertiveness Training: Help the patient learn to express their needs and desires in a healthy and assertive manner.
* Conflict Resolution: Teach strategies for resolving conflicts in a constructive way.
Describe normal human attachment.
- Characteristics?
- Behaviours?
- Outcomes?
Describe 3 abnormal human attachment styles.
- Characteristics?
- Behaviours?
- Outcomes?
Define the concepts of transference and countertransference and explain their relevance to both individual clinical encounters and systemic health care interactions.
What are eating disorders?
What triggers them?
Describe the Vicious Cycle of Eating Disorders.
- Illnesses which sit at the interface of physical and mental health.
- Associated with high morbidity, mortality and suffering in both patients and carers / families.
- Often develop as strategies to deal with a variety of distressed emotions and personal conflicts, esp. a sense of lack of adequate control and effectiveness for life situations.
- Disordered eating can develop out of an overvaluation of the benefits of “slimness” to deal with these issues, but in genetically vulnerable individuals can also be triggered by weight loss of any cause.
What is Bulimia Nervosa? (4 points)
What is the difference between BN and Binge Eating Disorder? (4 points)
Bulimia Nervosa
1. Binge eating = Eating an objectively large amount of food + Experiencing a sense of loss of control
2. Recurrent inappropriate compensatory behaviours in order to prevent weight gain, e.g.,
* purging (vomiting; laxatives, diuretics, enemas);
* fasting;
* excessive exercise
3. The binge eating and inappropriate compensatory behaviours both occur, on average, at least once a week for 3 months
4. Self-evaluation is unduly influenced by body shape and weight
- What is Avoidant Restrictive Food Intake Disorder (ARFID)?
- What are 5 other eating disorders?(OSFED)
- ARFID = Avoidant Restrictive Food Intake Disorder = new category - marked sensory difficulties with eating - more common in OCD and Autism
What is the approach the the management of Eating Disorders? (6 steps)
- How well are EDs managed in WA?
- What does the evidence emphasises in terms of managing EDs?
- Dire situation in W.A. with respect to management and outcomes for public patients with severe eating disorders.
- Eating Disorders have the highest mortality of any mental illness (approx 20% - from suicide and malnutrition)
- There is no comprehensive specialist public eating disorders service in W.A. for pts over the age of 16 – no beds/ multidisciplinary outpatients / day program or outreach service (CCI great psychological Tx but not MDT for high risk )
- With peak onset age 15-24 and average duration 7 years, around 85% of patients with an ED are over age 16
- Evidence emphasizes medical stabilization and treatment of starvation syndrome are essential for addressing cognitive effects and allowing engagement with psychological therapies
Which 5 psychiatric comorbid disorders commonly occur with eating disorders?
- Which personality disorders often align with AN/BN?
- Why should care be taken when diagnosing personality disorders in a patient with an ED?
Psychiatric comorbid disorders that commonly occur with EDs
1. Mood disorders (40-70%) - Major depression, dysthymia (but need to differentiate from mood disorder secondary to malnutrition)
2. Anxiety disorders – GAD +/- panic
3. OCD (common with anorexia nervosa)
4. ETOH / other substance abuse (esp. with BN)
5. Personality Disorders (again – diagnosis best made once nutrition restored!) - “No-one is “odd” until they are well nourished and odd”
What is the biggest risk of unintentional death in patients with an eating disorder?
- Which indicators of cardiac risk should you assess? (8)
- What are the normal clinical parameters for a BMI of 20-25?
Risk Assessment - The biggest risk is unintentional death due to the effects of starvation or purging - Person can feel great and have normal bloods just before sudden death due to arrhythmia
- Best indicators of cardiac risk are easily assessed:
1. BMI < 14
2. No oral intake for more than several days (always ask in detail about food intake)
3. Purging several times daily
4. BP < 90mm systolic
5. HR < 50 bpm or > 110 bpm
6. Postural tachycardia/hypotension > 20 bpm/mm
7. Serum potassium, phosphate or glucose below normal range
8. Prolonged QT interval on ECG
What are the effects of starvation on the brain? Which study examined this?
- At a BMI of 14-18, what clinical features do we see?
