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NRNP 6635 MID-TERM STUDY GUIDE
Week 1: History and Theories of
Psychopathology
Functions of Brain Regions Brainstem and the thalamic reticular activating system provide arousal and set up attention posterior cortex integrates perceptions and generates language frontal cortex generates programs and executes plans like an orchestra conductor (the highest level) Cerebrum - Higher cognitive functions such as judgment, imagination, perception, thought and decision-making o cerebral cortex is especially important for personality and intelligence o two symmetrical hemispheres that each play slightly different roles regarding speech, language learning, and vision Cerebellum - voluntary motor movements, balance, equilibrium, and muscle tone o Damage to the cerebellum can result in loss of motor control, weak muscles, abnormal eye movements, slurred speech, and staggering Diencephalon - thalamus and the hypothalamus o Hypothalamus – control of appetite, temperature, blood pressure, perspiration, and sexual drive o relay point between subcortical areas of the brain and the cerebral cortex o Autonomic nervous system “fight or flight” o relays information about the auditory, visceral, visual, somatic and gustatory systems o control of immune responses, blood pressure, digestion, and body temperature Brainstem - main junction between the brain and the rest of the body o brain joins with the spinal cord to send and receive information from every inch of our bodies o breathing, heart rate, digestion, and our body’s natural rhythms o includes the medulla oblongata, pons, and midbrain Pathophysiology neurotransmitter involvement with mental health disorders Serotonin - o involved in the regulation of various activities (e.g. behavior, mood, and memory, sleep, and appetite, encouragement of socialization) o has some influences on learning, memory, and other cognitive abilities o primary treatment target for many psychiatric and neurological disorders (e.g. major depressive disorder, post-traumatic stress disorder, bulimia nervosa, obsessive-compulsive disorder, anxiety, aggressive behavior, premenstrual dysphoric disorder, panic disorders, social phobia, bipolar disorder, atypical depression, and migraine Dopamine – o Too much – positive symptoms of schizophrenia and psychosis o Too little – Parkinson’s disease, depression, ADHD, anxiety o Mesolimbic pathway – pleasure and reward pathway; overstimulation of NAc leads to euphoria and risk for cravings and withdraw (addiction) involved in cognition, working memory and decision making in the prefrontal cortex o Nigrostriatal dopamine pathway –
Motor planning: lack of dopamine in this pathway results in motor control impairment (i.e. EPS, movement disorders, parkinsonism, TD, spasms) o Tuberoinfundibular dopamine pathway – Inhibits prolactin release Prevention of these functions increases prolactin affecting menstrual cycles, libido, fertility, bone health or galactorrhea Norepinephrine and Epinephrine Acetylcholine Theories of Personality and Psychopathology (theorist and stages of theories) Sigmund Freud – o psychosexual development o The Ego and the Id o Defense mechanisms o Theory of anxiety as “dammed up libido” and ego’s partial failure to cope with distressing stimuli o Character traits as result of successful repression to the defense system Erikson – o Dilemmas or polarities in the ego’s relations with family and larger social institutions at nodal points in childhood, adolescence and early, middle and late adulthood o Psychological development o Concept of identity, identity crisis and identity confusions o Epigenetic principle – development occurs in sequential, clearly defined stages and each stage must be satisfactorily resolved for development to proceed smoothly – failure results in a form of physical, cognitive, social or emotional maladjustment o Erikson’s Psychosocial stages Trust versus mistrust (birth to 18 months) Autonomy vs shame and doubt (18 months – 3 yrs.) Initiative vs guilt (3 yrs. – 5 yrs.) Industry vs inferiority (5 yrs. to 13 yrs.) Identity vs role confusion (13 yrs. to 20 yrs.) Intimacy vs isolation (20 yrs. to 40 yrs.) Generativity vs stagnation (40 yrs. to 60 yrs.) Healthy developmental stages and changes Piaget’s Stages of intellectual development o Sensorimotor (0 to 2 years) – Inborn motor and sensory development – uses motor and sensory reflexes (sucking, grasping, looking) to interact and accommodate to the external world Primary circular reaction – coordinates activities of own body and five senses (e.g. sucking thumb); reality remains subjective – does not seek stimuli outside of its visual field; displays curiosity Secondary circular reaction – seeks out new stimli in the environment; states noth to anticipate consequences of own behavior and act purposefully to change the environment; beginning of intentional bx
