Eating Disorders and Sleep Disorders: Diagnosis and Treatment, Exams of Psychiatry

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CLINMED - Feeding/Eating, Somatoform/

Chronic Pain, Neurocognitive, Sleep-

Wake Disorders

Patients restrict food intake but do not regularly engage in binge eating or purging behavior; some patients exercise excessively - ANS Restricting type Anorexia Nervosa Patients regularly binge eat and then induce vomiting and/or misuse laxatives, diuretics, or enemas. - ANS Binge-eating/purging type Anorexia Nervosa Anorexia nervosa can be distinguished from bulimia nervosa by BMI of what? - ANS < 17 Fear of gaining weight and patient weighs less than 85% of normal? - ANS Anorexia nervosa Which eating disorder is commonly associated with mitral valve prolapse, pericardial effusion, and myocardial atrophy? - ANS Anorexia nervosa What condition do you suspect in a patient who refuses to eat due to fear of being overweight? - ANS Anorexia nervosa If body weight is < what of expected body weight when should a pt be hospitalized - ANS if weight is < 75% Tx for Anorexia nervosa - ANS Restore nutritional state Intense fear of obesity despite slenderness - ANS Anorexia nervosa What CV effects may occur in pts with Anorexia nervosa - ANS Supraventricular long QT syndrome

Patient will present as → a 19-year-old female who has lost 40 pounds over the last 6 months. Her body mass index is 16. When asked about her most recent meal, the patient reports that she ate an apple the previous morning. - ANS Restricting type Anorexia Nervosa Frequent binge eating with or without purging - ANS Bulimia nervosa Purging commonly performed by self-induced vomiting resulting in metabolic alkalosis - ANS Bulimia nervosa May abuse laxatives/diuretics or exercise excessively Patients are disturbed by their behavior - ANS Bulimia nervosa Binging and compensatory behaviors occur at least once a week for 3 months - ANS Bulimia nervosa scars on knuckles, swollen parotid glands + dental erosions + normal weight +hypokalemia - ANS Bulimia nervosa Tx for Bulimia nervosa - ANS Restore Nutritional state Fluoxetine 60mg PO Self induced vomiting Laxative and/or diuretic abuse

Prolonged fasting Excessive exercise Teeth enamel destruction - ANS Bulimia nervosa What condition is the bipolar of eating disorders - ANS Bulimia nervosa Extreme caloric restriction between episodes occurs in what condition - ANS Bulimia nervosa A 20-year-old college student presents to her dentist. Her vital signs are normal, and her weight is 120 lb. On examination, extensive upper dental erosion is noted. The most likely diagnosis is - ANS Bulimia nervosa Which of the following electrolyte abnormalities is associated with bulimic patients? - ANS Metabolic alkalosis Patient will present as → a 14-year-old is female who is brought to your clinic by her mother who claims to hear the child vomiting after dinner in the evenings. The patient reportedly denies vomiting and feels fine. On physical exam, you notice petechial hemorrhages of the soft palate and conjunctiva. Further exam reveals scars on her knuckles, swollen parotid glands, dental erosions. Her weight is normal. Lab tests reveal hypochloremia and hypokalemia. - ANS Bulimia nervosa Recurrent binge eating at least once per week for 3 months - ANS Binge Eating Disorder Eating, in a discrete period of time, an amount of food that is definitely larger than what most people would eat - ANS Binge Eating Disorder

A sense of lack of control over eating during the episode - ANS Binge Eating Disorder Binge eating episodes associated with three (or more) sxs - ANS Binge Eating Disorder Tx for Binge Eating Disorder - ANS Psychotherapy Patient will present as → a 22-year-old female who admits to episodes of binge eating 3-4 days per week off and on for the past 3 years. She eats very quickly until she feels "stuffed" and she reports eating large amounts of food even when she is not hungry. Because she is embarrassed by her behavior she often chooses to eat alone. Afterward, she reports feeling disgusted, depressed, and guilty. The patient is 5 ' 7" and weighs 225 pounds, her BP is 135/75 and her fasting blood sugar is 121. She takes Fluoxetine (Prozac) 20 mg q day for depression. - ANS Binge Eating Disorder Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others - ANS Body Dysmorphic Disorder Preoccupation with an imagined defect in physical appearance/exaggerated distortion of a minor flaw - ANS Body Dysmorphic Disorder Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. performed repetitive behaviors (mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) i - ANS Body Dysmorphic Disorder Pts with what are most commonly preoccupied with hair or facial features such as the shape of the nose

