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Bulimia Help Method

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Bulimia Help Method Overview


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Classical anorexia nervosa postpubertal

Additional harmful behaviours which should be enquired into include self-induced vomiting, purgative abuse, and self-injury. Vomiting and purgative abuse are similar to the behaviours that occur in bulimia nervosa (see C.haP.teL,4,1.0,2.). In anorexia nervosa they may occur without the prelude of overeating and the patient's motive is simply to accelerate weight loss. Even so, vomiting is most likely to occur after the patient's frugal meals, and the laxative abuse is often at the end of the day. The favourite laxatives in the United Kingdom are Nylax, Senokot, and Dulcolax, and the patient is likely to take them in increasing quantities to achieve the wanted effect as tolerance develops. Self-injury should also be enquired into, and the skin of the wrists and forearms inspected for scratches or cuts with sharp instruments. The patient's dread of fatness is so common that it is pathognomonic of anorexia nervosa. There are, however, exceptions. Sometimes a patient may simply deny these...

Anorexia nervosa in males

The relative rarity of anorexia nervosa in the male might lead one to surmise that the disorder is likely to differ between the sexes in its aetiology, clinical manifestations, and prognosis. The first study that examined this premise in a sizeable series of male patients found remarkable similarities between the sexes as regards the age of onset and the specific features of the psychopathology. (104) For example, the male patients tended to select a diet which was low in fattening foods and resorted to subterfuges to dispose of food, such as self-induced vomiting and purging, and strenuous exercising. They expressed a fear of fatness and considered themselves overweight, even when they were thin. Other investigators were also struck by these surprising similarities. (105) The relative resistance of the male against developing anorexia nervosa remains a mystery. It is even unclear whether the sex difference is likely to be due to biomedical factors or psychosocial differences. It has...

Outcomes from followup studies in anorexia nervosa

There have been comprehensive appraisals of follow-up studies in anorexia nervosa (108) which have put forward criteria for the near-perfect follow-up study, which in practice are seldom fully met. Among the easier criteria are precision in the diagnostic features, the use of standardized interviews, 100 per cent success in tracing the patients, and a sufficiently long follow-up to determine eventual outcome. An arbitrary interval of at least 4 years was previously set (24) and most recent studies have adhered to this recommendation. Several groups of investigators have adopted the same measures of outcome based on the Morgan-Russell scales. fy0.9.) Their use gives rise to three possible categories of general outcome based on body weight and menstrual function 'good', 'medium', and 'poor'. The Swedish study was extended by two later follow-ups at 15 and 33 years, and showed a trend in two directions. On the one hand, the percentage of good outcomes gradually increased, while the...

Compulsory treatment in anorexia nervosa

In the United Kingdom the Mental Health Act Commission .35.) has recently (1997) clarified many of the doubts in the minds of clinicians and social workers called upon to consider a compulsory admission under the Mental Health Act 1983. It recognized that anorexia nervosa is a mental disorder within the meaning of the Act and that in some patients their ability to consent may be compromised by fears of obesity or denial of the consequences of their actions. The Mental Health Act Commission concluded that when the patient's health is seriously threatened by food refusal she may be detained in hospital so as to treat the self-imposed starvation. The Commission went as far as to state that nasogastric feeding can be a medical process forming an integral part of the treatment for anorexia nervosa, notwithstanding that nasogastric feeding is seldom required even in patients who are compulsorily admitted. In a study of the use of compulsory treatment in patients admitted to the Eating...

Relationship to other disorders Anorexia nervosa

Bulimia nervosa has many features in common with anorexia nervosa particularly the characteristic attitudes to shape and weight, and the forms of behaviour that arise as a result. In most cases, bulimia nervosa is preceded either by frank anorexia nervosa (in about a quarter of cases) or an anorexia-nervosa-like state. Movement from bulimia nervosa to anorexia nervosa is unusual although it occurs, and some patients remain on the cusp between the two disorders. There is some evidence of co-aggregation between bulimia nervosa and anorexia nervosa with increased rates of both disorders among the relatives of probands with either condition.(25) There is substantial overlap in the risk factors for anorexia nervosa and bulimia nervosa. (26,,2Z>

Management of bulimia nervosa

Given the large number of patients with bulimia nervosa and the scarcity of therapists with training in the treatment of eating disorders, a 'stepped care' approach to management has been advocated. With such an approach a simple treatment is used first and only if this proves insufficient is a more complex and specialized intervention provided. Four steps may be distinguished. Having established the diagnosis, the first decision is whether the patient may be treated on an outpatient basis. The great majority (over 95 per cent of referrals to non-specialist centres) may be managed this way. Exceptions are patients whose level of depression is so severe that they cannot make use of psychological treatment, significant risk of suicide, and physical complications necessitating inpatient or day patient care. Severe substance abuse requires treatment in its own right, although this can sometimes be integrated with the treatment of the eating disorder. For example, it is possible to adapt...

Cognitivebehaviour therapy for eating disorders

The cognitive-behavioural account of anorexia nervosa and bulimia.nervosa Evidence forth . .c.o.gp. tjy -beha.Yi.o.u.ra.l account implications .of th.e .c.oflnitive-be.ha.vio.ura . account The cognitive-behavioural treatment of, bulimia., nervosa Stage , Explainingthe, .cognitivein view ofthe main.te.n.a.nce of, bulimia. .nervosa The use pf. pgnitive-hehavipur the.rapy t0n .treat, .bulimia .nervosa lndicatlipnSn and. contraindications Brief cognitive-behayiourtherapy, .self-help,. and .the. issue. oftraining Patients. .who do. not respond The 0gnitiye-behayipura treatmentpf, .anorexia .nervosa

The cognitivebehavioural treatment of bulimia nervosa

Cognitive-behaviour therapy for bulimia nervosa is based on the cognitive-behavioural account of the maintenance of the disorder. It is outpatient based and generally involves about 15 to 20 treatment sessions over 5 months, each session being about 50 min in length. There follows a brief outline of the treatment. Readers who would like further details should refer to the treatment manual adopted by the main studies (U) and an article on its implementation. ( 2>

The cognitivebehavioural treatment of anorexia nervosa

There is no established cognitive-behavioural treatment for anorexia nervosa. A general cognitive-behavioural approach has been specified (21) but there is nothing approaching a treatment manual. There are two ongoing studies of the use of cognitive-behaviour therapy following weight restoration in hospital but their findings are not yet available. Furthermore, their relevance to the routine care of patients with anorexia nervosa is uncertain given that most patients are managed exclusively on an outpatient basis. As described above, the cognitive-behavioural account of the maintenance of bulimia nervosa can be readily extended to anorexia nervosa. As in bulimia nervosa, these patients' extreme dietary restriction may be understood as emanating from their concerns about shape and weight. In anorexia nervosa, however, the state of starvation also contributes to the maintenance of the disorder. A further maintaining factor is the egosyntonicity of the anorexic state. Unlike bulimia...

The cognitivebehavioural treatment of atypical eating disorders

Cognitive-behaviour therapy for bulimia nervosa may be regarded to some extent as modular since it contains groups of procedures directed at particular facets of the disorder. Thus there are techniques for addressing binge eating, the various forms of dieting, concerns about shape and weight, and the risk of relapse. Such techniques may also be used, within an overall cognitive-behavioural perspective, with patients who show just some of these features. As a result cognitive-behaviour therapy has a wide application since, as noted in C.h.ap.te.L.4 1 0. .2., there are many patients seen in clinical practice who have a significant eating disorder yet do not meet full diagnostic criteria for anorexia nervosa or bulimia nervosa.

Sleep Related Eating Disorder

This condition consists of recurrent episodes of involuntary eating and drinking during arousals from sleep with adverse consequences (30,113,114). They typically occur during partial arousals from sleep with subsequent partial recall. The problematic features of SRED include one or more of the following consumption of peculiar forms or combinations of food, and or of inedible or toxic substances (e.g., frozen pizzas, raw bacon, cat food, ammonia cleaning solutions), insomnia from sleep disruption, sleep-related injury, morning anorexia, weight gain, and obesity.