The psychiatric interview, history, and examination Interview is a not one single funnel of open-ended questions leading to close ended questions, rather it is a series of funnels, each beginning with open-ended questions, with closed questions to clarify Initial psychiatric interview: o Identifying data o Source and reliability o Chief compliant o Present illness (use psychiatric ROS) o Past psychiatric illness o Drug and alcohol abuse/use o Past medical history o Family history o Developmental and social history o ROS o Mental status exam o Physical exam o Formulation o DSM5 diagnosis o Treatment plan Be familiar with how to conduct a mental status exam Observation, with direct questioning to augment the MSE Parts of an MSE: o Appearance and Bx o Motor activity o Speech o Mood o Affect o Thought content o Thought process o Perceptual disturbances o Cognition (see table 5.1-5) o abstract reasoning o Insight
o Judgement Rating scales for various mental health screens o Perceived Stress Scale o Screen for Child Anxiety Related Emotional Disorders o Abnormal Involuntary Movement Scale o Adult ADHD Self Reporting (ASRS-V1.1) Tool o The Patient Health Questionnaire – Nine Item (PHQ-9) o Mood Disorders Scale o Beck Depression Inventory, 2nd Revision o Hamilton Depression Rating Scale o Mini-Mental State Examination (MMSE) o Geriatric Depression Scale o Zung Self-Rating Depression Scale o Hamilton Anxiety Rating Scale o Yale-Brown Obsessive-Compulsive Scale o Simpson Angus Scale o Dissociative Experiences Scale (DES) o Adverse Childhood Experiences o PTSD checklist (PCL-5) o The Clinical Opiate Withdrawal Scale (COWS) o Hamilton Rating Scale for Anxiety (HAMA o Montreal Cognitive Assessment (MoCA o Young Mania Rating Scale (YMRS) o Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form (Q-LES-QSF) o The Modified Overt Aggression Scale (MOAS o Positive and Negative Symptom Scale (PANSS) o Adverse Childhood Experience
Week 3: Mood Disorders
Persistent depressive disorder (aka dysthymic d/o).
- Decreased mood and SIGECAPS symptoms without meeting full MDD criteria for 2+ years; described as baseline sadness; still enjoy some things
- Treat with CBT first and then SSRIs Adjustment disorder
- Mood/anxiety symptoms < 3 months after a stressor, typically resolving within 6 months
- Treat with supportive therapy and meds for symptoms (insomnia, nausea etc)
Week 4: Anxiety Disorders, PTSD, and
OCD
GAD
- 5-10% lifetime prevalence. 2:1 women vs men
- Definition: excessive worrying and anxiety for > 6 months a. Worry about school/grades, job, money, relationships, events, life b. Pathophys: Disrupted functional connectivity of the amygdala and its processing of fear and anxiety
- Dx criteria: at least 3 of the following a. Restlessness b. Tires easily c. Problems concentrating d. Irritability e. Muscle tension f. Problems with sleep i. Symptoms must interfere with daily functioning
- Treatment: a. Psychotherapy: CBT b. Pharmacotherapy: SSRI, SNRI, buspirone, short-term benzos c. AMYGDALA problem Specific phobias
10% lifetime prevalence; 2:1 women vs men
- Definition: irrational fear of a specific object, place, situation, or concept for 6+ months a. Fear out of proportion to imminent threat b. Fear interferes with functioning in society c. Exposure induces immediate fear; removal reduces anxiety d. Fear might have developed from related trauma (fear of water post near-drowning) e. SOCIAL PHOBIA: fear of embarrassment in public situation f. Agoraphobia: fear of public places due to lack of ability to escape; fear of unsafe environment
- Treatment: a. First line: CBT b. Scheduled meds: SSRI, SNRI c. PRN meds: beta blockers or benzodiazepines Separation anxiety d/o
- Definition: Excessive anxiety regarding separation from home or form people to whome the individual has a strong emotional attachment. a. Children > 4 weeks b. Adults > 6 months c. May include anxiety/fear/distress when separated: reluctance to be alone/leave home/school/work; worry about harm to attachment figures
- Symptoms cause dysfunction in society
- Treat with CBT, family therapy, possibly adjunct SSRI
- Similar to anxiety during normal child development a. Stranger anxiety at 6mo b. Separation anxiety at 1 year Selective mutism (commonly comorbid with anxiety/attachment disorder)
- Consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations
- The disturbance interferes with educational or occupational achievement or with social communication
- Duration of disturbance is at least 1 month (not limited to the first month of school)
- The failure to speak is not attributable to lack of knowledge of, or comfort with, the spoken language required in the social situation.
