Psych II Flashcards

Question

The severity of Bulimia nervosa is also categorised based on the frequency of inappropriate compensatory behaviours (as per DSM-5): What determines mild, moderate, severe and extreme bulimia? [4]

Answer 1

**Mild**: An average of 1-3 episodes per week. **Moderate**: An average of 4-7 episodes per week. **Severe**: An average of 8-13 episodes per week. **Extreme**: An average of 14 or more episodes per week.

Answer 2

**Psychological Assessment** - **Semi-structured interviews: The Eating Disorder Examination (EDE)** is considered the **gold standard** for diagnosing eating disorders including BN. - **Self-report questionnaires**: **Tools such as the Bulimia Test-Revised (BULIT-R) or Eating Disorders Inventory (EDI)** can be used to supplement clinical interviews and provide additional information about symptom severity and related psychological features. **Laboratory Investigations** * **FBC**: anaemia or infection * **U&Es:** hypokalaemia; AKIs * **LFTS**: malnutrition or alcohol abuse **Radiological Investigations** (not routine) - **DEXA** scan - **Gastrointestinal imaging** **ECG**

Answer 3

The diagnostic criteria for Bulimia Nervosa, as per the ICD-10 and DSM-5, are outlined below. It's imperative to note that these criteria are not exhaustive and should be used in conjunction with clinical judgement. **ICD-10 Criteria:** * A **persistent preoccupation with eating, and an irresistible craving for food**; the patient succumbs to **episodes of overeating** in which **large amounts of food** are consumed in short periods of time. * The patient attempts to **counteract the 'fattening' effects of food by induced vomiting, purgative abuse, alternating periods of starvation, or use of drugs such as appetite suppressants**. * If the disorder occurs in diabetic patients they may choose to **neglect their insulin treatment.** **DSM-5 Criteria:** * **Recurrent episodes of binge eating** characterised by **both consuming an amount of food that is definitely larger than most people would eat during a similar period under similar circumstances and a sense of lack of control over eating during the episode**. * Recurrent inappropriate compensatory behaviours to** prevent weight gain such as self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise.** * The binge eating and inappropriate compensatory behaviours both occur, on average, **at least once a week for three months.** * Self-evaluation is unduly influenced by body shape and weight.

Answer 4

**Psychotherapy**: * **Step 1** - Bulimia-nervosa-focused guided self-help programmes * **Step 2**: Eating-disorder-focused cognitive behavioural therapy **(CBT-ED)** * Offer CBT-ED to adults with BN as it has been shown to reduce binge-eating and purging behaviours. * If CBT-ED is not available or the patient declines, consider other forms of psychological therapy such as interpersonal psychotherapy or dialectical behaviour therapy. **Pharmacotherapy**: * Selective serotonin reuptake inhibitors (SSRIs), specifically **fluoxetine**, have been approved by the Food and Drug Administration for BN treatment. However, they should be **used in conjunction with psychotherapy rather than standalone treatment.** * If SSRIs are contraindicated or not tolerated, consider other types of antidepressants like **tricyclics or monoamine oxidase inhibitors** after discussing potential side effects and monitoring requirements. **Dietetic Support:** * A registered dietitian can provide valuable input regarding meal planning and nutritional rehabilitation. They can also help address any distorted beliefs about food and weight. **Physical Health Monitoring:** * Routine monitoring of vital signs and electrolytes is crucial due to the risk of complications associated with purging behaviours. Electrocardiogram may be required in some cases. **Inpatient or Day Patient Care:** * Consider inpatient care for patients who are medically unstable or for whom outpatient treatment has failed. The goal should be to stabilise the patient's physical health while continuing with psychotherapeutic interventions.

Answer 5

**S** – Do you make yourself **S**ick because you feel uncomfortably full? **C** – Do you worry you have lost **C**ontrol over how much you eat? **O** – Have you recently lost more than **O**ne stone (6.35 kg) in a three-month period? **F** – Do you believe yourself to be **F**at when others say you are too thin? **F** – Would you say **F**ood dominates your life? **Two or more positive responses is considered indicative of anorexia nervosa or bulimia nervosa.**

Answer 6

The patients **height, weight and BMI** should be recorded - In those **under the age of 18**, the BMI should be **plotted on a centile chart**. Evaluate the **patient's hydration status** - dehydration can be significant, and may warrant inpatient management. **Vital signs:** - **bradycardia, hypothermia and postural blood pressure** drop are all red flags for severe disease. **Sit-up, Squat–stand test**: tests the patient's ability to sit up from lying and to squat down and stand back up. Scored from 0-3 with increasing risk with lower scores: * **0**: unable to complete action * **1**: requires the assistance of upper limbs * **2**: noticeable difficulty * **3**: no difficulty

Answer 7

**ECG**: - **bradycardia, prolonged QT interval or arrhythmias** are all signs of high-risk disease requiring urgent review. **Blood sugar**: - significant malnutrition can result in **hypoglycaemia** (also consider diabetes as a cause of unexplained weight loss). **Blood tests**: - consider FBC, LFTs, renal function, bone profile, magnesium, thyroid profile. - This allows review for anaemia, electrolyte disturbance and thyroid dysfunction amongst other abnormalities. In severe malnutrition mild derangement of liver function tests is common. **Additional**: - pregnancy test should be considered where appropriate. Hormonal panels may be indicated in women with menstrual dysfunction. Further tests may be required depending on the given individual presentation.