- At a BMI of <14, what clinical features do we see?
Effect of Starvation on Decision-Making, Self-perception and Insight
- The Minnesota Semi-starvation Study conducted by Ancel Keys
- Loss of 25% of body weight led to profound cognitive changes, including obsessive preoccupation with food and eating and loss of perspective and insight. Only reversed when weight restored.
- Thus cornerstone of initial treatment of severe eating disorders is nutritional rehabilitation.
- Many treated on a compulsory basis later agree that treatment was necessary and remain therapeutically engaged (Guarda et al).
- In Minnesota semi-starvation study normal men all became mentally disturbed: Obsessed with food, Nitpicky about detail, Lost touch with the big picture, Depressed, Suicidal, Withdrawn, Bingeing, Purging, Body Image Issues
List 7 medical complications of eating disorders and their respective treatments?
**What is Refeeding Syndrome? **
- 4 prevention methods?
Provide a Summary of Initial Medical Management (for the First 24 Hours after Presentation) of an Eating Disorder:
- 6 Medical parameters?
- 3 Pharmacological measures?
- Nutritional management?
REFEEDING SYNDROME
- In first 1-2 weeks of refeeding body can rapidly use up phosphate, potassium, magnesium, glucose and thiamine
- Can result in heart failure, brain injury and death
- Prevent by:
1. Awareness
2. Thiamine
3. Checking serum phosphate, magnesium, potassium daily and replace if low
4. Lowish meal plan to start (1500Kcal) but get up to 3000kcal within 2-3 weeks (don’t want ‘underfeeding syndrome’)
What kind of Inpatient Nursing Management should be provided to a patient admitted with an eating disorder?
Inpatient Nursing Management
- 1:1 special ideal (especially during and after meals; record intake)
- No leave off ward
- Observations qid including lying/standing BP/HR/BSL (inc 2am) + daily ECG
- Notify RMO if systolic BP<90, HR<60, postural changes greater 20 mm/bpm
- Monitor and contain food avoidance, exercise, vomiting
- Supervise toilet/shower
- Weigh twice weekly in morning after voiding
Outline the 2 general prognosis pathways of patients with an Eating Disorder?
- What is Siegel’s “hand model” of vertical integration of the brain?
- Explain how an eating disorder can result in impairment of brain functioning?
- What are 9 functions of the Medial Pre-frontal Cortex (PFC)?
- What happens to the PFC during starvation?
Eating Disorders and Impairment of Brain Functioning
- Malnutrition is associated with a range of difficulties with cognitive flexibility and emotional regulation.
- Many patients describe a sense of “razor sharp focus” during starvation, but exhibit memory difficulties, slowed processing and reduced flexibility of thinking. However bedside cognitive tests may still be in the high normal range.
- Assessment of decision-making requires a nuanced review as to whether this person can “walk the walk” not just “talk the talk” with respect to managing their nutrition.
Function of the Medial Pre-frontal Cortex (PFC)
1. Bodily regulation (autonomic NS)
2. Attuning to others – “being present”
3. Regulating emotional balance
4. Being flexible in our responses
5. Soothing fear
6. Empathy
7. Insight
8. Moral Awareness
9. Intuition
- Is Meal support really a Nurse-delivered DBT-informed Therapy?
- What are the 4 Cs?
- Is emotional dysregulation exacerbated by malnutrition in the younger patient with an eating disorder?
Is Meal support really a Nurse-
delivered DBT-informed Therapy
Research and feedback from patients themselves reinforce the 4 C’s;
1. Calm (Being present and containing)
2. Confident (knowledgeable and empathic)
3. Consistent (non-negotiables, need containment of potential for compensation or anxiety increases)
4. Compassionate (empathic, manage negative counter transference / stigma)
Treating Starvation - Consistency of the multidisciplinary approach “Non-negotiables”? (5)
- Relapse Prevention - Role of Inpatient and Community Mental Health Services in Monitoring Complex / High Risk Patients with Eating Disorders?