- The disturbance is not better explained by a communication disorder and does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder. Panic Attacks
- 4% lifetime prevalence. 2:1 women vs men
- Definition: sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something bad is going to happen. a. Occurrence of at least one attack b. Constant worry about recurrence c. Other symptoms: trembling, unsteadiness, personalization, palpitations, abdominal pain, chest pain 3. Must rule out medical etiologies which include a. Hyperthyroidism b. Atrial fibrillation c. Pheochromocytoma d. Drugs (amphetamines, sympathomimetics)
- Treatment a. Psychotherapy: CBT b. Pharmacotherapy: SSRI >? TCA i. Short term benzos Social Anxiety Disorder
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, and performing in front of others
c. Presence of 1 or more of the following intrusion symptoms i. Recurrent, involuntary, and intrusive ii. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event, and intrusive distressing memories of the traumatic event iii. Dissociative reactions (flashbacks) in which the individual feels or acts as if the traumatic events were recurring iv. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event v. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event
- Persistent avoidance of stimuli associated with the traumatic event beginning after the traumatic event occurred aeb one or both of the following a. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic events b. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic events
- Negative alterations in cognitions and mood associated with the traumatic events, beginning or worsening after the traumatic events occurred, aeb 2 or more of the following a. Inability to remember an important aspect of the traumatic events (typically d/t dissociative amnesia and not to other factors such as drugs/alcohol) b. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g. I am bad. No one can be trusted, etc) c. Persistent, distorted cognitions about the cause or consequences of the traumatic events that lead the individual to blame himself/herself or others d. Persistent negative emotional state (fear, horror, anger, guilt) e. Markedly diminished interest or participation in significant activities f. Feelings of detachment or estrangement from others g. Persistent inability to experience positive emotions
- Marked alterations in arousal and reactivity associated with the traumatic events beginning or worsening after the traumatic events occurred aeb 2 or more of the following a. Irritable behavior and angry outbursts typically expressed as verbal or physical aggression toward people or objects b. Reckless or self-destructive behavior c. Hypervigilance d. Exaggerated startle response e. Problems with concentration f. Sleep disturbance
- Duration of the disturbance is greater than 1 month
- Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
- The disturbance is not attributable to the physiological effects of a substance (medication, etoh, etc)
- Specify whether a. With dissociative symptoms
i. Depersonalization ii. Derealization
- Delayed expression (starts at least 6 months after the event)
- concentrating, hypervigilance, exaggerated startle, sleep difficulties a. Avoidance of triggers of symptoms b. Symptoms must last > 1 month
- Acute stress disorder (like PTSD, but within 1 month of trauma)
- Treatment a. Psychotherapy: CBT (Exposure therapy, Cognitive processing therapy) b. Rx i. SSRI, SNRI ii. Prazosin for nightmares (alpha blocker)
- With dissociative symptoms include a. Depersonalization b. Derealization Adjustment disorder
- Very common – up to 20% of people in outpatient clinics
- Patient unable to cope with stress or major life event a. Symptoms include loss of interest, crying, feeling of hopelessness i. Symptoms occur within 3 months of stressor and should resolve by 6 months ii. Symptoms resolve when pt adapts to new situation iii. Aka situational depression
- Treat with supportive therapy a. Temporary medications for symptoms such as insomnia, anxiety, or depression Child developmental disorders Reactive attachment disorder
- A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers manifested in both of the following a. Child rarely/minimally seeks comfort when distressed b. Child rarely/minimally responds to comfort
- Persistent social/emotional disturbance with a t least 2 of the following a. Minimal social/emotional responsiveness to others b. Limited positive affect c. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers
- The child has experienced a pattern of extremes or insufficient care as evidenced by at least one of the following a. Social neglect/deprivation in the form of persistent lack of basic emotional needs/comfort/stimulation/affection b. Repeated changes of primary caregivers that limit opportunities to form stable attachments c. Rearing in unusual settings that severely limit opportunities to form selective attachments
- Criteria are not met for ASD
- Disturbance is evident prior to age 5
b. Moderate: Some symptoms are present in at least 2 settings c. Severe: Some symptoms are present in 3 or more settings Intermittent Explosive Disorder – specifically affects anterior cingulate (limbic system) and orbitofrontal cortex – Amygdala responses to anger stimuli are higher Definition: Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following
- Verbal aggression (tantrums, tirades, verbal arguments, fights) or physical aggression toward property, animals, or other individuals. a. Occurring twice weekly on average for a period of 3 months b. Physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals
- 3 behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period a. The magnitude of aggressiveness expressed during the recurrent outburst is grossly out of proportion to the provocation or precipitating factors b. The recurrent aggressive outbursts are not premeditated (they are impulsive) c. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning or are associated with financial or legal consequences d. Chronological age is at least 6 years old (or equivalent developmental age) e. Recurrent aggressive outbursts are not better explained by another mental disorder Conduct Disorder – oddly, patients tend to have a lower HR than those without conduct disorder
- A repetitive and persistent pattern of behavior in which the basic rights of others or major age- appropriate societal norms are violated as manifested by the presence of at least 3 of the following 15 criteria. Aggression to people or animals a. Often bullies, threatens or intimidates others b. Often initiates physical fights c. Has used a weapon that can cause serious physical harm to others d. Has been physical cruel to people e. Has been physical cruel to animals f. Has stolen while confronting a victim (mugging etc) g. Has forced someone into sexual activity Destruction of property h. Has deliberately engaged in fire setting with the intention of causing serious damage i. Has deliberately destroyed others’ property (other than by fire setting) Deceitfulness j. Has broken into someone else’s house, building, or car k. Often lies to obtain goods or favors or to avoid obligations (con artist) l. Has stolen items of nontrivial value without confronting a victim (i.e. shoplifting etc) i. Serious violations of rules
m. Often stays out at night despite parental prohibitions, beginning before age 13 n. Has run away from home overnight at least twice while living in the parental or parental surrogate home or once for a lengthy period o. Is often truant from school, beginning before age 13
- Disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
- If the individual is age 18 years old, criteria are not met for antisocial personality disorder
- Specifiers a. F91.1 (312.81) – Childhood-onset b. F91.2 (312.82) – Adolescent onset c. F91.9 (312.89) – Unspecified onset
- Further specifiers a. With limited prosocial emotions b. Lack of remorse or guilt c. Callous – lack of empathy d. Unconcerned about performance e. Shallow or deficient affect
- Severity a. Mild – few if any conduct problems in excess of those required to make diagnosis are present b. Number of conduct problems and the effect is between mild and severe c. Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others Pyromania Diagnostic criteria A. Deliberate and purposeful fire setting, on more than one occasion B. Tension or affective arousal before the act C. Fascination with, interest in, curiosity about, or attraction to fire and its subsequent contexts D. Pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath E. Fire-setting is not done for monetary gain, as an expression of sociopolitical ideology or other rationale F. Fire setting is not better explained by conduct disorder, a manic episode, or antisocial personality disorder Kleptomania Steals shit Dissociative Disorders Characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. Very often a sign of trauma response. Dissociative Identity Disorder A. Disruption of identity characterized by 2 or more distinct personality states which can be described in some cultures as an experience of possession.
