Other Behavior/Emotional Disorders-
-Acute Reaction to Stress-
-Acute Stress Disorder is characterized by acute stress reactions that may occur in the initial month after a person is exposed to a traumatic event (threatened death, injury, or sexual violation)
-Treatment of acute stress disorder can have an additional benefit of limited subsequent post traumatic stress disorder (PTSD), which is diagnosed at least 4 weeks after the exposure to the trauma
-Trauma focused cognitive behavior for acute stress disorder include patient education, cognitive restructuring, and exposure
-Benzodiazepines may be helpful to manage acute anxiety
-For acute stress disorder it is recommended CBT for first ling therapy. Short term benzodiazepine use may be helpful
-Child/Elder Abuse-
-Elder Abuse is defined as behavior by someone with an ongoing relationship, that may constitute :
1. Willful infliction of physical pain or injury
2. Willful nonsexual contact
3. Willful infliction of emotional harm
-Elder is the finest person 60 or 65 years of age or older
-neglect is defined as a failure of a person to right needs for the protection of vulnerable order what a person have an ongoing relationship with the Elder, In a duty to provide those needs and protection.
-abandonment is defined as the desertion of a vulnerable when the had an ongoing relationship with the elder
-Elder mistreatment constitutes abuse, neglect, self-neglect, in financial exploitation
-Financial exploitation is a nonconsensual appropriation of an elderly person resources for the benefit of another by someone an ongoing relationship and a duty towards that person
-Community dwelling elders are protected by the adult protective services in all 50 states. This agency is responsible to investigate allegations, Complaints, and provide social and legal and medical intervention to help victims.
-Elderly patients in long-term care facilities are governed by State Long Term Care Ombudsman Programs
-warning signs of elder mistreatment include unexplained bruising a various stages Of healing, fractures that are not explained, malnutrition, dehydration, pressure ulcers, any indicators of sexual abuse such as evidence of venereal diseases.
-elders who are deemed competent may reject services offered by adult protective services. If the person is seemed incompetent courts may intervene and issue an emergency order for an Adult protective services.
-if a healthcare professional fields that there's mistreatment adult protective services should be notified.
-Child Abuse-
-findings that raises suspicion for child abuse on physical examination include: injuries indicate method of infliction such as slap or belt, cigarette burn, spatula burn, or immersion bruises at high tide level.
-other indications of abuse are fractures in various stages of healing
-other signs of abuse and neglect include: bruises and children who cannot cruise, bruises of the trunk, ears and neck. Long bone fractures and children do not walk, in rib fractures in children who are less than one year of age.
-sudden onset of altered mental status not a caused by a medical illness such as hypovolemia, Hypoxemia, hyperglycemia or shock.
-other signs of abuse include injury to genitalia, subdural hematoma in a children less than one year of age, or injuries that are physically impossible.
-parent behavior should be observed carefully and suspicious parenteral behavior may increase the suspicion for abuse.
-Workup for unusual bruising include CBC, PT, PTT, VWF antigen and activity, Factor VIII and IX level
-If intracranial bleeding consider DIC panel including d-dimer and fibrinogen
-Urinalysis should be obtained in children with abdominal trauma.
-Toxicology should be obtained if suspicious for poisoning or malicious materials
-Radiographic workup is dependent on age and physical exam findings. May need a skeletal survey
-Ophthalmologic evaluation is recommended for children less than 5 where head trauma is suspected.
-in the United States, Suspected child abuse is mandated to be reported to the appropriate governmental agency.
-Conduct Disorders-
-conduct disorder overlaps with antisocial personality disorder. Antisocial personality disorder is a pattern of socially irresponsible, exploitative, and guiltless behavior that begins in childhood or early adolescence and is manifested in many areas of a persons everyday life.
-Conduct disorder is a mental disorder of childhood and adolescence. It is diagnosed in children and adolescents with a repetitive and persistent pattern of violating basic rights of others and societies rules
-Conduct disorder is diagnosed with high rates of psychiatric diagnoses, substance misuse, mood disorder, anxiety disorders, ADHD, learning disabilities, pathologic gambling, and borderline personality disorder.
-Pathogenesis is unknown but research suggests both genetic and non genetic causes.
-clinical manifestations include: fights with peers, conflict with parents and authority figures, stealing, vandalism, fire setting, cruelty to animals, Poor academic performance, and ran away from home.
-Domestic Violence-
-Domestic violence is referred to intimate partner violence (IPV). The term describes actual or threatened psychological, physical, or sexual harm to a current or former partner or spouse.
-clinical presentation can include: inconsistent explanation of injuries, a delay in seeking treatment, frequent emergency department or urgent care visits, pregnant women may have delayed initiation in prenatal care, repeated abortions, medication noncompliance, inappropriate affect, over a attentive or verbally abusive partner, apparent social isolation, reluctance to undress, or refusal of genital or rectal examination.
-careful questioning must be done by the clinician to get an accurate and truthful history.
-These patients must be referred to social service and appropriate community resources to make sure they are in a safe environment.
-Grief Reaction-
-immediately after following death, survivors often experience feelings of numbness, shock, or disbelief.
-sleeplessness, appetite disturbances, agitation, chest tightness, sighing, exhaustion, and other somatic complaints are common
-shock, numbness, intense feelings of sadness, yearning for the deceased, anxiety for the future, disorganization, and emptiness often commonly arise in weeks after death.
-grief often comes in waves precipitated by Reminders of the deceased. The survivor may feel fine one moment and be overwhelmed with sadness and grief in the next moment. Feelings of pleasure or often experience as a betrayal of the relationship with the person who has died.
-these symptoms are all considered normal grief reaction.
-Rates of depression during the first year after loss of a spouse are 4-9 times higher than in the general population.
-patients with complicated grief reactions should be referred to a psychiatrist. It is difficult to differentiate between major depression and a complicated grief reaction by most primary care clinicians.
-Complicated grief treatment is a psychotherapeutic approach that includes behavioral methods similar to those with posttraumatic stress disorder.
-treatment with antidepressants is associated with improvement of symptoms associated with depression but it appears to be ineffective in treating symptoms associated with grief.
-Suicide-
-there is no data to support screening for suicide in primary care reduces mortality. Additionally, predicting which patients with suicidal thoughts will go on to attempt suicide cannot be achieved with a high degree of certainty.
-over twice as many patients who attempt suicide contact their primary care provider versus a psychiatrist one month prior to attempting suicide.
-Several risk factors have been associated with suicide: hopelessness and impulsivity, history of previous attempts, increasing age, female sex, white elderly men over 85, marital status, occupation, health, adverse childhood experience, family history of suicide, and accessibility to weapons.