- Consistency is crucial to reduce anxiety in the patient
- Consistency across and within MDT is crucial – eating disorders are great at exploiting “chinks in the armor”
- Weekly case conference MDT then together with pt. and carer - Agree as a team upon the “non-negotiables” and don’t change these outside the meeting
- Externalise dysfunctional behaviour of the “eating disorder” separate to the person
- Be transparent about use of the MHA and what is likely to trigger this, be clear that one of the goals of discharge is to know whether the pt or eating disorder is “driving the bus”
Name and explain the role of 7 health professionals involved in the MDT management of a patient with an eating disorder?
When can a person with an eating disorder be admitted under the 2014 Mental Health Act?
- 4 Criteria?
What are the Definitions of “medical stability”?
- Stable enough for transfer to MHU?
- Stable enough for discharge to community?
Outline the 3 biological, 3 psychological, and 4 social risk factors for developing an eating disorder.
Psychological Factors
1. Personality Traits: Traits like perfectionism, impulsivity, and obsessive-compulsiveness can predispose individuals to disordered eating behaviours. Low self-esteem and a tendency toward self-criticism.
2. Mental Health Issues: Pre-existing mental health conditions such as anxiety, depression, or obsessive-compulsive disorder (OCD). Trauma history, including physical, emotional, or sexual abuse.
3. Cognitive Patterns: Distorted body image and negative beliefs about body shape and weight. Rigid thinking and black-and-white thinking patterns.
Describe 4 biological, 3 psychological, 3 social consequences and 3 Long-Term Consequences of eating disorders.
Psychological Consequences
1) Cognitive Effects:
- Impaired Concentration and Memory: Poor cognitive functioning and difficulty with attention and memory.
- Obsessive Thoughts: Preoccupation with food, body weight, and shape, often leading to compulsive behaviours and thoughts.
2) Emotional and Mood Disorders:
- Depression and Anxiety: High rates of depression, anxiety disorders, and panic attacks.
- Mood Swings: Irritability, mood instability, and feelings of guilt or shame related to eating behaviours.
3) Behavioural Changes:
- Social Withdrawal: Isolation from friends and family, often due to shame or the need to maintain eating disorder behaviours.
- Self-Harm: Increased risk of self-harm or suicidal ideation, particularly in severe cases of anorexia nervosa or bulimia nervosa.
Discuss the family-systemic context of eating disorders and the role of family therapy in their treatment.
- 4 Family Dynamics and Influences?
- 4 Types of Family Therapy Approaches?
- 5 Roles of Family Therapy in Treatment?
Types of Family Therapy Approaches
1. Maudsley Family-Based Treatment (FBT): A structured approach that involves the family in refeeding the individual with anorexia nervosa. Focuses on empowering parents to take control of their child’s eating initially, and then gradually transferring control back to the adolescent as they recover.
2. Systemic Family Therapy: Looks at the family as a system and focuses on the interactions and relationships within this system. Aims to identify and modify systemic issues that contribute to the eating disorder.
3. Structural Family Therapy: Focuses on restructuring family interactions and hierarchies to promote healthier relationships and support the individual’s recovery. Involves modifying family roles, boundaries, and communication patterns.
4. Multidimensional Family Therapy (MDFT): Integrates individual therapy for the person with the eating disorder with family therapy. Addresses multiple aspects of the individual’s life, including family dynamics, peer relationships, and personal development.
Starvation Syndrome
- What is it?
- What was the Minnesota Starvation Experiment?
Starvation Syndrome
When starved of energy, the human body responds in a way known as “Starvation Syndrome”. Starvation syndrome (or semistarvation) refers to the physiological and psychological effects of prolonged dietary restriction. The effects of starvation syndrome are commonly observed in individuals with eating disorders, who often severely restrict their energy intake, eat irregularly, and engage in compensatory behaviours (e.g., purging), which reduce energy absorption. Many of the symptoms once thought to be primary symptoms of eating disorders are actually symptoms of starvation.
Starvation Syndrome
- 9 Physical Changes?
- 4 Emotional Changes?
- 4 Changes in Thinking?
- 5 Social Changes?
- Attitudes and Behaviour Relating to Eating?