• ANS Body Dysmorphic Disorder Tx for Body Dysmorphic Disorder - ANS SSRIs

Therapy Patient will present as → a 24-year-old male with a history of acne presents with concerns about acne scarring on his face. On exam, you notice very few scattered pustules but no noticeable scarring. You recommend the use of topical benzoyl peroxide cream and send him home. The patient returns for a follow-up three months later, this time very concerned. He reports that he is having trouble sleeping at night because of concern over his appearance. He feels people are staring at him because of his acne. He is very self-conscious, has been avoiding social events, and has trouble approaching girls. He is having trouble concentrating in class, which is now affecting his grades. He washes his face at least six times per day and admits to spending several hours each day in front of the mirror. He is requesting something stronger for his acne and heard from a friend about Accutane. Again on the exam, you notice only very mi - ANS Body Dysmorphic Disorder What is Functional Neurologic Symptom Disorder also known as - ANS conversion disorder The somatic manifestation that takes the place of anxiety in conversion disorder is what - ANS paralysis This is a mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation - ANS conversion disorder May display an unexpected lack of concern to symptoms Episodic, lasting a few days or up to 1 mos - ANS conversion disorder Acute stressor/trauma occurs Paralysis occurs suddenly and is debilitating

Lack of concern with physical sxs occuring - ANS conversion disorder Tx for conversion disorder - ANS Therapy +/- short term anxiolytics A mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation. - ANS conversion disorder Patient will present as → a 20-year-old female with dizziness, along with numbness and severe weakness on the left side of her body and her left leg. She also complains of moderate low back pain. The patient was recently involved in a bicycle collision with a motor vehicle 3 days ago where she was clipped while crossing an intersection, causing her to crash hard on her left side. She doesn't remember if she hit her head, but she was wearing a helmet. She was taken to the local, rural hospital to screen for a concussion, which came back negative. She had a CT of the head in the ED which was normal and she was released quickly from the hospital. Since the injury 3 days ago, the patient reports her dizziness has converted to double vision, has difficulty swallowing like there is a lump in her throat, and notices occasional slurred words. She continues to have difficulty walking and loss of balance since the accident. Sh - ANS conversion disorder Preoccupation with having a serious illness - ANS Somatization disorder The patient experiences excessive thoughts, feelings, and behaviors in relation to their somatic symptoms or their health concerns. - ANS Somatization disorder This is characterized by one or more somatic symptoms that are associated with significant distress or disability - ANS Somatization disorder o be diagnosed with somatic symptom disorder the somatic symptom must be persistent for ≥ _____________ although these symptoms don't have to always be present - ANS 6 months •Preoccupation with medical and surgical therapy becomes a lifestyle that may exclude other activities. - ANS Somatization disorder

Patient will present as → a 25-year-old female who presents today with multiple complaints that have been ongoing for more than 6 months. She reports that "it all started about 10 months ago with pain in my neck, shoulders, back, legs, and feet." She denies any trauma. There is no family history of juvenile rheumatoid arthritis or osteoarthritis. She stated that the pains do not respond to treatments, and they "just come and go making it difficult to hold a job." She is constantly worried about her symptoms. Now, she has a headache, abdominal pain, bloating, and "some seizures." She previously had seen a headache specialist, gastroenterologist, and obtained a number of electrocardiograms in the emergency department. Their respective thorough workup was negative. Her mother had similar episodes as well. On physical exam, you note an anxious woman with a depressed affect. No significant physical exam findings are noted - ANS Somatization disorder Patient consciously reports false symptoms, or induces symptoms, with the goal of playing the "sick" role. - ANS Factitious Disorder A condition in which a person, without a motive for reward, acts as if they have an illness - ANS Factitious Disorder Pts with what are characterized by self-induced or described symptoms or false physical and laboratory findings for the purpose of deceiving clinicians or other health care personnel. - ANS Factitious Disorder This is diagnosed when someone (often a parent) creates an illness in another person (often a child) for perceived psychological benefit of the first person, such as sympathy or a relationship with clinicians. - ANS Munchausen by proxy Tx for Factitious Disorder - ANS Conjoint confrontation by the PCP and the psychiatrist Factitious disorder imposed on self - ANS Munchausen syndrome Factitious disorder imposed on another person (e.g., a child) - ANS Munchausen syndrome by proxy