-There is an increase of suicide with age, but young adults attempt suicide more often then younger adults.
-Females attempt more often but men are 3 times more successful than women
-Suicide is greater in patients who have unskilled occupations
-Management of the acutely suicidal patient includes: reduce immediate risk, manage underlying factors, and monitoring and follow up
-If the patient is threatening to leave, in most jurisdictions the police can be called to detain the patient or the patient can be placed under a psychiatric hold for 72 hours
-If patients are going to be discharged, contracting for safety is assessing family support to maintain the patients safety.
-Lithium has been showed in patients with mood disorder to prevent suicide
-Psychotherapy may prevent subsequent suicide attempts
Thursday, February 19, 2015
Sunday, February 15, 2015
Substance Use Disorders
Substance Use Disorders-
-Abuse-
-Substance use disorder can be recognized when a patient requests help to discontinue the use of alcohol or drugs
-Risky use of alcohol or other drugs when consumption amounts that increase the likelihood of health consequences
-Substance Use Disorder replaced the psychiatric diagnoses once known as substance dependence and substance abuse
-Physical dependence is a state of adaption manifested by a withdrawal syndrome that is produced with an abrupt cessation of a substance or by tolerance to a substance
-Addiction-is a primary, chronic, neurologic disease, with genetic psychosocial and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include impaired control over substance abuse, compulsive use, and continue despite harm and craving
-Unhealthy Alcohol or Other Drug Use-refers to the spectrum that can result in health consequences
-Various types of substance use and approach to treatment
-Cocaine use and intoxication is treated with supportive care such as benzodiazepines to control agitation.
-Cocaine symptoms are best treated by allowing the patient to sleep and eat as needed in a supportive environment
-No medication has shown to be effective in cocaine withdrawal syndrome
-Psychosocial treatment is best for cocaine use and have shown to lead to mean reductions in cocaine use. No medication has been shown to be effective in cocaine dependence
-Patients with opioid use disorder wan achieve abstinence though medically supervised withdrawal often require long treatment to prevent relapse
-Long term treatment of opioid use disorder may take several forms:
1. Psychosocial treatment and abstinence based treatment can be provided in the outpatient setting
2. Opioid antagonist treatment-naltrexone base therapies exist that are antagonistic to opioids
3. Opioid agonists treatment with methadone, buprenorphine can be given to patients and then wean them down. Not ideal
-Opiate withdrawal is characterized by pupillary dilation, yawning, increased bowel sounds, and piloerection. Patients may have severe distress, heart rate, blood pressure and respiratory rate may be increased. Patients may present with volume depletion from vomiting and diarrhea.
-Other symptoms of opiate withdrawal include rhinorrhea and lacrimation, myalgia, arthralgia, and abdominal cramping
-Opiate withdrawal can occur within 6 hours of discontinuation of use
-Abstinence detoxification from opioids is largely supportive with hydration and control of symptoms such as vomiting, and agitation. Phenergan and Atarax are commonly used for control of symptoms.
-Benzodiazepine withdrawal onset may vary from the half life of the particular benzodiazepine involved. Symptoms may be delayed up to three weeks after discontinuation
-Symptoms of benzodiazepine withdrawal can include tremors, anxiety, perceptual disturbances, dysphoria, seizures, and psychosis
-BZD withdrawal is treated with a BZD that has a prolonged clinical effect, such as valium IV and titrated to the desired effect
-The BZD does should be tapered gradually over a period of months. BZD withdrawal can be fatal if not treated appropriately
-Alcohol withdrawal can present with a variety of symptoms
-Minor alcohol withdrawal symptoms include insomnia, tremulousness, mild anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations
-Alcohol withdrawal seizures are generalized tonic clonic seizures and usually occur within 12-48 hours of their last uses
-Alcohol hallucinosis and delirium tremens (DT) are not synonymous. Hallucinations are usually visual, although auditory may occurred can develop within 12-24 hours of last use and usually resolve within 24-48 hours
-DT is associated with global clouding of the sensorium with specific hallucinations and vital signs are normal
-Treatment of psychomotor can be done with benzodiazepines such as librium, ativan, or valium
-Thiamine and glucose should be administered to prevent Wernicke's encephalopathy
-Ativan or Serax should be used of patients with cirrhosis or acute alcoholic hepatitis
-Patients with moderate to severe alcohol withdrawal should be admitted to the ICU for monitoring and treatment
-Antipsychotics including haldol should not be used because they lower seizure threshold
-Abuse-
-Substance use disorder can be recognized when a patient requests help to discontinue the use of alcohol or drugs
-Risky use of alcohol or other drugs when consumption amounts that increase the likelihood of health consequences
-Substance Use Disorder replaced the psychiatric diagnoses once known as substance dependence and substance abuse
-Physical dependence is a state of adaption manifested by a withdrawal syndrome that is produced with an abrupt cessation of a substance or by tolerance to a substance
-Addiction-is a primary, chronic, neurologic disease, with genetic psychosocial and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include impaired control over substance abuse, compulsive use, and continue despite harm and craving
-Unhealthy Alcohol or Other Drug Use-refers to the spectrum that can result in health consequences
-Various types of substance use and approach to treatment
-Cocaine use and intoxication is treated with supportive care such as benzodiazepines to control agitation.
-Cocaine symptoms are best treated by allowing the patient to sleep and eat as needed in a supportive environment
-No medication has shown to be effective in cocaine withdrawal syndrome
-Psychosocial treatment is best for cocaine use and have shown to lead to mean reductions in cocaine use. No medication has been shown to be effective in cocaine dependence
-Patients with opioid use disorder wan achieve abstinence though medically supervised withdrawal often require long treatment to prevent relapse
-Long term treatment of opioid use disorder may take several forms:
1. Psychosocial treatment and abstinence based treatment can be provided in the outpatient setting
2. Opioid antagonist treatment-naltrexone base therapies exist that are antagonistic to opioids
3. Opioid agonists treatment with methadone, buprenorphine can be given to patients and then wean them down. Not ideal
-Opiate withdrawal is characterized by pupillary dilation, yawning, increased bowel sounds, and piloerection. Patients may have severe distress, heart rate, blood pressure and respiratory rate may be increased. Patients may present with volume depletion from vomiting and diarrhea.
-Other symptoms of opiate withdrawal include rhinorrhea and lacrimation, myalgia, arthralgia, and abdominal cramping
-Opiate withdrawal can occur within 6 hours of discontinuation of use
-Abstinence detoxification from opioids is largely supportive with hydration and control of symptoms such as vomiting, and agitation. Phenergan and Atarax are commonly used for control of symptoms.