Clinical evaluation of anorexia nervosa

Cardiovascular complications are the most likely cause of death in anorexia nervosa. Bradycardia, orthostatic hypotension, and mitral valve prolapse are common. E. A general laboratory screen is usually sufficient in the assessment of anorexia nervosa. Among individuals who purge, determination of electrolyte status is the most important concern, particularly serum potassium status. An electrocardiogram is indicated for cardiac symptoms, extremely low body weight, or history of exposure to syrup of ipecac. Laboratory Abnormalities in Anorexia Nervosa

Group format for bulimia IPTG

Drawing on the work of Fairburn and colleagues, Wilfley et a 75> modified IPT in a group format, meeting once a week for 16 weeks, and compared it with group CBT and a waiting-list control for 56 women with non-purging bulimia. At termination, IPT-G and CBT each significantly reduced binge eating, whereas the waiting-list control did not. These results persisted at 1-year follow-up. A randomized clinical trial of 162 women is now comparing group IPT and CBT for 20 sessions over 20 weeks. The initial IPT phase, in which the therapist identifies the problem area and presents IPT concepts and the treatment contract, is conducted individually. Groups meet for 90 minutes.

Anorexia nervosa of early onset

It would be too arbitrary to define an early onset by age limits such as an onset from 8 to 16 years. A more meaningful frame of reference is the onset in relation to the stage of puberty which has been reached by the child.(98) Because puberty is a complex developmental process spanning 2 to 3 years, it is best to name as 'premenarchal' the illness which commences some time after the first signs of puberty and before its completion, as shown by the first menstrual period. In true prepubertal anorexia nervosa the illness begins even earlier, before the very first signs of puberty. Postpubertal anorexia nervosa is when the illness commences after menstruation has been established. At some stage, however, the parents observe that their child is avoiding food and is reluctant to eat at normal meal times. She resorts to deviousness and secrecy. The omission of school meals often goes undetected. Eventually it is noticed that she has become thinner and may have lost a great deal of weight....

Has the incidence of anorexia nervosa increased since the 1950s

Hilde Bruch had no doubt about the answer to this question 'one might speak of an epidemic illness, only there is no contagious agent the spread must be attributed to psycho-social factors'. This is an exaggeration as the increase in anorexia nervosa does not merit the term 'epidemic'. (25) Indeed, such a notion was dismissed in an article 'The epidemic of anorexia nervosa another medical myth '.(26) It was concluded that there had been an increase in first admissions of patients over 10 years (1972-1981) but that this was due to an increase in the number of young women in the population. This rejection of a true increase in the incidence of anorexia nervosa has in its turn been criticized. The most reliable evidence for changes in the incidence of anorexia nervosa comes from repeated surveys of the same population. This has been achieved with the surveys conducted in southern Sweden 7 northeast Scotland 1. Switzerland 20 Monroe County, New York,(l8) and Rochester, Minnesota 21 The...

Pathophysiology of bulimia nervosa

Bulimia nervosa may have a genetic predisposition. Other predisposing factors include psychologic and personality factors, such as perfectionism, impaired self-concept, affective instability, poor impulse control and an B. Bulimia nervosa appears to have a chronic, sometimes episodic course in which periods of remission alternate with recurrences of binge purge cycles. Thirty percent of patients with bulimia nervosa rapidly relapse and up to 40 percent remain chronically symptomatic. C. Comorbid major depression is commonly noted. There is an increased incidence of rapid cycling mood disorders and anxiety and substance-related disorders. Substance abuse involving alcohol and stimulants, occurs in one third of patients with bulimia nervosa. Between 2 and 50 percent of women with bulimia nervosa have borderline, antisocial, histrionic or narcissistic personality disorder.

The multidimensional approach to anorexia nervosa

It is precisely because we do not know the fundamental (necessary) cause of anorexia nervosa that recourse has to be had to a multidimensional approach, faute de mieux. Although it has its limitations, a multidimensional approach permits one to consider a range of possible causal factors which not only act in an additive manner but may combine in a specific manner to bring about the illness 'It is the interaction and timing of these phenomena in a given individual which are necessary for the person to become ill'.(32) population in a developed 'Westernized' country. Within the circle there is a large sector representing females within an age range of 10 to 50 years who experience prevailing social pressures to acquire a slender body shape through dieting. Evidently only a small proportion of these women develop the illness. It is likely that for anorexia nervosa to develop it is also necessary to possess a genetic predisposition, represented by the small inner circle. The intersection...

The cognitivebehavioural account of anorexia nervosa and bulimia nervosa

Cognitive distortions are a prominent feature of anorexia nervosa and bulimia nervosa, and they have long been regarded as their 'core psychopathology'. For example, in the 1970s the psychotherapist Bruch(1> emphasized the 'relentless pursuit of thinness' of patients with anorexia nervosa, and Russell,(2) in the original paper on bulimia nervosa, highlighted these patients' 'morbid fear of becoming fat'. In both disorders thinness and weight loss are idealized and sought after, whereas there are strenuous attempts to avoid weight gain and any perceived 'fatness'. At the heart of this psychopathology is the tendency to judge self-worth largely, or even exclusively, in terms of shape and weight. Whereas it is usual to evaluate self-worth on the basis of perceived performance in a variety of domains (such as interpersonal relationships, work, sport, artistic ability, and so on), people with anorexia nervosa and bulimia nervosa evaluate themselves primarily in terms of their shape and...

Eating disorders

Patients with eating disorders may have a variety of sleep complaints, and some studies have documented objective sleep abnormalities. (36> Those with anorexia nervosa may report excess energy and symptoms of insomnia, particularly during periods of weight loss, whereas those with bulimia nervosa may experience hypersomnia, typically following eating binges. Comorbid depression is not uncommon in patients with eating disorders, and polysomnographic investigations of sleep patterns were motivated at least in part to determine if common biological markers could be identified in patients with depression and eating disorders. One of the major problems with this work has been the age of the subjects studied patients with eating disorders are typically young. A number of investigations have failed to document significant sleep changes in subjects with eating disorders, (3Z,38 and3 ) but this is also true for most sleep parameters in young depressives. (D In studies that have documented...

Anorexia nervosa

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The structure of DSMIV

The difference between DSM-IV and ICD-10 in the time criterion for the diagnosis of schizophrenia has already been mentioned, as has the distinction between conversion and dissociative disorders made in DSM-IV but not in ICD-10. Furthermore, the two systems classify eating disorders differently. DSM-IV includes two distinct forms of anorexia (the restricting type and the binge eating type) and two distinct types of bulimia (the purging and the non-purging types), whereas ICD-10 only includes only anorexia, bulimia, and their (undefined) atypical forms.

Pyrimidine Antagonists

Meta-analysis of several randomized trials comparing various 5-FU schedules of administration has shown the superiority of continuous infusion of 5-FU over bolus administration when given as a single agent.87 Moreover, bolus drug administration cannot achieve effective radiosensitization, as this requires constant drug exposure given the short half-life of 5-FU. Clinical toxicities also have some correlation with schedule of administration. Myelosuppression, especially leukopenia, is more pronounced with IV bolus schedules than with continuous infusion. Mucositis along the GI tract can be debilitating and dose limiting, especially with continuous infusion. Other GI symptoms, such as nausea, vomiting, and anorexia, can also be more severe with continuous infusion. With HAI regimens, systemic toxicities of 5-FU are dose limiting whereas hepatitis is usually mild. On the other hand, local-regional toxicities such as gastritis, gastric ulcers, enteritis, hepatitis, cholestasis, or...

Cytokine Influences on the Nervous System

In addition to these effects, TNF-a has been suggested to inhibit the hypothalamic-pituitary-thyroid axis at multiple levels (Dubuis et al. 1988) and the hypothalamic-pituitary-gonadal axis (Gaillard, Turnill, Sappino, and Muller 1990). Several recent studies also indicate that cytokines may synergize in the CNS. A form of motivation known as social investigation was used to demonstrate synergy between centrally injected (i.c.v.) IL-1 and TNF-a (Laye et al. 1995). IL-6 and its soluble receptor, when injected i.c.v., have been shown to interact in a way that potentiates fever and anorexia (Schobitz et al. 1995). Thus, the biological activity of cytokines may be dependent on the presence (or absence) of soluble receptors, which may exhibit either agonistic or antagonistic activity.