Physical Changes
1. Heart muscle mass reduced by 25%
2. Heart rate and blood pressure decreased
3. Basal metabolic rate slowed down
4. Feeling cold all the time
5. Fluid retention (edema)
6. Dizziness and blackouts
7. Loss of strength, high fatigue
8. Hair loss, dry skin
9. Decreased hormone levels, causing lack of sexual desire and other changes
Emotional Changes
1. Depression
2. Anxiety
3. Irritability
4. Loss of interest in life
Changes in Thinking
1. Impaired concentration, judgement and decisionmaking
2. Impaired comprehension
3. Increased rigidity and obsessional thinking
4. Reduced alertness
How is Starvation Syndrome Relevant to Eating Disorders?
- What did the Minnesota Experiment tell us about Reversing Symptoms of Starvation?
- Describe the Recovery from an Eating Disorder?
- A crucial distinction between men in the Minnesota Study and individuals with eating disorders is that, in addition to experiencing symptoms of starvation, individuals with eating disorders have significant fears about their shape, weight, appearance and eating.
- When a person who is starving has the opportunity to eat, they will eat. A person with an eating disorder will continue to restrict what they are eating due to their fears. It is therefore crucial that eating disorder recovery focuses on physical renourishment as well as psychological treatment to address anxiety and fear about eating.
Australia - Daily Tobacco Smoking
- What percentage of Australians are daily smokers?
- How many deaths is it responsible for?
- How has the prevalence of smoking in Australia changed over time?
- Which 7 groups of people are still smoking?
- ATSI rates - how do they vary by gender and by location?
Australia - Daily Tobacco Smoking
- 12.2% daily smokers
- Kills 15,000 p.a
- Up to 2/3 die from smoking
- Leading cause of preventable death in Australia
WHO IS STILL SMOKING? - Smokers with:
1. High dependence
2. ATSI
3. Mental health concerns
4. Drug and alcohol comorbidities
5. Diseases related to their smoking e.g. COPD
6. Multiple unsuccessful attempts
7. More stressors
Low socio-economic status is common amongst these groups
What are the smoking rates among those with a Mental Illness?
- What are 6 reasons for high smoking rates amongst certain populations?
MH Smoking Patterns
- Smoke more heavily
- Have higher levels of nicotine
dependence
Have more difficulty quitting
Reasons for high smoking rates
1. Shared genetic predisposition - Depression, Schizophrenia, Alcohol dependence
2. Common environmental factors
3. Self-medication
4. To reduce side-effects of medication
5. Culture of smoking in mental health facilities, group homes
6. Less likely to be offered treatment
Is it worth quitting smoking?
- At what age?
- Reasons?
- What are some of the myths around smoking and are they true?
Is it worth stopping?
- Stop at 30 = never smoker
- 3 months of life per year quit after 35yo
- Every smoker’s health improves when they quit.
- At the very least - O2 carrying capacity improves
- MH Patient more likely to die from smoking than from mental illness
- Mental Health Improves
- Need less caffeine, alcohol and medications
- Respond to evidence based therapies
- Financial implications
What percentage of patients are offered treatment for smoking compared to other chronic diseases at the GP?
- 5 Barriers for doctors to discuss smoking cessation?
- Do smokers usually want to quit?
Barriers for Doctors to offer Smoking cessation therapy
1. Is it a chronic illness?
2. Lack of time
3. Fear of alienating smokers
4. Lack of skills
5. Despondency re: efficacy
6. Fear of adverse events
Nicotine
- What is it?
- How is it absorbed?
- Pharmacokinetics/Half life?
Basics of Nicotine
- Nicotine is odourless and Colourless
- Most nicotine from smoking a cigarette is blown into the air
- Nicotine enters and is absorbed by the respiratory tract (nose, mouth) and lungs and then directly to arterial blood and brain very quickly
- Nicotine is not eaten and swallowed but can be chewed (buccal absorption)
- Accurate titration – topography of smoking
Nicotinic Receptors
- 3 types?
- 6 neurotrasmitters which are released with nicotine and their effects?
- 5 Nicotine effects?
- 5 symptoms of nicotine toxicity?