-Benzodiazepine withdrawal onset may vary from the half life of the particular benzodiazepine involved. Symptoms may be delayed up to three weeks after discontinuation
-Symptoms of benzodiazepine withdrawal can include tremors, anxiety, perceptual disturbances, dysphoria, seizures, and psychosis
-BZD withdrawal is treated with a BZD that has a prolonged clinical effect, such as valium IV and titrated to the desired effect
-The BZD does should be tapered gradually over a period of months. BZD withdrawal can be fatal if not treated appropriately
-Alcohol withdrawal can present with a variety of symptoms
-Minor alcohol withdrawal symptoms include insomnia, tremulousness, mild anxiety, gastrointestinal upset, anorexia, headache, diaphoresis and palpitations
-Alcohol withdrawal seizures are generalized tonic clonic seizures and usually occur within 12-48 hours of their last uses
-Alcohol hallucinosis and delirium tremens (DT) are not synonymous. Hallucinations are usually visual, although auditory may occurred can develop within 12-24 hours of last use and usually resolve within 24-48 hours
-DT is associated with global clouding of the sensorium with specific hallucinations and vital signs are normal
-Treatment of psychomotor can be done with benzodiazepines such as librium, ativan, or valium
-Thiamine and glucose should be administered to prevent Wernicke's encephalopathy
-Ativan or Serax should be used of patients with cirrhosis or acute alcoholic hepatitis
-Patients with moderate to severe alcohol withdrawal should be admitted to the ICU for monitoring and treatment
-Antipsychotics including haldol should not be used because they lower seizure threshold
Somatoform Disorders
Somatoform Disorders-
-Somatoform Disorders-
-Somatization is a syndrome of physical symptoms that are distressing and may not be explained by a medical condition after a full workup
-Somatoform disorders is an illness with symptoms that were not explained by a general medical condition
-Risk factors for somatization include: female sex, fewer years of eduction, minority ethnic status, and low socioeconomic status
-Somatization increases the use of medical services independent of any accompanying psychiatric or non psychiatric medical disorder
-Somatization patients present with a wide array of symptoms including pain, GI symptoms, cardiopulmonary symptoms, neurologic symptoms, and reproductive organ symptoms
-Somatoform Disorders include:
1. Somatization disorder
2. Pain disorder
3. Undifferentiated Somatoform Disorder
4. Hypochondriasis
5. Somatoform Disorder NOS
6. Conversion disorder
7. Body Dysmorphic Disorder
8. Somatofrom Autonomic Dysfunction
9. Other somatoform disorders
10. Factitious Disorder
11. Maligering
12. Abridged somatization
13. Multi-somatoform disorder
-Psychotherapy and pharmacologic therapy are each beneficial for patients with somatization
-These treatments may also be combined
-SSRI's have been shown to be beneficial in somatization disorder
-Clinicians should avoid giving opioid analgesics for pain complaints
-Cognitive behavior therapy (CBT) to treat somatization is most helpful to treat somatization more so than any other psychotherapy
Tuesday, February 10, 2015
Psychoses
Psychoses-
-Delusional Disorder-
-Delusional disorder is characterized by the presence of one or more delusions for a month or longer in the absence of meeting the criteria for schizophrenia
-There is also a lack of being attributed to a manic or depressive episodes, and other medical conditions other than a medical disorder
-Delusions are classified as erotomaniac type, grandiose type, jealous type, persecutory type, somatic type, mixed type or unspecified type
-They are also classified by rather than have bizarre content
-Treatment of choice for delusions is antipsychotic medication
-Needs a medical evaluation especially with initial episode to exclude this as being attributed to medical disorder
-Schizophrenia-
-The DSM 5 Criteria for Schizophrenia is as follows:
A. Characterized by two or more of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Gross disorganized or catatonic behavior
5. Negative symptoms (affective flattening, alogia, or avolition)
B. For a significant portion of the time since the onset of the disturbance, one or more of the major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset. When onset is in childhood or adolescence: failure to achieve expected level of interpersonal, academic, or occupational achievement
C. Continuous signs of disturbance persist for at least 6 months. The six months of symptoms must include one mont of symptoms that meet criterion A
D. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
E. The disturbance is not due the direct physiologic effects of a substance such as drug abuse or medication or due to a general medical condition
F. If the patient has a history of autistic disorder or other pervasive developmental disorder, the diagnosis of schizophrenia is is made only if prominent delusions or hallucinations are also present for at least one month
-People with schizophrenia present with several areas of symptoms such as:
1. Positive symptoms (exaggeration of normal processes, distortion of symptoms, hallucinations, and delusions)
2. Negative symptoms (conceptualized as an absence or diminution of normal processes, decreased expressiveness, apathy, flat affect, and lack of energy)
3. Cognitive impairment
4. Mood symptoms
5. Anxiety
-Anti-psychotic medications are first line treatment for schizophrenia and have been shown to reduce positive symptoms
-Patients should be observed on a stable dose of antipsychotic medications for 2-6 weeks before concluding the medication is ineffective
-Antipsychotic medication should be continued indefinitely after the acute phase is passed at the lowest effective dose
-Delusional Disorder-
-Delusional disorder is characterized by the presence of one or more delusions for a month or longer in the absence of meeting the criteria for schizophrenia
-There is also a lack of being attributed to a manic or depressive episodes, and other medical conditions other than a medical disorder
-Delusions are classified as erotomaniac type, grandiose type, jealous type, persecutory type, somatic type, mixed type or unspecified type
-They are also classified by rather than have bizarre content
-Treatment of choice for delusions is antipsychotic medication
-Needs a medical evaluation especially with initial episode to exclude this as being attributed to medical disorder
-Schizophrenia-
-The DSM 5 Criteria for Schizophrenia is as follows:
A. Characterized by two or more of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Gross disorganized or catatonic behavior
5. Negative symptoms (affective flattening, alogia, or avolition)
B. For a significant portion of the time since the onset of the disturbance, one or more of the major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset. When onset is in childhood or adolescence: failure to achieve expected level of interpersonal, academic, or occupational achievement
C. Continuous signs of disturbance persist for at least 6 months. The six months of symptoms must include one mont of symptoms that meet criterion A
D. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
E. The disturbance is not due the direct physiologic effects of a substance such as drug abuse or medication or due to a general medical condition
F. If the patient has a history of autistic disorder or other pervasive developmental disorder, the diagnosis of schizophrenia is is made only if prominent delusions or hallucinations are also present for at least one month
-People with schizophrenia present with several areas of symptoms such as:
1. Positive symptoms (exaggeration of normal processes, distortion of symptoms, hallucinations, and delusions)
2. Negative symptoms (conceptualized as an absence or diminution of normal processes, decreased expressiveness, apathy, flat affect, and lack of energy)
3. Cognitive impairment
4. Mood symptoms
5. Anxiety
-Anti-psychotic medications are first line treatment for schizophrenia and have been shown to reduce positive symptoms
-Patients should be observed on a stable dose of antipsychotic medications for 2-6 weeks before concluding the medication is ineffective
-Antipsychotic medication should be continued indefinitely after the acute phase is passed at the lowest effective dose
Thursday, January 15, 2015
Personality Diorders
Personality Diorders-
-Cluster A-Individuals are odd and eccentric
1. Paranoid
2. Schizoid
3. Schizotypal
-Cluster B-Individuals are often dramatic, emotional, or erratic in their emotions and behavior
1. Histrionic
2. Narcissistic
3. Antisocial
4. Borderline
-Cluster C- Individuals often appear anxious or fearful
1. Avoidant
2. Dependent
3. Obsessive-compulsive
-The consistence of certain behaviors beginning in mid to late adolescence and continuing to adult life are suggestive of personality disorder
-Paranoid Personality Disorder DSM 5 Diagnostic Criteria:
1. A distrust and suspiciousness of other such that their motives are interpreted as malevolent, beginning by early adulthood, and present in a variety of context, as indicated by 4 or more of the following:
a. Suspects without basis that others are exploiting, harming or deceiving him or her.