Influence of products of the immune system on the central nervous system

The immune system affects brain and behaviour, especially via the effects of immune cytokines on the central nervous system.(42) Although cytokines are relatively large molecules, some, particularly IL-1, can cross the blood-brain barrier via active transport. IL-1 is also produced in the brain by both microglia, which are macrophages resident in the central nervous system, and astrocytes. Peripheral IL-1 can affect the brain, including its production of cytokines, via stimulation of the vagus afferent fibres. There are cytokine receptors in the brain, including those for IL-1, IL-8, and interferon, on both glial cells and neurones. Cytokines play a role in the development and regeneration of myelin-producing oligodendrocytes. Brain cytokines play a role in immune effector mechanisms as regulated by the brain, including a role in brain infection and inflammation. Cytokines are relevant to the progression of multiple sclerosis, gliomas, HIV-associated dementia, brain injury, and...

Secular changes in incidence

This refers to the rise and fall of diseases in populations, with the possibility of making projections into the future. For example, there is some evidence that schizophrenia has been dropping in incidence and becoming more benign in its clinical course, (8) it is possible that depressive disorder has become more frequent in persons born since the Second World War(9l0) (the suicide rate of young persons has indisputably increased in many industrialized countries), it is likely that eating disorders have increased in frequency in some industrialized countries, and it is certain that the use of heroin and the AIDS epidemic with its neuropsychiatric sequelae are new arrivals and will be a continuing burden.

Appetitive motivation in MDD

A number of theorists have hypothesized that appetitive motivation is deficient in depression (Clark et al., 1994 Depue & Iacono, 1989 Fowles, 1988). Evidence for this idea is robust. A common set of clinical features of depression, for example, involves impairment in appetitive motivation depressed individuals frequently exhibit anhedonia, psychomotor retardation, fatigue, anorexia, and apathy. These features are all easily interpretable in terms of a reduced responsivity to appetitive stimuli and or a reduced drive to engage with positive or rewarding features of the external environment in MDD. Not surprisingly, and also consistent with this interpretation, depressed individuals have been found to report lower levels of appetitive motivation than do nondepressed controls (Kasch et al., 2002).

Which patients should be assessed

Geriatric patients undernutrition is more frequent in older persons because aging is associated with a physiological anorexia, as well as other causes such as poor dentition, economic problems, and chronic illness. Nutrition-mediated complications are more frequent in these patients.

Pathophysiology of malnutrition

Malnutrition can be classified as either primary or secondary 1 . Primary malnutrition is caused by inadequate calorie and nutrient intake. In developed societies, calorie intake is usually presumed to be adequate. However, inadequate intake of micronutrients including vitamins A and E, calcium, iron and zinc are prevalent among children of 1-10 years of age and often unrecognized, especially in minority populations 2 . Primary malnutrition in infants can also occur through child neglect or accidental nutrient insufficiency 3, 4 . For example, a genetic defect impairing zinc transport into breast milk from maternal blood can lead to zinc deficiency in infancy 5 . Eating disorders associated with psychosocial disorder are a common cause for primary failure-to-thrive in children 6 . Other causes include inadequate diet due to food intolerance or imposition of special diets unsuited to growing children. Vegetarian, macrobiotic or vegan diets in children may be associated with low vitamin...

Obesity And Type 1 Diabetes

Of concern also is that obesity, or the fear of it, can have detrimental effects, particularly in young (predominantly female) patients with Type 1 diabetes. The desire to remain thin can lead these patients to reduce or omit insulin dosages and or to engage in purging and laxative abuse (14-16). This particular form of'eating disorder' is probably one of the prevailing causes of 'brittle' or unstable diabetes, and often leads to recurrent episodes of diabetic ketoacidosis with an increased risk of developing chronic diabetic complications and of premature death (17). Consideration should therefore be given to the management of those with Type 1 diabetes who are obese or at risk of becoming obese, and to vulnerable individuals who are in danger of adversely controlling their own treatment for fear of becoming obese. It remains true, however, that the prevalence of being overweight in Type 1 diabetes is lower than that in the general population (13).

Etiology and diagnosis

Symptoms of pure magnesium deficiency are non-specific and very variable. Many may be due to coexisting hypocalcemia. They are difficult to separate from those commonly present in critical illness. They include lethargy, apathy, generalized weakness, anorexia, nausea, and vomiting. Signs and metabolic features of magnesium deficiency are summarized in TabieJ,.

Clinical features and diagnosis

If another Axis I disorder is present, it is mandatory that the content of the obsessions or compulsions is not restricted to it (e.g. a preoccupation with food or weight in eating disorders, or guilt feelings in the presence of a major depressive episode). The disturbance should not be due to the direct effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition.

Epidemiology Screening instruments

The most commonly used screening test in the detection of anorexia nervosa is the Eating Attitudes Test ( EAT).(8) Doubt has, however, been expressed about the predictive value of the EAT in the very populations where its use was introduced, as only a small percentage of the EAT-screened positive scores will have an actual eating disorder.(9) Thus, the EAT has limited usefulness in surveys for detecting anorexia nervosa unless it is supplemented by detailed clinical assessments. A survey depending on initial screening by questionnaire also runs the risk of failing to detect cases of anorexia nervosa as it was found that patients currently receiving active treatment were among the non-respondents, presumably because they wished to conceal their disorder. (19

Results of epidemiological surveys

Incidence of anorexia nervosa The studies which counted only hospitalized patients tended to yield low estimates of the annual incidence of anorexia nervosa expressed per 100 000 population (e.g. 0.45 in Sweden(l7)). Estimates based on case registers of psychiatric patients similarly yielded fairly low incidence rates (e.g. 0.64 in Monroe County, New York(18> ). The incidence found in community-based studies was by far the highest (6.3 in The Netherlands (l1) and 8.2 in Rochester, Minnesota .1.,)), presumably because they included the less severe cases. Prevalence of anorexia nervosa in vulnerable populations A high prevalence rate was found among Canadian ballet students (6.5 per cent) and modelling students (7 per cent). (12) A similar survey in an English ballet school also showed a high prevalence of 'possible' cases of anorexia nervosa (7.0 per cent). (1.3> Surveys among schoolgirls have shown a fairly wide variation in prevalence rates, ranging from zero to 1.1 per cent. In...

Aetiology Aetiological concepts

According to one robust opinion, it is essential to pursue the search for a specific and necessary cause of anorexia nervosa because the currently popular 'multifactorial' approach has little explanatory power.(31.) Accordingly the failure to identify a necessary causal element is regrettable. Many of the factors within a wide range of psychological, social, and physical causes so far studied may therefore only be relevant in predisposing to anorexia nervosa. The patients 'become terribly afflicted victims of an often-incurable illness whose causes still elude clarification'. (3 )

Childhood sexual abuse

Since it was reported that a high proportion of patients in a treatment programme for anorexia nervosa gave histories of sexual abuse in childhood, it has been supposed that this trauma would be a contributory causal factor.(43) It would be better if this history could be corroborated, but for obvious reasons it is often difficult to do so. Investigators often stress that their patients' accounts are convincing and that they should be believed. Hence this subject raises unusual difficulties in judging the reliability of the data. Child sexual abuse is also discussed in the chapter on bulimia nervosa ( Ch ipteL4J.0 2.). In a careful study of childhood sexual experiences reported by women with anorexia nervosa, the authors classified the events according to the seriousness of the sexual act in childhood and concentrated on sexual experiences with someone at least 5 years older. (44) They found surprisingly high rates (about one-third) of adverse sexual experiences in women with eating...

Personality disorders

A sizeable proportion of patients (30 per cent(lZ> and 32 per cent(2S) were said to have had a 'normal' personality during childhood before their illness. Nevertheless there is general agreement of a close relationship between obsessional personalities and the later development of anorexia nervosa. In fact Janet, who carefully described obsessions and psychasthenia, was dubious about the validity of the diagnostic concept of anorexia nervosa ( anorexie hyst rique). He thought that the patient's fear of fatness was an elaborate obsessional idea. (51> In a study of patients admitted for treatment they were classified into anorexia nervosa, bulimia nervosa, or a combination of the two disorders. (52) Personality disorders were identified through the Structured Clinical Interview for DSM-IIIR personality disorders (SCID-II). Seventy-two per cent of the patients met the criteria for at least one personality disorder. Anorectics were found to have a high rate of obsessive-compulsive...