Answer 8

The combination of binging and inappropriate compensatory behaviours occurs, on average, **at least once a week for 3 months.**

Answer 9

**Step 1 - Bulimia-nervosa-focused family therapy (FT-BN)** **Step 2 - Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)**

Answer 10

In the management of anorexia nervosa with comorbid depression, **mirtazapine** can be effective due to its ability to promote weight gain, improve anxiety and depression symptoms, and increase growth hormone release.

Answer 11

The **VMPFC** is **hyperactive** in depression1 The **LOPFC** is **hyperactive** in depression1 The **DLPFC** is **hypoactive** in depression1

Answer 12

**Hippocampus**: has a role in episodic, contextual learning and memory - The hippocampus is involved in cognitive, emotional, and neuroendocrine regulation. It is rich in glucocorticoid receptors and is a recipient of significant input from excitatory glutaminergic neurons - get **shrinking / atrophy of the hippocampus during depression** - **Stress impairs neo neurogenesis** (develop new neurons) ## Footnote **NB**: Chronic repeated episodes of depression may lead to progressive hippocampal atrophy over time, possibly increasing the risk for subsequent depressive relapse

Answer 13

Antidepressants cause an increased release of **brain derived neutrophin** - Use of **antidepressants with 5-HT and/or NA** can possibly **regulate the expression of BDNF** by **activating** intracellular cascades that eventually lead to synthesis of **BDNF2** **Delayed action**: - Requirement for **adaptive changes** at **different receptor sites** - Activation transcription factors and gene expression - Activation of **neo neurogenesis**(hippocampus) **possibly via ↑BDNF concentrations**

Answer 14

**Anticholinergic** * Dry mouth, * Blurred vision * Urinary hesitancy (urinary retention) * Constipation * Memory impairment * Aggravation of narrow angle glaucoma **Antihistaminic** * Sedation * Weight gain **Alpha1 adrenoceptor antagonism** * Orthostatic hypotension * Cardiac effects

Answer 15

**Cardiovascular effects** * Sinus tachycardia * Arrhythmias * Conduction delay at AVN - risk of VT and VF (how they die if by TCA OD) * Sudden death **Other side effects** * Sexual dysfunction * Impaired cognitive and psychomotor skills * Convulsions

Answer 16

**Nausea/vomiting** Abdominal pain Dry mouth Constipation/diarrhoea **Headache** Asthenia Dizziness Insomnia/somnolence **Sweating** Anorexia Weight loss Nervousness/agitation Tremor Convulsions Dystonic reactions **Sexual dysfunction** (reduced libido, anorgasmia)

Answer 17

**Alpha 2 adrenoceptor blockade** - when NT concentration reaches a critical concentration in the cleft - the alpha 2 receptors are activated (which stops further release of NTs). So when blocked - continue releasing - Also works post-synaptically..

Answer 18

**Sedation and weight gain** - due to increased appetite (also due to an anti-histaminic effect) - But can be useful e.g. if have **insomnia** ## Footnote NB: Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications.

Answer 19

**Grapefruit juice with carbamazepine**. CY p450 3A4 inhibited. **Carbamazepine blood level rises significantly.** →**Sedation, nausea, and tremor**.

Answer 20

A **response** is defined as a **50% improvement** in symptoms as measured by the HAM-D score2

Answer 21

After **6 months** of **normal, stable mood** - **Taper off slowly – 8-12 weeks/longer** Antidepressant drugs are **not addictive** and **do not cause dependence however**, their **abrupt discontinuation** may cause **unpleasant symptoms** and it is advisable they **tapered off in clinical practice** - get **discontinuation syndrome**

Answer 22

**amitriptyline and dosulepin (dothiepin)** are considered the most dangerous in overdose **lofepramine** has a lower incidence of toxicity in overdose

Answer 23

Tricyclic OD is managed by **Sodium bicarbonate**

Answer 24

**Patients** should be counselled to be **vigilant for increased anxiety and agitation** after starting a **SSRI** Following the initiation of antidepressant therapy patients should normally be **reviewed by a doctor after 2 weeks** - For **patients under the age of 30 years or at increased risk of suicide** they should be **reviewed after 1 week**. - If a patient makes a good response to antidepressant therapy they should continue on treatment for at **least 6 months after remission as this reduces the risk of relapse.**

Answer 25

adults: **40mg** - adults over 65: **20mg** - adults with hepatic impairment: **20mg**

Answer 26

**Aspirin & NSAIDs** - inreasd risk of ulcers. Prescribe alongside a PPI if need NSAID **Triptans** **Warfarin / heparin** - use mirtazapine instead

Psych II Flashcards

(52 cards)