B. Define: Patient has at least 1 somatic symptom (such as pain) along with excessive fear, worry, stress or behavioral change regarding this pain a. Duration of at least 6 months b. Disproportionate and persistent thoughts about the seriousness of ones symptoms c. Excessive time and energy devoted to these symptoms or health concerns d. Similar to illness anxiety in the fear/stress but with actual somatic symptoms e. Symptom(s) is/are subconsciously driven; patients actually believe they have a disorder C. Prevalence F>M. Low SES, low education, older age, underemployment D. Prognosis: symptoms can get better or worse over time based on mood and/or stress E. Patients often present frustrated, having seen many doctors all not believing their symptoms with many negative workups F. Specifiers a. With predominant pain b. Persistent c. Mild (only one of the symptoms in criterion B is filled) d. Moderate – 2 or more symptoms specified in Criterion B e. Severe (2 or more other symptoms specified in criterion B are filled, plus multiple somatic complaints) G. Management a. Acknowledge symptoms – they may be real b. Schedule regular follow up swith single PCP i. Build rapport ii. Allows you to monitor any changes in symptoms iii. Avoid unnecessary workup/treatment Illness anxiety Disorder F45.21/300.7 (less prevalent than Somatic Symptom Disorder) A. Preoccupation with having or acquiring a serious illness B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition, the preoccupation is clearly excessive or disproportionate C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status D. The individual performs excessive health-related behaviors or exhibits maladaptive avoidance E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time F. The illness-related preoccupation is not better explained by another mental disorder G. Specifiers a. Care-seeking b. Care-avoidant
- Also previously called hypochondriasis, hypochondria, health anxiety
- Excessive and undue fear, worry, stress and/or behavioral change regarding having or being diagnosed with a serious illness a. Duration of at least 6 months b. Somatic symptoms are absent or very minor
c. Preoccupation with illness severely impacts their daily functioning. I.e. missing work/appts d/t worry d. Sometimes caused by recent psychological stressor i. i.e. recent death in the family – worry about same disease in self e. Reassurance is often ineffective f. Epi: M=F 2/3 have another psychiatric illness; most prevalent in 20s-30s. i. Acknowledge concerns ii. Schedule regular follow ups with single PCP iii. Psychotherapy (CBT) iv. Screen for v. comorbid anx/dep – consider SSRI Conversion Disorder (Functional Neurological Symptom Disorder) A. 1 or more symptoms of altered voluntary motor or sensory function B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical condition C. The symptom or deficit is not better explained by another medical or mental disorder D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation E. Coding. a. F44.4 – With weakness or paralysis i. With Abnormal movement ii. With swallowing symptoms iii. With speech symptoms b. F44.5 With attacks or seizures c. F44.6 With anesthesia or sensory loss i. With special sensory symptom d. F44.7 With mixed symptoms F. Specify if a. Acute b. Persistent (for greater than 6 months) c. With psychological stressor d. Without psychological stressor
- Aka functional neurological symptom
- Patient presents with at least one symptom (usually neurologic, such as numbness, blindness, mutism, or paralysis) that cannot be explained neurologically (not in normal stroke pattern) a. Symptom onset is usually abrupt and follows significant life stress event (death of family member, bereavement) b. Patients are often indifferent to or unconcerned with their symptoms i. La belle indifference c. Epi: W>M by 2-3x– most frequent in adolescence and early adulthood d. Pseudoseizures, or psychogenic nonepileptic seizures, can be the symptom of conversion d/o i. Differentiate from epileptic seizure with prolactin level (elevated in epileptic) and EEG (normal in pseudoseizure) e. Management
Malingering i. Confront patient in a nonthreatening manner ii. Document and contact PCP and other providers to avoid unnecessary procedures
1. Patient fabricates symptoms of mental or physical disorders for secondary gain or external reward a. Secondary gain is oftentimes getting out of work/school, obtaining drugs, clearing charges/legal record, free room and board etc.