b. Is occupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
c. Is reluctant to confide in others because of unwarranted fear that information will be used against him or her
d. Reads hidden demeaning or threatening meanings not benign remarks or events
e. Persistent bears grudges
f. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react or to counterattack
2. Does not occur exclusively during the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic features and is not attributable to another medical condition
-Schizoid Personality Diorder DSM 5 Diagnostic Criteria:
1. A pervasive pattern of detachment from social relationships and is a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:
a. Neither desires nor enjoys close relationships, including being part of a family
b. Almost always chooses solitary activities
c. Has little interest in having sexual experiences with another person
d. Takes pleasure in a few, if any activities
e. Lacks close friends or confidants other than first degree relatives
f. Appears indifferent to the praise or criticism of others
g. Shows emotional coldness, detachments, or flattened activity
2. Does not occur exclusively during the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic features and is not attributable to another medical condition
-Histrionic Personality Disorder DSM 5 Diagnostic Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 2 or more of the following:
a. Is uncomfortable in situations in which he or she is not the center of attention
b. Interaction with others is often characterized by inappropriate sexuality seductive or provocative behavior
c. Displays rapidly shifting and shallow expression of emotions
d. Consistently uses physical appearance to draw attention to self
e. Has a style of speech that is excessively impressionistic and lacking in detail
f. Shows self dramatization, theoretically and exaggerated expression of emotion
g. Is suggestible
h. Considers relationships to be more intimate than what they are
-Narcissistic Personality Disorder DSM 5 Diagnostic Criteria-
1, A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 5 or more of the following:
a. Is preoccupied with details, rules, list order, organization or schedules to the extent the major point of the activity is lost.
b. Shows perfectionism that interferes with task completion
c. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
d. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
e. Is unable to discard worn out or worthless objects even when they have no sentimental value
f. Is reluctant to delegate tasks to work with others unless they submit exactly to his or her way of doing things
g. Adopts miserly spending style toward both self and others, money is viewed as something to be hoarded for future catastrophies
h. Shows rigidity and stubbornness
-Schizotypal Personality Disorder DSM 5 Criteria-
-General Treatment of Personality Disorders-
1. Psychotherapy is generally regarded as first line treatment for patients with personality disorder
2. Pharmacotherapy is used as augmentation targeted at specific symptoms such as anxiety, depression, and insomnia
3. Benzodiazepines should be avoided whenever possible
4. Schizotypal patients may benefit from social training skills
-Personality disorder is diagnosed when personality traits are so inflexible and maladaptive across a wide range of situations they cause significant distress and impairment of social, occupational, and role functioning
-The DSM 5 includes 10 personality disorders grouped in three clusters based on similar qualities
-The DSM 5 includes 10 personality disorders grouped in three clusters based on similar qualities
-Cluster A-Individuals are odd and eccentric
1. Paranoid
2. Schizoid
3. Schizotypal
-Cluster B-Individuals are often dramatic, emotional, or erratic in their emotions and behavior
1. Histrionic
2. Narcissistic
3. Antisocial
4. Borderline
-Cluster C- Individuals often appear anxious or fearful
1. Avoidant
2. Dependent
3. Obsessive-compulsive
-The consistence of certain behaviors beginning in mid to late adolescence and continuing to adult life are suggestive of personality disorder
-Paranoid Personality Disorder DSM 5 Diagnostic Criteria:
1. A distrust and suspiciousness of other such that their motives are interpreted as malevolent, beginning by early adulthood, and present in a variety of context, as indicated by 4 or more of the following:
a. Suspects without basis that others are exploiting, harming or deceiving him or her.