Management of Munchausen by proxy? - ANS children must be removed by child protective services Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. - ANS Factitious disorder Patient will present as → a 35-year-old female with c/o palpitations and chest pain for 2 days. She reports that she had been sweating with nausea and vomiting. She reports that she "checked her pulse which was about 156." She denies any personal or family history of heart disease or anxiety disorders. She rated her chest pain as 10/10 "which radiates down my left arm and up my jaw." ECG reads normal sinus rhythm. Troponin, CKMB, and other labs were normal. When she was told that her labs were normal, she flopped onto the bed and started "seizing." She stated, "I am seizing. Why won't you help me?" When the ER PA calls her out, she got angry and left against medical advice. - ANS Factitious disorder This is an unreasonable, persistent concern that something is wrong with the body - ANS Hypochondriasis Obsession with the idea of having a serious but undiagnosed medical condition. - ANS Hypochondriasis In what condition is the individual usually not delusional and may recognize that the behavior is excessive. - ANS Hypochondriasis Patient's are worried about having or developing a serious illness and preoccupation is present for at least 6 months - ANS Hypochondriasis Obsession with the idea of having a serious but undiagnosed medical condition - ANS Hypochondriasis In what condition are concerns limited to the body, and there are no other obsessions and compulsions - ANS Hypochondriasis

This can lead to repeated requests for medical care or reassurance. - ANS Hypochondriasis Tx. for Hypochondriasis - ANS Group/insight-oriented therapy SSRI Patient believes sxs or signs are real Psychological distress manifests as physician sxs No identifiable pathology Often present with dysmenorrhea, sensation of lump in throat, vomiting, SOB, burning in sex organs, painful extremities, amnesia - ANS Somatization disorder Sudden and dramatic onset of single sx Presents with paralysis, pseudoseizure, blindness, sensory deficit No patho or anatomical explanation Usually involves neuro and ortho manifestations Lack of appropriate concern of sign or sx - ANS Conversion Disorder Physical sxs disproportionate to demonstrate organic disease

Fear of disease ad conviction one is sick Persistent and unsatisfying pursuit of medical care (doctor shopping) - ANS Hypochondriasis What tx can be used early and may be helpful in resolving conversion disorders - ANS hypnosis What is a problem in the management of pain - ANS lack of distinction between acute and chronic pain syndromes. How long does it take for acute pain to be considered chronic pain - ANS > 3 months (90 days) Pts with what frequently take many medications, stay in bed a great deal, have seen many clinicians, have lost skills, and experience little joy in either work or play. - ANS chronic pain Components of the chronic pain syndrome consist of what? - ANS anatomic changes chronic anxiety and depression anger changed lifestyle Patients may have started avoiding usual behaviors when they first developed pain, and then chronic avoidance of usual physical functioning can lead to the development of what? - ANS chronic pain

What are the two components that comes into play when dx a pt with chronic pain syndrome - ANS Medical component psychological component A marked decrease in pain threshold is apparent in what condition - ANS Chronic pain syndrome In what condition does the patient accept the role of being sick, and this role then becomes the focus of most family interactions and may become important in maintaining the family. - ANS Chronic pain syndrome The cornerstone of a unified approach to chronic pain syndromes is a what? - ANS comprehensive behavioral program. What comprehensive treatment approach is the highest priority in pts with chronic pain syndrome - ANS a single clinician in charge Tx for pts with Chronic pain syndrome - ANS group therapy This is a transient global disorder of attention, with clouding of consciousness - ANS Delirium This is usually a result of systemic problems (ex: medications, hypoxemia) - ANS Delirium Onset is usually rapid and condition is short-term & reversible. The mental status fluctuates - ANS Delirium

In what condition is there a marked deficit of short-term memory and recall - ANS Delirium This is mild to moderate delirium at night - ANS Sundowning This is more common in patients with preexisting dementia and may be precipitated by hospitalization, medications, and sensory deprivation - ANS Sundowning This delirium may be related to multiple medical causes, including organ failure, and may be unrecognized - ANS Terminal delirium The first aim is to identify & treat the etiologic medical problem of what condition - ANS Delirium This is an acute syndrome caused by a medical condition, substance, intoxication or withdrawal, or medication side effect - ANS Delirium This has a rapid in onset, short-term and reversible - ANS Delirium Acute confusional change or loss of consciousness and perceptual disturbance caused by a drugs or diseases - ANS Delirium Is delirium rapid or slow? - ANS Rapid This is: Rapid Short term Reversible - ANS Delirium