- Not a mental illness or psychiatric pathology
- Oftentimes present as ill-defined, nonspecific complaints that don’t add up; often unsatisfied with reassurance or negative workup a. Symptoms improve once secondary gain is achieved b. Epi: M>>W; often in patients with antisocial personality d/o
- Management: a. Present the patient with discrepancies between objective findings and their subjective report i. Give opportunity to admit malingering b. Do not confront with hostility
Week 6: Eating, Sleeping, and Elimination Disorders
Feeding and eating disorders
- Characterized by persistent disturbance of eating or eating-related behavior resulting in altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning Anorexia Nervosa
- Categorized by: a. Self-induced starvation to a significant degree (behavior) b. Relentless drive for thinness or morbid fear of fatness (psychopathology) c. Presence of medical signs and symptoms resulting from starvation (physiology)
- Subtypes – restricting and binge/purge
- Highly disproportionate emphasis on thinness as a vital source or only source of self-esteem, with weight and shape overriding and consuming daylong preoccupation of thoughts, mood, and behaviors
- Most common ages are midterms with onset in early 20’s (14 years to 18 years) and occurs 10 to 20 times more in females than males
- Associated with hypothalamic-pituitary axis (neuroendocrine) dysfunction and dysfunction in serotonin, dopamine, and norepinephrine, three neurotransmitters involved in regulating eating behavior in the paraventricular nucleus of the hypothalamus
- DSM5 diagnostic criteria: a. an individual voluntarily reduces and maintains an unhealthy degree of weight loss or fails to gain weight proportional to growth b. an individual experiences an intense fear of becoming fat, has a relentless drive for thinness despite obvious medical starvation, or both c. an individual experiences significant starvation-related medical symptomatology, often, but not exclusively, abnormal reproductive hormone functioning, but also hypothermia, bradycardia, orthostasis, and severely reduced body fat stores d. the behaviors and psychopathology are present for at least 3 months
- Secrecy and refusal to eat in front of friends and family is a common feature along with rigidity and perfectionism with somatic GI complaints
- Early physiological signs: a. Delay in sexual development b. ECG changes
- Treatment: a. Hospitalization to restore nutritional status (electrolytes and rehydration) b. Psychotherapy: CBT, dynamic expressive supportive psychotherapy, family therapy c. Pharmacology: i. cyproheptadine (pertactin) – drug with antihistamine and anti-serotonergic properties ii. amitriptyline iii. clomipramine, pimozide, chlorpromazine and fluoxetine Bulimia Nervosa
- characterized by episodes of binge eating combined with inappropriate ways of stopping weight gain
- Typically remain a normal body weight unlike anorexia nervosa
- May represent failed attempt at anorexia nervosa with inability to sustain prolonged semistarvation, or binge behavioral is a means to self-medicate during times of emotional dysregulation – eating provokes panic as a result of feeling like eating was out of control (may lead to compensatory mechanisms such as purging or excessive exercise)
- More common in women, onset is later in adolescents (20% of college women experience transient bulimic symptoms during college years)
- Since serotonin has been linked to satiety, serotonin and norepinephrine have been implicated in Bulimia, and also exaggerated perception of hunger signals related to sweet taste mediated by the right anterior insula area of the brain
- Social factors – high achievers, comorbid depression, neglectful or rejecting parents
- Psychological factors – have more difficulties in adolescents; more outgoing, angry and impulsive than anorexia (associated with emotional lability, including SI, shop lifting and AUD)
- Diagnosis: a. episodes of binge eating occur relatively frequently (once a week or more) for at least 3 months b. compensatory behaviors are practiced after binge eating to prevent weight gain, primarily self- induced vomiting, laxative abuse, diuretics, enemas, abuse of emetics (80 percent of cases), and, less commonly, severe dieting and strenuous exercise (20 percent of cases) c. weight is not severely lowered as in anorexia nervosa d. the patient has a morbid fear of fatness, a relentless drive for thinness, or both and a disproportionate amount of self-evaluation that depends on body weight and shape. e. When making a diagnosis of bulimia nervosa, explore the possibility that the patient has experienced a brief or prolonged prior bout of anorexia nervosa, present in approximately half of those with bulimia nervosa. Binging usually precedes vomiting by about 1 year.
- Increased rates of anxiety, BPD, dissociate disorders and histories of sexual abuse
- Treatment: a. CBT, dynamic psychotherapy, SSRI’s (fluoxetine), as well as imipramine, desipramine, trazodone and MAOIs Binge eating disorder
- One of the most common eating disorders