b. Is occupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
c. Is reluctant to confide in others because of unwarranted fear that information will be used against him or her
d. Reads hidden demeaning or threatening meanings not benign remarks or events
e. Persistent bears grudges
f. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react or to counterattack
2. Does not occur exclusively during the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic features and is not attributable to another medical condition
-Schizoid Personality Diorder DSM 5 Diagnostic Criteria:
1. A pervasive pattern of detachment from social relationships and is a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more of the following:
a. Neither desires nor enjoys close relationships, including being part of a family
b. Almost always chooses solitary activities
c. Has little interest in having sexual experiences with another person
d. Takes pleasure in a few, if any activities
e. Lacks close friends or confidants other than first degree relatives
f. Appears indifferent to the praise or criticism of others
g. Shows emotional coldness, detachments, or flattened activity
2. Does not occur exclusively during the course of schizophrenia, bipolar disorder, or depressive disorder with psychotic features and is not attributable to another medical condition
-Histrionic Personality Disorder DSM 5 Diagnostic Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 2 or more of the following:
a. Is uncomfortable in situations in which he or she is not the center of attention
b. Interaction with others is often characterized by inappropriate sexuality seductive or provocative behavior
c. Displays rapidly shifting and shallow expression of emotions
d. Consistently uses physical appearance to draw attention to self
e. Has a style of speech that is excessively impressionistic and lacking in detail
f. Shows self dramatization, theoretically and exaggerated expression of emotion
g. Is suggestible
h. Considers relationships to be more intimate than what they are
-Narcissistic Personality Disorder DSM 5 Diagnostic Criteria-
1, A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 5 or more of the following:
a. Has grandiose sense of self importance
b. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
c. Believes he or she is "special" and unique and can only be understood by, or should associate with, other special or high status people
d. Requires excessive admiration
e. Has a sense of entitlement or favorable treatment or automatic compliance with his or her expectations
f. Is interpersonally exploitive (takes advance of others too achieve his own ends)
g. Lacks empathy
h. Is often envious of others believes others are envious of him or her
i. Shows arrogant, haughty behavior
-Avoidant Personality Diorder DSM 5 Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 4 or more of the following:
a. Avoids occupational activities that involve significant interpersonal conduct because of fears of criticism, disapproval, or rejection
b. Is unwilling to get involved with people unless certain of being liked
c. Shows restraint within intimate relationships because of the fear of being shamed or ridiculed
d. Is preoccupied with being criticized or rejected in social situations
e. Is inhibited in new interpersonal situations because of feelings of inadequacy
f. Views self as socially inept, personally unappealing and inferior to others
g. Is usually reluctant to take personal risks or to engage in any other new activities because they may prove to be embarrassing
-Dependent Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 5 or more of the following:
a. Has difficulty making everyday decisions without excessive amount of advice from others
b. Needs others to assume responsibility for most major areas of his or her life
c. Has difficulty expressing disagreement with others because of fear of loss of support or approval
d. Has difficulty initiating projects or doing things on his or her own because of lack of confidence in own judgement
e. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
f. Feels uncomfortable or helpless when alone because of exaggerated fear of being unable to care for self
g. Urgently seeks another relationship as a source of care and support when a close relationship ends.
h. Is unrealistically preoccupied with fears of being left to take care of themselves.
-Obsessive Compulsive Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 4 or more of the following:
f. Feels uncomfortable or helpless when alone because of exaggerated fear of being unable to care for self
g. Urgently seeks another relationship as a source of care and support when a close relationship ends.
h. Is unrealistically preoccupied with fears of being left to take care of themselves.
-Obsessive Compulsive Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 4 or more of the following:
a. Is preoccupied with details, rules, list order, organization or schedules to the extent the major point of the activity is lost.
b. Shows perfectionism that interferes with task completion
c. Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships
d. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values
e. Is unable to discard worn out or worthless objects even when they have no sentimental value
f. Is reluctant to delegate tasks to work with others unless they submit exactly to his or her way of doing things
g. Adopts miserly spending style toward both self and others, money is viewed as something to be hoarded for future catastrophies
h. Shows rigidity and stubbornness
-Schizotypal Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in variety of contexts as indicated by 5 or more of the following:
a. Ideas of reference (excluding delusions of reference)
b. Odd beliefs of magical thinking that influences behavior and is inconsistent with subcultural norms
c. Unusual perceptual experiences including bodily illusions
d. Odd thinking and speech
e. Suspicious or paranoid ideation
f. Inappropriate or constricted affect
g. Behavior or appearance that is odd, eccentric, or peculiar
h. Lack of close friends or confidants other than first degree relatives
i. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self
2. Does not occur exclusively during a schizophrenia course, a bipolar disorder or depressive disorder with psychotic features rather than negative judgements about self
-Antisocial Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of disregard for and violation to the rights of others, occurring since the age of 15, as indicated by three or more of the following:
a. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
b. Deceitfulness, as indicated by repeated lying, and use of aliases or conning others for personal profit or pleasure
c. Impulsivity or failure to plan ahead
d. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
e. Reckless disregard for safety or self or others
f. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
2. The individual is at least 18 years of age
3. There is evidence of conduct disorder with onset before the age of 15 years
4. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder
-Borderline Personality Disorder DSM 5 Criteria-
1. There is 3 homogenous components or dimensions of the disorder:
a. Impaired relatedness- unstable relationships with others, identity disturbance, and chronic emptiness
b. Affective dysregulation-affective lability, excessive anger, and efforts to avoid abandonment
c. Behavior dysregulation-impulsivity, suicidality, and self injurious behavior
b. Odd beliefs of magical thinking that influences behavior and is inconsistent with subcultural norms
c. Unusual perceptual experiences including bodily illusions
d. Odd thinking and speech
e. Suspicious or paranoid ideation
f. Inappropriate or constricted affect
g. Behavior or appearance that is odd, eccentric, or peculiar
h. Lack of close friends or confidants other than first degree relatives
i. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self
2. Does not occur exclusively during a schizophrenia course, a bipolar disorder or depressive disorder with psychotic features rather than negative judgements about self
-Antisocial Personality Disorder DSM 5 Criteria-
1. A pervasive pattern of disregard for and violation to the rights of others, occurring since the age of 15, as indicated by three or more of the following:
a. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest
b. Deceitfulness, as indicated by repeated lying, and use of aliases or conning others for personal profit or pleasure
c. Impulsivity or failure to plan ahead
d. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
e. Reckless disregard for safety or self or others
f. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
2. The individual is at least 18 years of age
3. There is evidence of conduct disorder with onset before the age of 15 years
4. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder
-Borderline Personality Disorder DSM 5 Criteria-
1. There is 3 homogenous components or dimensions of the disorder:
a. Impaired relatedness- unstable relationships with others, identity disturbance, and chronic emptiness
b. Affective dysregulation-affective lability, excessive anger, and efforts to avoid abandonment
c. Behavior dysregulation-impulsivity, suicidality, and self injurious behavior
-General Treatment of Personality Disorders-
1. Psychotherapy is generally regarded as first line treatment for patients with personality disorder
2. Pharmacotherapy is used as augmentation targeted at specific symptoms such as anxiety, depression, and insomnia
3. Benzodiazepines should be avoided whenever possible
4. Schizotypal patients may benefit from social training skills
Monday, November 24, 2014
Mood Disorders
Mood Disorders-
Adjustment Disorder-
-Adjustment mood disorder usually comes with depression that occurs in response to an identifiable psychosocial cause (ex marital discord, job loss, academic failure, or persistent painful illness)
-The stressor can be a single event or can involve many psychosocial stressors
-Adjustment disorder describes patients suffering from significant symptoms that do not meet the criteria for a specific depressive disorder
-Diagnostic criteria for adjustment disorder is as follows:
1. Decreased mood, tearfulness, and feeling of hopelessness that occur in response to an identifiable stressor within 3 months of the onset of the stressor
2. Symptoms are clinically significant by at least one of the following:
-Significant distress that exceeds what would be expected given the nature of the stressor
-Impaired social or occupational functioning
3. The syndrome does not meet criteria for another psychiatric disorder
4. The syndrome does not represent an exacerbation of a preexisting psychiatric disorder
5. The syndrome does not represent bereavement
6. After the stressor has ended, the syndrome resolves within 6 months
-Patients may need counseling. Sometimes require SSRI's.