Biomedical factors and pathogenesis Historical notes

Since the early part of the twentieth century a recurring theme has been the possibility that anorexia nervosa is primarily caused by an endocrine or cerebral disturbance. From 1916 there was much preoccupation with the concept of Simmonds' cachexia 55 the assumed result of latent disease of the pituitary gland. There was diagnostic confusion between anorexia nervosa and hypopituitarism which was only clarified much later when it became known that in true hypopituitarism weight loss and emaciation are uncommon. Hormonal deficits indicative of impaired pituitary function are indeed common in anorexia nervosa, but are merely a secondary manifestation of prolonged malnutrition. Interest in the neuroendocrinology of anorexia nervosa led to the formulation of the hypothalamic model. (7,56) From the beginning the model was aimed at explaining pathogenesis rather than aetiology it was not considered an alternative to the psychological origin for anorexia nervosa, but a means of explaining a...

Obsessivecompulsive features

The patients frequently eat in a ritualistic way, for example restricting their food intake to a narrow range of foods which experience tells them are 'safe' because they will not lead to weight gain. There is often a compulsive need to count the daily caloric intake. One patient rejected prescribed vitamin tablets in case they contained 'calories'. The frequency of obsessive-compulsive disorder in anorexia nervosa was found to be 22 per cent in a clinical series. (24) In studies using structured clinical interviews the frequency ranges from 25 to 70 per cent.

The impairment of hypothalamicpituitarygonadal function

Amenorrhoea is an early symptom of anorexia nervosa and in a minority of patients may even precede the onset of weight loss. Amenorrhoea is an almost necessary criterion for the diagnosis of anorexia nervosa. An exception is when a patient takes a contraceptive pill which in fact replaces some of the hormonal deficit and may lead her to say she still has her periods.

Acute dilatation of the stomach

This complication has also been described in anorexia nervosa during the course of refeeding. (94) The patient develops copious vomiting, upper abdominal pain, distension of the upper abdomen, and rapid dehydration. Treatment is by continuous gastric aspiration, and this complication is one of the rare indications for intravenous infusions of glucose and saline. Gastric dilation is best prevented by avoiding a food intake above 2000 cal daily during the first week of refeeding.

Comparison of mortality rates

In a review of 42 studies the aggregate annual mortality rate from anorexia nervosa was found to reach 0.56 per cent on average. ( 12) Complications of anorexia nervosa accounted for 54 per cent of deaths, suicide for 27 per cent, and other causes for 19 per cent. When the death rate is expressed as a percentage per annum a fair measure of consistency has been found in different parts of the world, especially when allowance is made for selection biases in Denmark 0.5 per cent per annum (younger patients) 1,,13) in Sweden 0.75 per cent per annum 1, 0) in the United States 0.66 per cent per annum, (H4) and in the United Kingdom 0.75 per cent per annum.(111)

The steppedcare approach

The principle of stepped-care is that with an early presentation of anorexia nervosa the clinician should first apply relatively simple remedies. Only if they fail should more vigorous and time-consuming treatments be provided. In practice, however, the patient who has avoided treatment as long as possible may first be seen when weight loss is already substantial and abnormal attitudes entrenched. If this happens it is not possible to follow a graduated sequence and a short cut may be needed to a more vigorous method including admission to hospital. Admission is also indicated in the presence of 'famine' oedema or proximal myopathy.

Models of psychotherapy

Bruch developed her aetiological model of anorexia nervosa as the child becoming involved with her family in such a way that she fails to achieve a sense of independence. Thus a paralysing sense of ineffectiveness pervades all her thinking and activities. Bruch used this model to provide an entry into the psychotherapy. She engaged her patient in a dialogue which became central for the resolution of her conflicts. Patients are often receptive and reassured when the therapist does not criticize them for behaviours associated with their illness. They may even obtain a relief from the implication that in some way the families are to blame for the anorexia nervosa. Using this model the therapist will engage his patient in the therapeutic metaphor in which she is seen as 'a sparrow in a golden cage'. She is then encouraged to think of ways of fulfilling her own needs and desires, rather than relying on others, and seek an autonomy that frees her from the tyranny of anorexia Crisp's model...

Cognitivebehavioural therapy

Although a strictly cognitive-behavioural model for the aetiology of anorexia nervosa has not yet been recognized, a theory for faulty cognitions maintaining the illness has been put forward by Fairburn et al.(l29) The argument for examining the role of faulty cognitions in anorexia nervosa is inescapable. The original description of perceptual and conceptual disturbances in anorexia nervosa was put forward by Bruch in 1962. (6) It was appreciated that faulty attitudes to body size contributed in part to the patient's determination to reduce her food intake and lose weight.(56) These observations led to the first development of a cognitive-behavioural therapy for anorexia nervosa 1 30) Despite the appeal of a therapy based on a cognitive-behavioural approach, there have been virtually no controlled clinical trials of this therapy. The current evidence of its benefit relies therefore on clinical impressions and case reports. (126) The patient's weight and food intake is monitored at...

Inpatient treatment

At one time inpatient programmes were run on behavioural principles, but in recent years 'lenient' programmes have found favour. (H8) The great advantage of treating a patient in a specialist eating disorders unit programme is the certainty that considerable benefit will accrue, including a substantial gain in weight, if the patient can

Introduction Origins of the concept

The history of the diagnosis bulimia nervosa begins as recently as 1979. It was in this year that Russell published his now seminal paper 'Bulimia nervosa an ominous variant of anorexia nervosa' in which he described 30 patients (28 women and two men), seen between 1972 and 1978, who had three major features in common. First, they had recurrent episodes of uncontrolled overeating second, they regularly used self-induced vomiting or laxatives as means of weight control and third, they had a morbid fear of becoming fat. Russell described many other features shared by these patients, including a history of anorexia nervosa (present in 80 per cent), the presence of severe depressive symptoms, and the fact that in most cases their body weight was in the healthy range. He noted that the disorder tended to run a chronic course and that it was 'extremely difficult to treat'. Finally, he suggested that this clinical picture should be viewed as a syndrome, distinct from anorexia nervosa, and he...

Clinical features

The great majority of patients with bulimia nervosa are female and most are in their twenties (although the age range is between 10 and 60years). In considering the psychopathology of the disorder, a distinction may be drawn between its 'specific' and 'general' features. The former comprises features that are largely peculiar to eating disorders (e.g. self-induced vomiting), whereas the latter consists of features seen in other psychiatric conditions (e.g. depressive symptoms). The clinical features of bulimia nervosa are similar in men and women'9) and in those with and without a history of anorexia nervosa.

Specific psychopathology

The eating habits of patients with bulimia nervosa are characterized by strict dieting punctuated by repeated episodes of binge eating ( Fig. .2). The dieting is extreme, in that little tends to be eaten, and it is governed by multiple self-imposed dietary rules. These rules tend to be applied to all aspects of eating, including when to eat, what to eat, and how much to eat. As a result, the food eaten (when not binge eating) is restricted in quantity and range. Fig. 2 A monitoring record illustrating the eating habits of a patient with bulimia nervosa. In DSM-IV bulimia nervosa is subdivided into two types, a purging and non-purging type. In the purging type there is self-induced vomiting or the misuse of laxatives or diuretics, or both, whereas in the non-purging type purging is either not present or it is infrequent. The majority of patients seen in clinical practice have the purging form of the disorder and it has been the focus of most research. Other forms of weight control...

General psychopathology

General psychiatric symptoms are prominent in bulimia nervosa, more so than in anorexia nervosa.( . 19) The nature of the comorbid symptoms also differs. Depressive features are particularly striking indeed, the level of depressive symptoms in bulimia nervosa is equivalent to that seen in major depressive disorder. Depressed mood, feelings of hopelessness and worthlessness, poor concentration, guilt, and suicidal ideation are seen. Anxiety symptoms are also encountered, many of which are directly related to the eating disorder for example, there is often pronounced anxiety about eating in public. Obsessive- compulsive features are sometimes present, although they are less common than in anorexia nervosa. Similarly, social functioning is less impaired. A subgroup of patients with bulimia nervosa have 'impulse-control' problems, such as the overconsumption of alcohol or drugs, or repeated self-harm. Some of these patients also meet diagnostic criteria for borderline personality...