What type of hallucinations are the most common type experienced by patients with delirium? - ANS Visual hallucinations Delirium, unlike dementia, is usually.. - ANS Reversible What is the most common cause of delirium? - ANS Alcohol abuse What is the treatment of choice for delirium treatments in alcohol withdrawal? - ANS Benzodiazepines (Lorazepam) Patient will present as → a 77-year-old female who for the past 4 days, has been crying easily, confused, and rambling incoherently. Her medical history is remarkable for mild dementia and well-controlled hypertension. She has never had anything like this in the past and she has not had any recent changes to her medications. When questioned, she has no difficulty articulating a sentence but difficulty remembering what she was asked. Laboratory testing is significant for leukocytosis. - ANS Delirium This is a progressive decline in intellectual function that is severe enough to compromise social or occupational functioning - ANS Dementia Gradual onset Pts age >60 - ANS Dementia Presents with

• Short term memory loss

• Difficulty recalling names of people, places, objects
• poor navigation/getting lost in familiar places
• Executive dysfunction -Apathy
• Apraxia - ANS Dementia What is used to dx dementia - ANS Mini-Mental Status Examination (MMSE) What is indicated in any patient with a new, progressive cognitive complaint - ANS MRI or CT w/o contrast What labs need to be conducted to dx Dementia - ANS TSH B This is a memory disturbance without delirium or dementia - ANS Amnestic syndrome What syndrome is usually associated with thiamine deficiency and chronic alcohol use - ANS Amnestic syndrome Disorder of frontal or temporal lobe - ANS Amnestic syndrome

In what condition is there an impairment in the ability to learn new information or recall previously learned information - ANS Amnestic syndrome This is the difficulty recalling events that happened or facts that they learned before the onset of the amnestic disorder. - ANS Retrograde Amnesia This is the inability to learn new facts or retain new memories. - ANS Anterograde Amnesia This is generally due to a head injury sustained by a fall or knock on the head - ANS Post Traumatic Amnesia This is from a psychological as opposed to the physical trauma such as an injury directly to the brai - ANS Dissociative Amnesia This is the loss of memory of one specific event - ANS Lacunar Amnes This is the common inability to remember events that took place during one's childhood. - ANS Childhood Amnesia Amnesia caused by Wernicke-Korsakoff syndrome involves a lack of what? - ANS thiamine Tx for Amnestic syndrome - ANS strategies to help make up for the memory problem, and addressing any underlying diseases causing the amnesia This is a sudden temporary episode of memory loss that cannot be attributed to another neurological condition - ANS Transient global amnesia (TGA)

The patient's behavior is normal except for a very characteristic incessant, repetitive questioning about his immediate circumstances—usually of the identical question over and over at intervals of 20 to 60 s after a response to the query has already been given by the examiner - ANS Transient global amnesia (TGA) Presents with characteristic incessant, repetitive questioning about his immediate circumstances - ANS Transient global amnesia (TGA) This lasts less than 24 hours & is BENIGN - ANS Transient global amnesia (TGA) Pts with what are alert and attentive but have anterograde amnesia - ANS Transient global amnesia (TGA) Patient complaints -> difficulty getting to sleep, staying asleep, intermittent w - ANS Insomnia What "normal" factors contribute to insomnia - ANS stress caffeine physical discomfort daytime napping early bedtimes Difficulty initiating or maintaining sleep at least 3 times per week for 3 months - ANS Insomnia What is the TOC for primary insomnia & the elderly regardless of etiology - ANS Psychological treatment Psychological tx for Insomnia - ANS education on good "sleep hygiene

Pharm tx for Insomnia - ANS Benzos (Lorazepam & Temazepam) Non-benzos Difficult falling asleep Difficult staying asleep, with frequent awakenings or difficulty falling back asleep Early morning awakening - ANS Insomnia Excessive nighttime or daytime sleep for > 1 month - ANS hypersomnia Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day - ANS Narcolepsy Npping during the day, occurring at least 3 times per week for at least 3 months associated with at least 1: Cataplexy Hypocretin deficiency in the CSF Reduced REM sleep latency on PSG - ANS Narcolepsy This is Caused by Hypocretin deficiency in lateral hypothalamus - ANS Narcolepsy Presents with:

Excessive daytime sleepiness Hallucination Cataplexy Sleep paralysis - ANS Narcolepsy Defined as recurrent episodes of irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. - ANS Narcolepsy How is Narcolepsy dx - ANS polysomnography Pharm tx for narcolepsy - ANS modafinil (Provigil) methylphenidate (Ritalin) What can help during the day to prevent sleep attacks caused by narcolepsy - ANS planned naps This is a chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep often with cataplexy - ANS Narcolepsy How is narcolepsy diagnosed? - ANS polysomnography and multiple sleep latency testing Drug of choice for cataplexy? - ANS Xyrem (sodium oxybate) Patient will present as → a 23-year-old man complaining of feeling tired during the day. He is concerned as his grades in school have worsened and he does not want to lose his scholarship. Upon further questioning, the patient describes frequently experiencing a dreamlike state before falling asleep and after waking up. He also has frequent nighttime awakenings where he finds himself unable to move. He

denies snoring. The patient does not drink alcohol or abuse any other drugs. The patient's BMI is 21 kg/m2, and his vital signs are all within normal limits. - ANS Narcolepsy Patient will present as → a 19-year-old female complaining of an irresistible urge to sleep at sudden times throughout the day. This has disturbed her school functioning. She sometimes feels like she "is paralyzed" for several minutes when she wakes up. She "passed out" one day at school when she was startled by her boyfriend. - ANS Narcolepsy These are characterized by NREM sleep arousal disorder, nightmare sleep disorder, and REM sleep behavior disorder. - ANS Parasomnias •Characterized by abnormal behaviors, experiences, or feelings while sleeping, during specific sleep stages, or as individuals wake up - ANS Parasomnias Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episod - ANS NREM sleep disorders What are the NREM Sleep Arousal Disorders - ANS sleep walking and sleep terrors A phenomenon primarily occurring in non-REM sleep in which people walk while asleep - ANS Sleepwalking Frightening dreamlike experiences that occur during the first third stage of deep slow-wave non-REM sleep, shortly after the child has gone to sleep - ANS Sleep Terrors Tx for NREM Disorders - ANS Supportive Clonazepam

•Patient will present as → a 22-year-old university undergraduate, who was urged to come to the student health clinic by his roommates for shouting and walking in his sleep. Since the age of 12, he was noted to be talking and shouting in his sleep. Speech centered on incidents that occurred during the day, which became worse when he was under stress. He cannot remember walking and talking in his sleep. Stresses include examinations, interviews and meeting datelines. There were no biological disturbances to suggest an affective disorder: There was no family history of sleepwalking or sleep talking. - ANS Non- Rapid Eye Movement Sleep Arousal Disorders (sleepwalking and sleep terrors) Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode - ANS Nightmare disorder A type of sleep-wake disorder involving a pattern of frequent, disturbing nightmares occurring in the last third of REM sleep - ANS Nightmare disorder Spontaneously awakening from the nightmare and feeling oriented and alert right away - ANS Nightmare disorder Tx for Nightmare disorder - ANS psychotherapy Prazosin •Patient will present as → a 70-year-old retired bus driver reports a seven-year history of disturbed sleep. Every two to three weeks he experienced a night where his dreams were vivid and violent involving being chased by animals or attacked by strangers. - ANS Nightmare disorder Move a lot while sleeping and reenacting violent nightmares with the possibility of hurting themselves (falling out of bed) - ANS REM sleep behavior disorders Polysomnographic evidence of episodes of arousal or stimulation during sleep, vocalization (talking, screaming), or movement (hitting, kicking) - ANS REM sleep behavior disorders

During polysomnography recordings muscles don't have atonia during REM sleep - ANS REM sleep behavior disorders Patient will present as → a 38-year-old woman with a 1-year history of frequent episodic movements during sleep. Her husband noted that during sleep the patient talks in her sleep and that from 2 to 4 am she has sudden strong movements in all her extremities, which have generated bodily harm to herself or to him. The patient is not conscious of these movements, but when her husband wakes her up she remembers exactly what she was dreaming - ANS REM sleep behavior disorders These occur in the first half of the night. - ANS Sleepwalking disorders These occur in the last third, sleep terrors in the first third - ANS Nightmare disorders These occur in the second half of the night. - ANS REM sleep behavior disorders