-Bipolar Disorder-
-Bipolar disorder is a mood disorder that is characterized by episodes of mania, hypomania, and major depression
-There is subtypes of bipolar disorder such as bipolar I and bipolar II
-Bipolar I- experience manic episoders and nearly always experience major depressive and hypomania episodes
-Bipolar II-is at least one hypomanic episode, at least one depression episode, and the absence of manic episodes
-Some patients will have euthymia between episodes and other patients will not have euthymia between cycles
-Many studies have demonstrated a promo and symptoms such as irritability, anxiety, mood lability, agitation, aggressiveness, sleep disturbance, and hyperactivity may precede a diagnosable disorder
-Mania episoders involve clinically significant changes in mood, behavior, energy, sleep, and cognition
-Hypomanic episodes involve changes in mood, behavior, energy, sleep, and cognition, that are similar to mania, but are less severe
-Psychosis such as delusions and hallucinations can occur during manic, major depression, and mixed episodes
-Biopolar disorder patients will often have comorbid disorders such as anxiety disorder, substance use disorders, ADHD, Eating Disorders, intermittent explosive disorders, and personality disorders
-Suicide attempts are common with bipolar disorder
-Bipolar I is diagnosed in patients with one or more manic episodes. Hypomania often occurs. Bipolar I disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder. The course of the illness is characterized by rapid cycling or a seasonal pattern, and whether the mood episodes are marked by psychotic features, catatonia, anxious distress, mixed features, melancholic features, atypical features, or peripartum onset.
-Bipolar II is diagnosed in patients with at least one episode of hypomania, at least one major depression episode, and no history of mania. Bipolar II disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder.
-The goal of treatment of acute mania and hypomania is remission.
-Drugs commonly used in acute mania and hypomania include: Lithium, Anticonvulsants, Antipsychotics, and Benzodiazepines.
-It is reasonable to allow up to two weeks in a treatment trial to determine if effective
-Patients that do not respond to 4-6 medication combinations for treating mania are candidates for ECT.
-Hypomania can usually be treated with monotherapy with Risperdal or Zyprexa
-Benzodiazepines are appropriate for patients that cannot tolerate lithium, anticonvulsants, or anti-psychotics
-Depressive symptoms can be treated with SSRI's but need to be started with a mood stabilizers
-Depression-
-The term depression refers a mood state which may be part of a syndrome. Depression may refer to a constellation of symptoms and signs. It may also refer to a mental disorder that identifies a distinct clinical condition (unipolar major depression)
-During an assessment of a depression patient you should assess suicide risk, agitation, history of mania.
-Unipolar Major Depression (Major Depression Disorder) is characterized by a history of one or more major depressive episodes with no history of mania or hypomania
-A major depressive episode is characterized by 5 or more of the symptoms occurring for at least two consecutive weeks; and at least one symptom either depressed mood or loss of interest or pleasure
1. Depressed mood for most of the day, nearly every day
2. Loss of interest or pleasure in most of all activities, nearly every day
3. Insomnia or hypersomnia nearly every day
4. Significant weight loss or weight gain (5 percent with a month)
5. Psychomotor retardation or agitation that is observable by others
6. Fatigue or low energy nearly every day
7. Decreased concentration
8. Thoughts of worthlessness or excessive guilt
9. Recurrent thought of death or suicide ideation, or a suicide attempt
-There are subtypes of of depressive episodes they include: anxious distress, atypical features, catatonia, melancholic features, mixed features, peripartum onset, seasonal onset, and psychotic features
-Most minor depressive episodes are treated by primary care clinicians
-For patients with minor depression who are moderately to severely ill psychotherapy should be considered first line therapy
-Moderate to severe episodes of minor depression that are not responsive to psychotherapy should have an antidepressant such as an SSRI introduced to regimen
-Patients should be referred when patients whom the diagnosis of depression or comorbidities are uncertain, depression that endangers the life of the patient or others, severe psychotic or catatonic depression, and depression that occurs within the context of bipolar disorder
-Dysthymia (Persistent Depressive Disorder)-DSM 5 Criteria
1. Depressed for most of the day, for most days than not for at least two years. Children and adolescents must be at least 1 year
2. The presence of a 2 or more of the following:
-Poor appetite or overeating
-Insomnia or hyperinsomnia
-Low energy or fatigue
-Low self esteem
-Poor concentration or difficulty making decisions
-Feelings of hopelessness
3. During the period of time the individual has not been without the symptoms for at least two months.
4. Criteria for major depression disorder may be continuous present for two years
5. There has never been any mania or hypomania
6. The disturbance is not better explained my a persistent schizoaffective disorder, schizophrenia, delusional disorder, or unspecified schizophrenia spectrum and other psychotic disorder
7. Symptoms are not attributable to substance abuse or other medical condition (hypothyroidism)
8. These symptoms cause a significant distress or impairment in social, occupational, or other areas of functioning
-Dysthymia is best treated with SSRI's or SNRI's and atypical antidepressants, serotonin modulators, tricyclic antidepressants
-Dysthymia really should have some combination of psychotherapy and antidepressants
-The stressor can be a single event or can involve many psychosocial stressors
-Adjustment disorder describes patients suffering from significant symptoms that do not meet the criteria for a specific depressive disorder
-Diagnostic criteria for adjustment disorder is as follows:
1. Decreased mood, tearfulness, and feeling of hopelessness that occur in response to an identifiable stressor within 3 months of the onset of the stressor
2. Symptoms are clinically significant by at least one of the following:
-Significant distress that exceeds what would be expected given the nature of the stressor
-Impaired social or occupational functioning
3. The syndrome does not meet criteria for another psychiatric disorder
4. The syndrome does not represent an exacerbation of a preexisting psychiatric disorder
5. The syndrome does not represent bereavement
6. After the stressor has ended, the syndrome resolves within 6 months
-Patients may need counseling. Sometimes require SSRI's.