Development of the disorder

As noted in Chapter 4,10,1, anorexia nervosa generally starts in mid-adolescence with a period of voluntary dietary restriction which proceeds to get out of control. As a result body weight falls and a state of starvation develops. Shape and weight concerns may predate the onset of the dieting or develop as weight is lost. Bulimia nervosa starts in a similar way although the age of onset is typically some years later, and shape and weight concerns usually antedate the dieting. The dietary restriction resembles that seen in anorexia nervosa and it leads to weight loss sufficient to result in anorexia nervosa in about a quarter of cases. (As a result of referral bias, this proportion is higher in cases seen in specialist centres.) In the remaining cases there is also weight loss but it is less extreme. After a variable length of time (generally within 3years) dietary control breaks down with the patient's dieting becoming punctuated by episodes of overeating. At first, the episodes of...

Predisposing factors and processes

There are many risk factors for the development of bulimia nervosa Ll2,) and these overlap with those for anorexia nervosa.(26) The risk factors may be usefully divided into a number of categories. 2. Exposure to an immediate social environment that encourages dieting this includes being brought up in a family in which there is intense interest in shape, weight, and eating as a result of one or more members either having some degree of eating disorder or having a medical condition that affects eating or weight (such as diabetes mellitus). Extreme occupational or recreational pressures to diet also appear to be associated with increased risk (e.g. ballet dancing (43> ), although there may also be an element of self-selection. Another important influence is parental and childhood obesity, the rates of which are substantially increased in bulimia nervosa. Both are likely to sensitize individuals to their appearance and weight, and thereby make them prone to diet. There is also some...

The contribution of genetic factors

The magnitude of inherited influences is unclear. Several studies have found an increased rate of anorexia nervosa and bulimia nervosa among the relatives of probands with bulimia nervosa,(25) whereas other studies have found either no increase or only an increase in atypical eating disorders. (30) The findings of the first twin series of note suggested that the inherited contribution was minimal. More recent studies from the Virginia Twin Registry have yielded inconsistent findings with estimates of heritability varying from negligible (48> to 55 per cento to 83 per cent.(iE> A number of factors are likely to have contributed to the variability in the findings, including the small sample sizes (which render twin models unstable) and the difficulty making lifetime diagnoses of bulimia nervosa. It is also of note that, in contrast with other psychiatric disorders, the findings suggest that there may be violations of the equal environments assumption that underpins twin studies. (4...

Maintaining factors and processes

Once established, bulimia nervosa tends to run a chronic course with the proviso that it tends to improve over the long term (see below). There are a number of processes which account for its self-perpetuating character which are discussed in ChapteL4J.Q.J They include the ongoing influence of the extreme concerns about shape and weight the form of these patient's dieting, which encourages binge eating the moodmodulating effect of binge eating and the fact that the loss of control over eating perpetuates fears of weight gain.

Studies of pharmacological treatment

A variety of drugs have been tested as possible treatments for bulimia nervosa including antidepressants, appetite suppressants, anticonvulsants, and lithium. Only antidepressants have shown promise. 3. Few studies have evaluated the effects of antidepressant drugs on features other than binge eating and purging. Mood improves as the frequency of binge eating declines but this effect is common to all treatments for bulimia nervosa. Antidepressant drugs do not appear to modify the patient's extreme dieting which may account for the apparently poor maintenance of change.

Diagnosis and clinical presentation

As an endstage in the symptoms of starvation, particularly in the edematous variety of kwashiorkor. Paradoxically, starvation is rarely associated with hypoglycemia in its early stages, despite exhaustion of glycogen stores, as ketone bodies can act as energy substrates for the brain. Hypoglycemia is occasionally seen and is a poor prognostic sign in anorexia nervosa.

Pharmacological treatment of obesity

Weight-loss medications are usually reserved for patients with a body mass index over 30 kg m 2 who have failed to reduce with conservative approaches. They may also be appropriate for patients with a body mass index over 27 kg m2 who have a comorbid condition which will be improved with weight loss. Weight-loss medications are inappropriate for lactating or pregnant women, as well as for people with eating disorders (i.e. anorexia nervosa and bulimia nervosa). (38)

Chapter References

Spitzer, R.L., Devlin, M., Walsh, T.B., et al. (1992). Binge eating disorder a multisite field trial of the diagnostic criteria. International Journal of Eating Disorders, 11, 191-203. 8. Spitzer, R.L., Yanovski, S.Z., Wadden, T.A., et al. (1993). Binge eating disorder its further validation in a multisite trial. International Journal of Eating Disorders, 13, 137-53. 42. Kral, J. (1995). Surgical interventions of obesity. In Eating disorders and obesity a comprehensive handbook (ed. K.D. Brownell and C. Fairburn), pp. 510-15. Guilford Press, New York.

Interpersonal relationships

Narcissistic personality disorder is often comorbid with major depression, dysthymic disorder, substance abuse, and anorexia nervosa. Patients meeting criteria for narcissistic disorder have a high overlap with histrionic, borderline, and antisocial personality disorders, and also with schizotypal, paranoid, and passive-aggressive personality disorders.

Beyond Surgery Radiation Therapy and Chemotherapy

Potential nutritional interventions range from oral to par-enteral and from cancer prevention to the support of patients with metastatic disease.126-128 Some investigators have found that oral intake of fish oil can reverse cancer anorexia and weight loss while others have observed no benefit.129,130 Although the use of parenteral nutrition for patients with end-stage cancer can prolong survival, the associated cost and adverse effect on quality of life add complexity to the decision to undertake this therapy.131

Early Surgical Complications

In the early postoperative period, the pediatric recipient can experience any complication associated with operation (bleeding, infection, wound complications, etc.). Those unique to renal transplant recipients usually revolve around graft dysfunction. Signs and symptoms of graft dysfunction include anorexia, malaise, weight gain, fever, abdominal pain, allograft tenderness, decreased urine output (< 1 cc kg hour), and elevated creatinine. The differential diagnosis includes vascular occlusion, urinary obstruction, urine leak, prerenal azotemia, rejection, CsA toxicity, and acute tubular necrosis. The diagnostic approach to this common scenario is systematic.2 The recipient is examined and the Foley irrigated to remove clots and demonstrate patency. A duplex ultrasound is obtained to rule out vascular thrombosis, external compression (hematoma, lymphocele), and hydronephrosis. If duplex ultrasound is not available or cannot exclude thrombosis, a renogram is done. Vascular thrombosis...

Associated psychopathology and comorbidity

Intermittent explosive disorder often co-occurs with other psychiatric disorders. For example, of 46 impulsive violent offenders ( n 24) and fire-setters (n 22) in one study,(8) 33 (72 per cent) of whom met the DSM-III criteria for intermittent explosive disorder, 44 (96 per cent) had a lifetime diagnosis of alcohol abuse, 41 (89 per cent) had borderline personality disorder, 24 (52 per cent) had a mood disorder, and nine (20 per cent) had antisocial personality disorder. Of 27 subjects with DSM-IV intermittent explosive disorder evaluated with the Structured Clinical Interview for DSM-IV, (6) 25 (93 per cent) met lifetime criteria for a mood disorder (with 15 (55 per cent) meeting criteria for a bipolar disorder), 13 (48 per cent) for a substance use disorder, 13 (48 per cent) for an anxiety disorder (with six (22 per cent) meeting criteria for obsessive-compulsive disorder), six (22 per cent) for an eating disorder, and 12 (44 per cent) for an impulse control disorder other than...

Epidemiology and course

Repetitive self-mutilation often co-occurs with other Axis I and II psychiatric disorders, especially mood, substance use, eating, psychotic, and borderline personality disorders. For example, in a 1983 review of 56 cases from the literature of patients with the 'deliberate self-harm syndrome', 45 per cent of patients were depressed, 41 per cent were psychotic, and 36 per cent were substance abusers.(28) In another evaluation of 54 psychiatric inpatients with 'self-injurious behaviour', eating disorders were the most common associated ICD-10 Axis I diagnosis, present in 54 per cent of patients, followed by substance use (33 per cent), affective disorders (20 per cent), and schizophrenic disorders (18 per cent). (29> Borderline and histrionic were the most frequent personality disorders, present in 52 and 23 per cent of the group, respectively. However, 22 per cent of patients did not fulfil criteria for any personality disorder.