Nicotine (Nicotinic) Receptors
- nACHr all over the body and brain (Hipp, NA, Cortex)
- Receptors are sensitive to nicotine
- Configurations of α and β types:
1. α4β2 responsible for dependence
2. β4 for cognition
3. α3β4 for apetite
- Types and subtypes are heritable
- Up- and Downregulate quickly
Nicotine
- How is it metabolised?
- How do women metabolise nicotine differently?
What chemicals are produced by smoking organic material?
- Which 7 drugs require higher doses in smokers?
- What is the effect of tobacco on alcohol?
- What is the effect of tobacco on caffeine?
Polycyclic Aromatic Hydrocarbons
- Produced by smoking organic material
- Induces CYP 1A2, therefore need more:
1. Insulin
2. Antipsychotics eg olanzapine, clozapine, haloperidol
3. Antidepressants eg fluoxetine, fluvoxamine
4. Diazepam
5. Analgesia, eg methadone
6. Caffeine
7. Alcohol
- This is NOT a nicotine effect.
- Important to think about during inpatient admissions/discharge
Outline 5 Acute and 7 Chronic Symptoms of Nicotine Withdrawal?
Acute
1. Cravings
2. Anxiety
3. Distress
4. Aggression
5. Reduced concentration
Chronic
1. Insomnia
2. Headaches
3. Constipation
4. Increased appetite
5. Low mood
6. Apthous Stomatitis
7. Cough
Smoking Relapse - What are the Abstinence Rates after an Unaided Quit Attempt?
- Outline the Stressors, distress and cues to smoke
- What are 4 Predictors of Smoking Relapse?
- Which 3 groups of people usually require extra help to quit?
- What usually is of little relevance in the success of smoking abstinence?
Stressors, distress and cues to smoke
- Nicotine has an acute anxiolytic effect
- Nicotine has an acute antidepressant effect
- Nicotine has a very short half-life (40 mins → 2 hrs) and wears off
- Nicotine wearing off → acute anxiety and depression (withdrawals): the “stress” paradox
- Smokers “manage” stressors better when on NRT
- After cessation smokers are “calmer”, less volatile, less “reactive” to stressor.
- This is a learned process and takes time→ 3 months to unlearn
What is the 3 As Approach to Smoking Cessation?
- What should you include in your assessment of a patient wishing to cease smoking? (5)
- What is a Carboxymeter? Normal value in Australia?
3As Approach
- Internationally accepted – USA, Canada, UK, NZ
- 3As
1. Ask and record smoking status
2. Advise all patients to quit in clear, non confrontational , personalised way
3. Act (Help): Information, Referral to Quitline, Medications
Assessment of a Smoker
1. TTFC < 30min (number and type irrelevant)
2. Medical History (psychiatric in particular)
3. Quitting History (previous short lived attempts, pharmacological failures)
4. Family History (heritability)
5. Environmental Contexts (others smoke at home and/or at work)
Smoking Cessation
- What are the 4 basic treatment principles?
- What are the Evidence-Based Pharmacotherapies for Nicotine Withdrawals?
- 6 first line? 2 2nd line?
Treatment Principles
1. Best practice is pharmacotherapy + professional counselling - “…pharmacotherapy should be offered to all smokers who have evidence of nicotine dependence”
3. Combination therapy is more effective than monotherapy (NRT) 3
4. Compliance is a major issue: correct use, duration and dose
5. Individuals respond differently to different medications
NRT - Individual Responses to Medication
- What are 3 Genetic variations associated with response to smoking cessation therapies?
- How much nicotine is in 1 cigarette? What is the equivalent in gums/lozenges/sublingual tablets?
Individual Responses to Medication
* Genetic variations associated with response to therapies:
1. Varenicline = Nicotine receptors
2. Bupropion = Rate of metabolism (CY2B6)
3. NRT = Rate of metabolism (CYP2A6)
- How do the nicotine blood levels vary between cigarettes vs. NRTs?
- Evidence around use?
- Use in pregnancy?
NRT
- NRT-as blood levels vary MOST smokers are underdosed with single form (1 x 21mg patch =10ng/ml)
- Combination NRT better
- Longer NRT better
- No evidence to cut down (21 –> 14 –> 7mg)
- No evidence to start on lower doses
- Safe (except patch in pregnancy)
NRT options?