-Bipolar Disorder-
-Bipolar disorder is a mood disorder that is characterized by episodes of mania, hypomania, and major depression
-There is subtypes of bipolar disorder such as bipolar I and bipolar II
-Bipolar I- experience manic episoders and nearly always experience major depressive and hypomania episodes
-Bipolar II-is at least one hypomanic episode, at least one depression episode, and the absence of manic episodes
-Some patients will have euthymia between episodes and other patients will not have euthymia between cycles
-Many studies have demonstrated a promo and symptoms such as irritability, anxiety, mood lability, agitation, aggressiveness, sleep disturbance, and hyperactivity may precede a diagnosable disorder
-Mania episoders involve clinically significant changes in mood, behavior, energy, sleep, and cognition
-Hypomanic episodes involve changes in mood, behavior, energy, sleep, and cognition, that are similar to mania, but are less severe
-Psychosis such as delusions and hallucinations can occur during manic, major depression, and mixed episodes
-Biopolar disorder patients will often have comorbid disorders such as anxiety disorder, substance use disorders, ADHD, Eating Disorders, intermittent explosive disorders, and personality disorders
-Suicide attempts are common with bipolar disorder
-Bipolar I is diagnosed in patients with one or more manic episodes. Hypomania often occurs. Bipolar I disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder. The course of the illness is characterized by rapid cycling or a seasonal pattern, and whether the mood episodes are marked by psychotic features, catatonia, anxious distress, mixed features, melancholic features, atypical features, or peripartum onset.
-Bipolar II is diagnosed in patients with at least one episode of hypomania, at least one major depression episode, and no history of mania. Bipolar II disorder may not be better accounted for by schizoaffective disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder.
-The goal of treatment of acute mania and hypomania is remission.
-Drugs commonly used in acute mania and hypomania include: Lithium, Anticonvulsants, Antipsychotics, and Benzodiazepines.
-It is reasonable to allow up to two weeks in a treatment trial to determine if effective
-Patients that do not respond to 4-6 medication combinations for treating mania are candidates for ECT.
-Hypomania can usually be treated with monotherapy with Risperdal or Zyprexa
-Benzodiazepines are appropriate for patients that cannot tolerate lithium, anticonvulsants, or anti-psychotics
-Depressive symptoms can be treated with SSRI's but need to be started with a mood stabilizers
-Depression-
-The term depression refers a mood state which may be part of a syndrome. Depression may refer to a constellation of symptoms and signs. It may also refer to a mental disorder that identifies a distinct clinical condition (unipolar major depression)
-During an assessment of a depression patient you should assess suicide risk, agitation, history of mania.
-Unipolar Major Depression (Major Depression Disorder) is characterized by a history of one or more major depressive episodes with no history of mania or hypomania
-A major depressive episode is characterized by 5 or more of the symptoms occurring for at least two consecutive weeks; and at least one symptom either depressed mood or loss of interest or pleasure
1. Depressed mood for most of the day, nearly every day
2. Loss of interest or pleasure in most of all activities, nearly every day
3. Insomnia or hypersomnia nearly every day
4. Significant weight loss or weight gain (5 percent with a month)
5. Psychomotor retardation or agitation that is observable by others
6. Fatigue or low energy nearly every day
7. Decreased concentration
8. Thoughts of worthlessness or excessive guilt
9. Recurrent thought of death or suicide ideation, or a suicide attempt
-There are subtypes of of depressive episodes they include: anxious distress, atypical features, catatonia, melancholic features, mixed features, peripartum onset, seasonal onset, and psychotic features
-Most minor depressive episodes are treated by primary care clinicians
-For patients with minor depression who are moderately to severely ill psychotherapy should be considered first line therapy
-Moderate to severe episodes of minor depression that are not responsive to psychotherapy should have an antidepressant such as an SSRI introduced to regimen
-Patients should be referred when patients whom the diagnosis of depression or comorbidities are uncertain, depression that endangers the life of the patient or others, severe psychotic or catatonic depression, and depression that occurs within the context of bipolar disorder
-Dysthymia (Persistent Depressive Disorder)-DSM 5 Criteria
1. Depressed for most of the day, for most days than not for at least two years. Children and adolescents must be at least 1 year
2. The presence of a 2 or more of the following:
-Poor appetite or overeating
-Insomnia or hyperinsomnia
-Low energy or fatigue
-Low self esteem
-Poor concentration or difficulty making decisions
-Feelings of hopelessness
3. During the period of time the individual has not been without the symptoms for at least two months.
4. Criteria for major depression disorder may be continuous present for two years
5. There has never been any mania or hypomania
6. The disturbance is not better explained my a persistent schizoaffective disorder, schizophrenia, delusional disorder, or unspecified schizophrenia spectrum and other psychotic disorder
7. Symptoms are not attributable to substance abuse or other medical condition (hypothyroidism)
8. These symptoms cause a significant distress or impairment in social, occupational, or other areas of functioning
-Dysthymia is best treated with SSRI's or SNRI's and atypical antidepressants, serotonin modulators, tricyclic antidepressants
-Dysthymia really should have some combination of psychotherapy and antidepressants
Sunday, November 23, 2014
Eating Disorders
Eating Disorders-
Anorexia Nervosa-
-Anorexia nervosa is a disorder that the patient has an abnormally low body weight, intense fear of gaining weight, and distorted perception of body weight and shape.
-The term anorexia is not correct because the patient maintains their appetite
-Associated features of anorexia nervosa include: relentless pursuit of thinness, fear of certain foods, obsessional preoccupation with food, preference for low calorie foods, overuse of condiments, concerns about eating in public, social withdrawal, exercise related rituals, restlessness or hyperactivity, resistance to treatment and weight gain, feeling of ineffectiveness, poor sleep, dysphoria, low libido, inflexible thinking, need to control their environment, and perfectionism
-Anorexia occurs more in females than males
-Medical complications of anorexia include: emaciation, hypothermia, bradycardia, hypotension, hypoactive bowel sounds, amenorrhea, xerosis, brittle hair, and hair loss
-Common laboratory findings with anorexia include: leukopenia, elevated BUN, hypercholesterolemia, low estrogen levels, low T3, and low testosterone in males, and low bone mineral density
-Common comorbid conditions include with anorexia nervosa include: anxiety disorders, obsessive compulsive disorders, body dysmorphic disorders, post traumatic stress disorder, mood disorders, substance abuse disorders, disruptive impulse control and conduct disorders
-According to the DSM 5 Anorexia Nervosa must have all of the following:
1. Restriction of energy intake that leads to low body weight, given the patients age, sex, developmental trajectory, and physical health
2. Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight
3. Distorted perception of body weight and shape, undue influence, of weight and shape on self worth or denial of medical seriousness of one's low body weight.
-The treatment of anorexia nervosa involves nutritional rehabilitation and psychotherapy.