Mental disorders and suicide

Attempted suicide, which carries about 40 times the expected value (Tab e 3). In anorexia nervosa and major depression the risk is about 20-fold, and in other mood disorders and psychoses about 10 to 15 times higher than expected. In anxiety, personality, and substance use disorders the suicide risk is at lower levels, but about five to 10 times higher than the expected value. In subtance disorders the risk is dependent on the type of disorder, being clearly lowest in alcohol, cannabis, and nicotine abusers.(23)

How to Maintain Weight Loss

Overall, patients who have undertaken repeated diets quickly regain the kilos they have lost. When facing the yo-yo phenomenon, eating disorders should be investigated. This is associated with a feeling of restriction, nibbling or compulsions, and has the effect of making patients feel guilty and reducing their self-esteem. Behavioral work, combined with a hypocaloric diet and a program of physical activity, allows weight loss to be maintained 12 . It involves only a small loss of weight but helps alleviate eating disorders, depression and anxiety. A prospective study with a 5-year follow-up 13 confirms that this multidisciplinary approach is entirely beneficial in the long term. Fifty percent of patients maintained their weight loss, and even continued to lose weight. Lately, Wadden et al. 14 confirmed that the combination of medication and group lifestyle modification resulted in more weight loss than either medication or lifestyle modification alone. In conclusion, there is no...

Genderrelated aspects

Two studies (n 188,(5) n 58(14> ) found that men and women have generally similar clinical features, although one of these studies (5) found that women were more likely to focus on their hips and weight, pick their skin, and camouflage with make-up and have comorbid bulimia nervosa men were more likely to be preoccupied with body build, genitals, and hair thinning, use a hat for camouflage, be unmarried, and have alcohol-abuse or dependence problems. In the other study, (1.4> women were more likely to focus on their breasts and legs, check themselves in a mirror, and use camouflage techniques and have panic disorder, generalized anxiety disorder, and bulimia, whereas men were more likely to focus on their genitals, height, and excessive body hair, and have bipolar disorder.

Decompression sickness

The occurrence of symptoms is related to the number of bubbles formed, their location, and the presence of predisposing factors. Bubbles mechanically injure tissues by distortion, tearing, or the production of ischemia as a result of vessel compression. Bubbles within the circulation activate the coagulation, kininogen, and complement systems, leukocytes, and thrombocytes, leading to non-mechanical tissue injury. On rare occasions uncontrolled bubble formation leads to the fatal consequences of diffuse massive arterial air embolization known as the 'blow-up' syndrome. Symptoms of decompression sickness are classified as type I, which includes musculoskeletal pain, cutaneous manifestations, and constitutional symptoms (fatigue, anorexia, malaise), or type II, which includes central nervous system

Causes of hypothermia

Hypothermia can be precipitated by alteration of thermoregulatory mechanisms for example, alcoholic intoxication induces peripheral vasodilatation, decreases shivering capacity, depresses central thermoregulatory mechanisms, and impairs judgment. Alcoholics may stay outside for many hours wearing few clothes, either asleep or unconscious, in parks, on river banks, or in snow. Many drugs, such as tricyclic antidepressants, phenothiazines, or barbiturates, can lead to hypothermia either when used at toxic levels for self-poisoning or when administered in normal dose range for therapeutic purpose. Endocrine dysfunction, such as hypothyroidism, hypopituitarism, hypoglycemia, or diabetic ketoacidosis, may also result in hypothermia. Additional risk factors include central nervous system lesions (stroke, hemorrhage, trauma, tumor), spinal cord injuries, Parkinson's disease, Wernicke's encephalopathy, Alzheimer's disease, schizophrenia, anorexia nervosa, agenesis of the corpus callosum, or...

Immediate Questions

Nutritional repletion or refeeding syndrome. Can occur with enteral or parenteral nutrition in patients who are malnourished or those with anorexia nervosa or AIDS. 2. Decreased intake. Starvation, anorexia nervosa, protein-calorie malnutrition. At high risk for refeeding syndrome (see III, A, 1, earlier). Premature infants require phosphate supplementation.

Chronic renal failure

Patients with chronic renal failure usually become symptomatic when glomerular filtration rate is less than 10 ml min. Uraemia affects every organ system, including the central nervous system. There may be arrhythmias, anorexia, nausea, vomiting, anion gap acidosis, hypocalcaemia, fluid overload, hyperlipidaemia, hyperparathyroidism, increased insulin resistance, pruritus, anaemia, bleeding disorders, pulmonary oedema, pneumonitis, pleuritis, gout, and muscle weakness. Neuropsychiatric manifestations of chronic renal failure include irritability, insomnia, lethargy, anorexia, seizures, and restless legs syndrome. (89 In contrast to acute renal failure where neuropsychiatric signs and symptoms may appear with a creatinine level as low as 4 mg dl in chronic renal failure, patients may have a normal mental status examination with a serum creatinine level as high as 10 to 11 mg dl. Symptomatic treatments with low-dose neuroleptics, antiseizure medications, or

Referrals to mental health CL services in the general hospital

General hospital referrals to CL services are fewer than warranted by prevalence rates and other indicators of need. Across Europe they range from 1 to 2 per cent. Referral patterns reflect the everyday realities of care delivery. The psychiatrist is most frequently consulted about the following disorders (in order of frequency) psychiatric consequences of physical illness (adjustment disorders, organic mental disorders), psychiatric problems with physical complications (self-harm, substance abuse, eating disorders), psychiatric and physical disorders appearing together (comorbidity), and psychiatric disorders presenting with physical symptoms (somatoform disorders). The most frequent psychiatric symptoms across these groups are depressed mood, often with a somatic syndrome, delirium and dementia, and anxiety (Table 2).

Psychobiology Of Impulsivity

Research into the neurobiology of impulse control is further complemented by studies conducted within the impulsive compulsive conceptual framework (Hollander, & Cohen 1996). Compulsive disorders, to some degree the reverse of impulsive disorders, are characterized phenomenologically by an increased sense of harm avoidance, risk aversiveness, and anticipatory anxiety. Such disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, and anorexia nervosa. Moreover, the neurobiology of compulsive disorders is largely the inverse of the impulsive findings, providing additional evidence of the neuro-biological substrates of impulsivity.

The severity of a patients psychopathology23

In the European study described above, patients seen by CL services included those with delirium, dementia, psychoses, mood and anxiety disorders, somatoform disorders, less common diagnoses such as eating disorders, no psychiatric diagnosis, and problems of coping, and those who were not alert enough for a psychiatric diagnosis to be made. Those findings closely follow the classification in ICD-10 and DSM-IV, and reflect the broad range of referable disturbances.

Neurotransmitter Function

Considerable evidence implicates serotonergic dysfunction in the neurobiol-ogy of impulsivity. While the complexity of neurotransmitter systems demands cautious interpretation, there is evidence of decreased serotonergic tone in impulsive disorders in contrast to increased serotonergic tone found in compulsive disorders. Serotonergic (5-HT) function may be measured by cerebrospinal fluid (CSF) metabolites of 5-HT (5-hydroxyindoleacetic acid 5-HIAA), by responses to serotonergic probes (m-CPP and others), and by treatment outcome to serotonin reuptake blockers (fluoxetine, clomipramine, fluvoxamine and others). Patients with impulsive aggressive (Linnoila, Virkkunen, Scheinen et al. 1983) and violent suicidal (Asberg, Traskin, Thoren, 1976) behavior have decreased levels of cerebrospinal fluid metabolites of 5-HT (CSF 5HIAA). Patients successfully completing violent suicide also have decreased 5-HT receptors in the frontal cortex (Arora, Meltzer, 1989). In 22 violent offenders,...

Tuberculosis and Other Mycobacteria Donald E Gardner PhD Fellow ATS

TB is a particularly good illustration of an infectious disease process that involves an ecological lifelong balance between a host and a microbe. TB in humans is predominately an airborne infection of the lungs that is almost always initiated by inhalation. Once the organisms have been inhaled and deposited in the lung, these organisms can be found in the lung's phagocytic cells (alveolar macrophages) that tend to protect them from antibodies and other host immune defenses. Individual susceptibility to TB and the severity of the disease are based on the virulence of the organism, the duration of exposure, concomitant exposure to other toxicants, medication for treatment of other diseases, and the nutritional status of the host. Once the organism has survived the transport through the environment and has infected a susceptible host, the TB infectious process can be divided into two stages that are commonly referred to as primary and secondary infections. During the primary phase,...

Counselling in primary care

One of the most conspicuous areas of growth in counselling has been within the primary health care setting, perhaps following Balint's seminal work with general practitioners 40 years ago.(48) The upsurge in the demand for counselling in primary care has been stimulated by greater demands for the non-drug treatment of emotional disorders, and by continuing debate about the most effective way of managing emotional difficulties and mental health problems in primary care. In the United Kingdom National Health Service, for example, more than one-third of general practices employ counsellors from a variety of disciplines and offering a range of counselling models. A survey of general practitioners in England and Wales found that 31 per cent had 'counsellors', including community psychiatric nurses, clinical and counselling psychologists, and practice counsellors. Community psychiatric nurses were more likely to see patients with moderate to severe mental illness and psychoses patients with...

Evidence for the cognitivebehavioural account

There is a sizeable body of research that supports this cognitive view on the maintenance of anorexia nervosa and bulimia nervosa. (7) This includes descriptive and experimental studies of the clinical characteristics of these patients and the research on dietary restraint and 'counter-regulation' (a possible analogue of binge eating).(8) However, it is the research on the effects of treatment that provides the strongest support. Thus indirect support comes from the large body of research indicating that cognitive-behaviour therapy has a major and lasting impact on bulimia nervosa (see ChapteL4.10,2). Further support comes from the finding that 'dismantling' cognitive-behaviour therapy by removing those procedures designed to produce cognitive change attenuates its effects and results in patients being markedly prone to relapse.(9) The most direct support comes from the finding that, among patients who have recovered in behavioural terms, the severity of concerns about shape and...

Brief cognitivebehaviour therapy selfhelp and the issue of training

To facilitate cognitive-behaviour therapy. Two of the books are directly based on cognitive-behaviour therapy for bulimia nervosa. (1, 14) They provide the information patients need in the course of treatment together with guidelines for the implementation of the simpler behavioural and cognitive procedures. Therefore they may be used to facilitate therapist-led treatment.

Patients who do not respond

Cognitive-behaviour therapy for bulimia nervosa is far from being a panacea. As discussed in Chapter.4.1,0.2, only a half to two-thirds of those who complete treatment obtain a substantial and lasting benefit, the remainder responding either partially or not at all. About 15 per cent of patients drop out. There are no evidence-based guidelines for the treatment of patients who do not respond to cognitive-behaviour therapy. There are various logical alternatives including adding an antidepressant drug (fluoxetine 60 mg being an appropriate choice (l9i) and switching to interpersonal psychotherapy (29 (see Chapter.6.3.3) since both are treatments for bulimia nervosa in their own right. Modifying cognitive-behaviour therapy is also an option. For example, components of the treatment may be intensified (for example, by adding exposure with response prevention procedures (12> or more emphasis on body image(17> ) or cognitive-behaviour therapy may be broadened to address more general...

Enhancing motivation to change

To help motivate the patient, the therapist also needs to identify clinical features that the patient might view as a problem. It is often useful to ask patients to read about anorexia nervosa and its characteristics. Good accounts have been written by Palmer (23> and by Bruch.(24) Initially, many patients are reluctant to accept the diagnosis but once they have read about the disorder most find that they identify with it. It is particularly important to educate them about the physiological and psychological effects of starvation, especially the impaired concentration, preoccupation with food and eating, sleep disturbance, sensitivity to cold, ritualistic eating, and enhanced fullness secondary to delayed gastric emptying. Most patients have these features and once they understand their origin, they are more willing to countenance weight gain. It also needs to be explained how starvation tends to perpetuate the eating disorder.

Studies of Adults with Severe Malnutrition

Malnutrition is a feature of several adult diseases like anorexia nervosa, chronic illnesses including malignancy, and acquired immune deficiency disease, and also inflicts postoperative patients placed on prolonged periods of nutritional depriva-tion.27 93-95 In human adult volunteers on a semistarvation regimen, significant reductions of heart rate, stroke volume, cardiac output, and heart size were observed. The fall in cardiac output, as in children, was only proportionate to the diminished metabolic requirements or reduction in body weight. The reduced cardiac output was associated with echocardiographically measured reductions in left ventricular end diastolic diameter and mass.27 Cardiac changes are pronounced also in anorexia nervosa.99 Responses of heart rate and blood pressure to exercise are reduced substantially, although resting brady-cardia and hypotension are less common. Patients may develop arrhythmias including tachycardia, sinus arrest, and ectopic rhythms....

Other treatment components

Many other treatment components have been described as elements of cognitive-behaviour therapy for anorexia nervosa including measures for addressing interpersonal problems, low self-esteem, and difficulty recognizing emotions.(21) In practice such problems only need to be addressed if they prove to be a barrier to progress or if they persist despite the successful treatment of the eating disorder. As with bulimia nervosa, there are generally improvements in many areas of functioning following the treatment of the core eating disorder. In a new cognitive-behavioural formulation of anorexia nervosa it has been proposed that the central feature is an extreme need for self-control upon which shape and weight concerns are superimposed.(3) If true, this would suggest that the cognitive-behavioural treatment of anorexia nervosa should be extended to address self-control, inflexibility, and perfectionism, in addition to eating, shape, and weight.

Epithelioid haemangioendothelioma

Suggestion of a relationship to oral contraceptive use has not been validated 1270 . Epithelioid haemangioendothe-lioma causes systemic symptoms (weakness, malaise, anorexia, episodic vomiting, upper abdominal pain, and weight loss) and hepato-splenomegaly 807, 1150 . Some patients develop jaundice and liver failure. Uncommon modes of presentation include the Budd-Chiari syndrome 2040 or portal hypertension. Macroscopy. Macroscopically, lesions are usually multifocal ill-defined lesions scattered throughout the liver vary from a few millimeters to several centimeters in greatest dimension. They are firm, tan to white on sectioning, and often have a hyperaemic periphery calcification may be evident grossly.

IPT for other disorders

Bulimia Fairburn and colleagues altered IPT for studies of bulimic patients, eliminating the use of the sick role and of role playing, so that relatively distinct strategies could be used in a comparison of IPT and CBT 71 ,7 7 and 74) This research showed that although CBT worked faster, IPT had long-term benefits comparable with CBT and superior to a behavioural control condition.

The Patient Intake Questionnaire

The value of the intake survey is threefold. First, it contains a tremendous amount of patient information related to the patient's weight loss expectations, review of comorbidities, previous weight loss attempts, family obesity history, dietary lifestyle, self-efficacy assessment, and the possibility of eating disorders (Figure 8.3). Second, the wide array of data the survey contains helps validate coding for the visit. Third, the survey reflects a serious effort on the physician's part to understand the patient's obesity condition as a potential medical-legal Question 23 is important in helping identify a possible binge eating disorder. The prevalence of binge eating disorder (BED) is not known. Earlier studies by Spitzer et al. suggested 29 of people seeking obesity treatment have a BED 3 . More recent studies suggest the prevalence is between 8.9 and 18.8 4,5 . Whatever the actual percentage, the reality is that many patients who want obesity treatment in the primary care...

Clinical evaluation of PMS

The differential diagnosis includes hypothyroidism, anemia, perimenopause, drug and alcohol abuse, and affective disorders. Common alternative diagnoses in patients complaining of PMS include affective or personality disorder, menopausal symptoms, eating disorder, and alcohol or other substance abuse. A medical condition such as diabetes or hypothyroidism, is the cause of the symptoms in 8.4 , and 10.6 have symptoms related

Poor Intake and Absorption

Inadequate calorie intake or absorption remains the predominant cause in most patients, especially for those who are symptomatic from congestive heart failure.114 Several investigators documented low calorie intakes in patients with CHD compared with intakes of age-matched controls.115 In their study of 22 children with CHD, Hansen and Dorup noted that the children consumed only 88 of RDAs and that most did not meet the recommendations for iron, zinc, calcium, and vitamins D, E, C, B1, and B6.116 The energy intakes correlated with weight standard deviation (SD) scores. Thommessen et al. reported poor appetite and feeding problems among children with CHD, and the problems related well with the degree of malnutrition.117 Children with feeding problems also tended to eat less than children without feeding problems. Unger et al. found that underweight children with CHD consumed only 89 of RDAs whereas the figure was 108 in those with normal weights.118 For most parents, feeding of infants...