-Patients should also be monitor for complications of their anorexia nervosa
-Types of psychotherapy involved include: cognitive behavior therapy, specialist supportive clinical management, motivational interviewing, and family therapy
-Medications are not the indicated for the initial treatment of anorexia. Adjunctive medical therapy is indicated for the acutely ill patients who do not respond to initial treatment with nutritional rehabilitation and psychotherapy
-Bulimia Nervosa-
-Bulimia nervosa is episodes of binge eating which patients use inappropriate compensatory methods to prevent weight gain, including self induced vomiting, misuse of laxatives, diuretics, and enemas. Can also use excessive exercise, fasting and strict diets
-Common physical signs of bulimia nervosa include: tachycardia, hypotension, xerosis, parotid gland swelling, and erosion of dental enamel
-Many medical complication of bulimia nervosa and affects many systems: gastrointestinal, cardiac, endocrine, dental, skin, and renal and electrolytes
-Core features of bulimia nervosa include: binge eating, inappropriate compensatory behavior, excessive concern about body weight and shape
-Patients with bulimia nervosa can have comorbid disorders: anxiety disorders, depression disorders, post traumatic stress disorder, and substance use disorders
-Common personality disorders associated with Bulimia Nervosa include: borderline, avoidant, dependent, paranoid, histrionic, and obsessive compulsive disorder
-DSM 5 Criteria for Bulimia Nervosa includes the each of the following:
1. Episodes of binge eating
2. Inappropriate compensatory behavior to prevent weight gain
3. The patients self evaluation is unduly influenced by the body shape and weight
4. The disturbance does not occur exclusively during episodes of anorexia nervosa
-The treatment of Bulimia Nervosa includes nutritional rehabilitation, psychotherapy, and pharmacology.
-First line medication for Bulimia is the SSRI, Prozac
-Second line medication consider celexa, luvox, or zoloft
-Obesity-
-Obesity is defined by a BMI over 30 kg/m2
-Severe obesity is considered a BMI over 40 kg/m2
-The initial management of individuals who would benefit from weight loss is lifestyle intervention, a combination of diet, exercise, and behavior modification
-Some patients may require pharmacologic therapy or bariatric surgery
-Pharmacologic therapy can include: orilstat, locaserin, combination phentermine or topamax
-For patients with a BMI greater than 30 kg/m2 or a BMI 27-29.9 kg/m2 with comorbidities who have failed to achieve weight loss goals though diet and exercise alone, pharmacologic therapy should be added to lifestyle intervention
-For patients with a BMI greater than 40 kg/m2 who have failed diet and exercise, bariatric surgery is recommended
-The term anorexia is not correct because the patient maintains their appetite
-Associated features of anorexia nervosa include: relentless pursuit of thinness, fear of certain foods, obsessional preoccupation with food, preference for low calorie foods, overuse of condiments, concerns about eating in public, social withdrawal, exercise related rituals, restlessness or hyperactivity, resistance to treatment and weight gain, feeling of ineffectiveness, poor sleep, dysphoria, low libido, inflexible thinking, need to control their environment, and perfectionism
-Anorexia occurs more in females than males
-Medical complications of anorexia include: emaciation, hypothermia, bradycardia, hypotension, hypoactive bowel sounds, amenorrhea, xerosis, brittle hair, and hair loss
-Common laboratory findings with anorexia include: leukopenia, elevated BUN, hypercholesterolemia, low estrogen levels, low T3, and low testosterone in males, and low bone mineral density
-Common comorbid conditions include with anorexia nervosa include: anxiety disorders, obsessive compulsive disorders, body dysmorphic disorders, post traumatic stress disorder, mood disorders, substance abuse disorders, disruptive impulse control and conduct disorders
-According to the DSM 5 Anorexia Nervosa must have all of the following:
1. Restriction of energy intake that leads to low body weight, given the patients age, sex, developmental trajectory, and physical health
2. Intense fear of gaining weight or becoming fat, or persistent behavior that prevents weight gain, despite being underweight
3. Distorted perception of body weight and shape, undue influence, of weight and shape on self worth or denial of medical seriousness of one's low body weight.
-The treatment of anorexia nervosa involves nutritional rehabilitation and psychotherapy.
-Patients should also be monitor for complications of their anorexia nervosa
-Types of psychotherapy involved include: cognitive behavior therapy, specialist supportive clinical management, motivational interviewing, and family therapy
-Medications are not the indicated for the initial treatment of anorexia. Adjunctive medical therapy is indicated for the acutely ill patients who do not respond to initial treatment with nutritional rehabilitation and psychotherapy
-Bulimia Nervosa-
-Bulimia nervosa is episodes of binge eating which patients use inappropriate compensatory methods to prevent weight gain, including self induced vomiting, misuse of laxatives, diuretics, and enemas. Can also use excessive exercise, fasting and strict diets
-Common physical signs of bulimia nervosa include: tachycardia, hypotension, xerosis, parotid gland swelling, and erosion of dental enamel
-Many medical complication of bulimia nervosa and affects many systems: gastrointestinal, cardiac, endocrine, dental, skin, and renal and electrolytes
-Core features of bulimia nervosa include: binge eating, inappropriate compensatory behavior, excessive concern about body weight and shape
-Patients with bulimia nervosa can have comorbid disorders: anxiety disorders, depression disorders, post traumatic stress disorder, and substance use disorders
-Common personality disorders associated with Bulimia Nervosa include: borderline, avoidant, dependent, paranoid, histrionic, and obsessive compulsive disorder
-DSM 5 Criteria for Bulimia Nervosa includes the each of the following:
1. Episodes of binge eating
2. Inappropriate compensatory behavior to prevent weight gain
3. The patients self evaluation is unduly influenced by the body shape and weight
4. The disturbance does not occur exclusively during episodes of anorexia nervosa
-The treatment of Bulimia Nervosa includes nutritional rehabilitation, psychotherapy, and pharmacology.
-First line medication for Bulimia is the SSRI, Prozac
-Second line medication consider celexa, luvox, or zoloft
-Obesity-
-Obesity is defined by a BMI over 30 kg/m2
-Severe obesity is considered a BMI over 40 kg/m2
-The initial management of individuals who would benefit from weight loss is lifestyle intervention, a combination of diet, exercise, and behavior modification
-Some patients may require pharmacologic therapy or bariatric surgery
-Pharmacologic therapy can include: orilstat, locaserin, combination phentermine or topamax
-For patients with a BMI greater than 30 kg/m2 or a BMI 27-29.9 kg/m2 with comorbidities who have failed to achieve weight loss goals though diet and exercise alone, pharmacologic therapy should be added to lifestyle intervention
-For patients with a BMI greater than 40 kg/m2 who have failed diet and exercise, bariatric surgery is recommended
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