The family in problem maintenance

First, the illness becomes a way of 'solving' a family problem, the best that can be achieved. Anorexia nervosa in a teenager due to attend a distant university may lead to her abandoning this plan since she feels unable to care for herself. Were she to leave, parental conflict would become more exposed and her mother, with whom the patient is in coalition against her father, would find herself unsupported. The illness therefore keeps the patient at home and enmeshed in the parental relationship, and also provides a focus for shared concerns and an ostensible sense of unity.

Perry Shen and Shayn Martin

The ability to consume an adequate quantity of calories and nutrients is commonly decreased in the setting of malignancy. Dietary intake is often inappropriately decreased, even when the malignant condition has increased caloric needs.3 Anorexia is frequently present, manifesting as a loss of appetite with early satiety. This can be present in as many as one half of newly diagnosed cancer patients. Alterations in the taste and smell of food contribute to this phenomenon.2 Depression, which is not uncommon among the oncologic population, can greatly decrease a patient's appetite.1

Obstructive Sleep Apnea Syndrome in Children Clinical Features

Will progress to cor pulmonare (Brouillette, Fembach, and Hunt 1982). Failure to thrive is a frequent complication of OSAS in children. Causes for poor growth include anorexia or dysphagia secondary to adenotonsillar hypertrophy, increased work of breathing, hypoxia, or abnormal nocturnal growth hormone secretion (Marcus, Koerner, Pysik, and Loughlin 1994).

Gastrointestinal Tract Toxicity

The nausea and vomiting frequently observed after anticancer drug administration are actually thought to be caused by a stimulation of the vomiting center or chemoreceptor trigger zone in the central nervous system (CNS) rather than by a direct gastrointestinal effect. These symptoms are ameliorated by treatment with phenothiazines and other centrally acting antiemetics. Commonly, nausea begins 4 to 6 hours after treatment and lasts 1 or 2 days. Although this symptom is distressing to patients, it is rarely severe enough to require cessation of therapy. Anorexia and alterations in taste perception also may be associated with chemotherapy.

Interleukins Aldesleukin

Several serious toxicities have been observed, with a fatality rate of 5 in the initial studies. The major adverse effect is severe hypotension in as many as 85 of patients, which may lead to myocardial infarctions, pulmonary edema, and strokes. This hypotension is thought to be due to a capillary leak syndrome resulting from extravasation of plasma proteins and fluid into ex-travascular space and a loss of vascular tone. Patients with significant cardiac, pulmonary, renal, hepatic, or CNS conditions should not receive therapy with aldesleukin. Other adverse reactions include nausea and vomiting, diarrhea, stomatitis, anorexia, altered mental status, fevers, and fatigue.

Periodic Limb Movement Disorder

PLMD is a sleep-related movement disorder characterized by the presence of PLMS and by clinical sleep disturbance that cannot be accounted for by another primary sleep disorder (30). The PLMS are considered responsible for sleep fragmentation and a complaint of EDS. However, PLMS are present in 6 of the general population and in more than 45 of adults aged 65 years or older (95). Also, there are a number of conditions other than RLS where PLMS are also recorded, for example, in about 45 to 60 with narcolepsy (96), 70 with RBD (97,98), 27 to 38 with OSA (95,99-101) and also in insomnia, sleep-related eating disorder (SRED), fibromyalgia, and attention deficit-hyperactivity disorder. Medications, for example, selective serotonin reuptake inhibitors, tricyclic antidepressants, lithium, and dopamine receptor antagonists are also known to precipitate PLMS. Low brain iron, as reflected by serum ferritin may also play a role. Thus, persistence of PLMS and related clinical sleep disturbance...

Initiating treatment with medication

Initiation of the treatment involves a slow increase of the dose to some target dose, often in the range of 0.5 to 0.7 mg kg, given twice daily to begin with. However, a dose based on the milligram-per-kilogram calculation may result in doses that are too high for older or heavier children. Conversely, fixed doses (e.g. a target dose of 10 or 15 mg, twice daily) could result in doses that are too high for younger or lighter children. Some hybrid approach seems optimal for example, targeting a dose of 0.7 mg kg, but stopping at a maximum single dose set at 20 mg. The use of a third late-day dose of medication may be particularly useful for social and academic activities in the evening. To minimize insomnia and anorexia in the evening, typically, the third dose is half the dose administered during the day.

Schoolrefusal anxiety disorder

On psychiatric examination, many such children meet the criteria for one or more anxiety disorders, the most frequent being separation anxiety disorder. A small proportion may meet criteria for other disorders, including depression (generally mild). Physical symptoms are very evident in the presentation and include abdominal pain, frequency of micturition, anorexia, diarrhoea, pallor, and headache. They may be limited to mornings, reflecting the somatic consequences of physiological arousal associated with specific anticipatory worry about school. Invariably, the physical and emotional symptoms recede if avoidance is allowed.

Obsessivecompulsive disorder

Both DSM-IV(23) and ICD-10(24) define OCD, regardless of age, by obsessions and or compulsions (criterion A), which are described, at some point during the course of the disorder, as excessive or unreasonable (criterion B), and are severe enough to cause marked distress or to interfere significantly with the person's normal routine, or usual social activities or relationships (criterion C). The specific content of the obsessions or compulsions cannot be restricted to another Axis I diagnosis, such as an eating disorder, a mood disorder, or schizophrenia (criterion D). DSM-IV adds that the disturbance is not due to the direct physiological effects of a substance or a general medical condition (criterion E).

Carbonic Anhydrase Inhibitors

Carbonic anhydrase inhibitors can cause fluid and electrolyte imbalance, metabolic acidosis, nausea, vomiting, anorexia, confusion, orthostatic hypotension, and crystalluria. Hemolytic anemia and renal calculi can also occur. Carbonic anhydrase inhibitors are contraindicated in the first trimester of pregnancy.

Selective serotonin reuptake inhibitors

All selective serotonin reuptake inhibitors effectively treat depression and some lead to improvement of obsessive-compulsive disorder and bulimia nervosa. Selective serotonin reuptake inhibitors do not cause anticholinergic side-effects, cardiac conduction abnormalities, weight gain, or orthostatic hypotension. They are far safer than cyclic antidepressants when taken in overdose. The major side-effects are insomnia, gastrointestinal discomfort, sexual dysfunction, and headache. Lack of therapeutic response or development of side-effects with one selective serotonin reuptake inhibitor does not necessarily predict the same outcome with

Potassiumsparing Diuretics

Caution should be used with patients who have poor kidney function. Urine output should be at least 600 mL per day. Patients should not use potassium supplements while taking this group of diuretics. If given with an ACE inhibitor, hyperkalemia could become severe or life-threatening because both drugs retain potassium. Gastrointestinal disturbances (anorexia, nausea, vomiting, diarrhea) can occur.

Psychopharmacological interventions

In the past decade, there has been much controversy over whether the SSRI antidepressants can induce suicidal ideation and or behaviour. A number of case reports appeared in 1990 describing patients who had developed suicidal preoccupations after starting treatment with fluoxetine. These reports were not supported by meta-analyses and reanalyses of large SSRI-treatment trials of depressed, bulimic, or anxious patients.(45,,46) The conclusion was reached that suicidal ideation is a common feature of depression and that the prevalence in SSRI-treated depressives was no greater than expected.

Systemic Manifestations

Systemic manifestations reported in 30 patients with congenital HSV include low birth weight, small for gestational age, microcephaly, seizures, diffuse brain damage, intracranial calcifications, scars on skin or digits, pneumonitis, and hepatomegaly 38 . Infants with natal or postnatal herpes commonly present 5-15 days post-natally and resemble bacterial sepsis alterations in temperature, lethargy, respiratory distress, anorexia, vomiting, and cyanosis. The overall mortality rate from untreated, neonatal HSV infection is 49 and only 26 of survivors develop normally 26 .

Breaking Bulimia

Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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