Anorexia Nervosa Treatment Overview
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.
Anorexia and bulimia nervosa and binge-eating disorder have strict diagnostic criteria set forth by the American Psychiatric Association. However, these three do not cover the entire spectrum of disordered eating patterns. Those people who induce vomiting after consuming only a small amount of food, for example, or those who chew large amounts of food and spit it out rather than swallow it, do not fit the diagnosis of bulimia. For such persons, a diagnosis of Eating Disorder, Not Otherwise Specified is used.
Anorexia nervosa is the rarest of the eating disorders, affecting fewer than 1 percent of adolescent and young women (that is, women ages thirteen to twenty-five) and a tiny proportion of young men. Bulimia nervosa, on the other hand, affects up to 3 percent of teenage and young adult women and about 0.2 percent of men. Even more of this age group, probably 5 percent, suffer from binge-eating disorder. In obese patients, fully one-third meet the criteria for this disorder. Binge eating is the most common eating disorder in men, although more women actually have this disorder. Eating Disorders, Not Otherwise Specified, are even more common.
Preventive measures should include education about normal body weight for height and techniques used in advertising and the media to promote an unrealistic body image. Parents, teachers, coaches, and health care providers all play a role in prevention. Parents, coaches, and teachers need to be educated about the messages they give to growing children about bodies, body development, and weight. In addition, they need to be aware of early signs of risk. Health care providers need to include screening for eating disorders as a routine part of care. Specific indicators include dieting for weight loss associated with unrealistic weight goals, criticism of the body, social isolation, cessation of menses, and evidence of vomiting or laxative or diuretic use.
Unlike anorexia patients, bulimic patients tend to be at or above their expected weight for age. Bulimic patients tend to be ashamed of their behavior and often hide it from their families and physicians. B. There is an increased frequency of affective disorders, substance abuse (30 ), and borderline personality disorder (30 ) in bulimia patients. D. Prognosis is generally better than for anorexia nervosa, and death rarely occurs in bulimia.
No single cause has been identified for eating disorders. However, nearly all eating disorders begin with dieting to lose weight. Because these disorders are found almost exclusively in the developed world, where food is plentiful and where thinness in women is idealized, it appears that social and cultural Anorexia nervosa is a body-image disorder in which fear of being fat results in undereating and other behaviors that lead to emaciation and, if unchecked, death. (Hans & Cassidy, Inc.) Anorexia nervosa is a body-image disorder in which fear of being fat results in undereating and other behaviors that lead to emaciation and, if unchecked, death. (Hans & Cassidy, Inc.) Studies suggest a genetic predisposition to eating disorders, particularly in those persons who engage in binge eating and purging behaviors. Their family histories typically include higher than expected numbers of persons with mood disorders and substance abuse problems. Dysfunctions in the pathways for the substances...
The diagnosis of anorexia nervosa is made in persons who have lost 15 percent or more of the body weight that is considered normal for their height and age and who have an intense and irrational fear of gaining weight. Even with extreme weight loss, anorexics perceive themselves as overweight. Their attitude toward food and weight control becomes obsessive and they frequently develop bizarre or ritualistic behaviors around food, such as chewing each bite a specific number of times. Anorexics minimize the seriousness of their weight loss and are highly resistant to treatment. The two basic types of anorexia nervosa are the restricting type and the binge-eating purging type. The restricting type is characterized by an extremely limited diet, often without carbohydrates or fats. This may be accompanied by excessive exercising or hyperactivity. Up to half of anorexics eventually lose control over their severely restricted dieting and begin to engage in binge eating. They then induce...
Persons who have bulimia nervosa are similar in behavior to the subset of anorexics who binge and purge, but they tend to maintain their weight at or near normal for their age and height. They intermittently have an overwhelming urge to eat, usually associated with a period of anxiety or depression, and can consume as many as 15,000 calories in a relatively short period of time, typically one to two hours. Binge foods are usually high calorie and easy to digest, such as ice cream. The binge eating provides a sense ofnumb-ing of the anxiety or relief from the depression. Failing to recognize that they are full, bulimics eventually stop eating because of abdominal pain, nausea, being interrupted, or some other non-hunger-related reason. At that point, psychological stress again increases as they reflect on the amount they have eaten. Most bulimics then induce vomiting, but some use laxatives, diuretics, severe food restriction, fasting, or excessive exercise to avoid gaining weight....
The American Psychiatric Association has developed provisional criteria for binge-eating disorder in order to study this disorder more completely. The criteria include compulsive and excessive eating at least twice a week for six months without self-induced vomiting, purging, or excessive exercise. That is, binge-eating disorder is bulimia nervosa without the compensatory weight-loss mechanisms. For this reason, most binge eaters are slightly to significantly overweight. In addition to the eating problems, many binge eaters experience relationship problems and have a history of depression or other psychiatric disorders.
Strasburger, Victor C., and Robert T. Brown. Adolescent Medicine A Practical Guide. 2d ed. Philadelphia Lippincott-Raven, 1998. This book addresses the physical and psychosocial problems of teenagers that physicians are most likely to treat. The emphasis is on practical information. Applied diagnostic and treatment guidelines cover conditions such as asthma, diabetes mellitus, developmental problems, headaches, sexually transmitted diseases and pregnancy, depression, and eating disorders.
Fatigue, lethargy, anorexia, nausea and weakness are common in patients with advanced cancer. It had been suggested that progestagens, including megestrol acetate (MA), might have a useful function for palliative treatment of advanced endocrine-insensitive tumours. Beller et al. (1997) reported a double-blind RCT of 240 patients randomised to 12 weeks of high- or low-dose MA, or to matching placebo. Nutritional status was recorded, and QoL was measured using six linear analogue self-assessment (LASA) scales, at randomisation and after four, eight and twelve weeks.
The average incubation period is a little longer than with hepatitis A, with a mean of 6 weeks. The virus is spread by water and food contaminated by faeces. Secondary cases do not appear to be common. Individual cases cannot be differentiated from other cases of viral hepatitis on the basis of clinical features, although cholestatic features may be more prominent, and fulminant hepatic failure occurs in 10-20 during the third trimester of pregnancy. In epidemics, most clinical cases, which occur predominantly in young adults, will exhibit anorexia, jaundice and hepatomegaly. Serological tests indicate that clinically inapparent cases occur. There is no evi
Cognitive therapy has been successfully applied to panic disorder, resulting in practically complete reduction of panic attacks after twelve to sixteen weeks of treatment. Additionally, cognitive therapy has been successfully applied to generalized anxiety disorder, eating disorders, and inpatient depression.
Like HAV, HEV causes malaise, anorexia, jaundice and liver enzyme serum elevation. The first outbreak occurred in India in 1955 involving over 30 000 people and was associated with a breach in the city's water supply system. The incubation period is around 40 days, a case fatality rate of 20 occurred in pregnant women in India, while 60 of sporadic cases of fulminant hepatitis seen in the country are all due to HEV.
In both immunocompetent and immunocom-promised hosts, a non-specific watery diarrheal illness accompanied by abdominal cramps, nausea, malaise, anorexia and weight loss is the most common presentation of I. belli infection. Most infections in immunocompetent individuals are expected to be short-lived, whereas individuals with defects in cell-mediated immunity, such as AIDS, are predominantly reported to experience chronic diarrheal illnesses (DeHovitz et al., 1986 Forthal and Guest, 1984 Whiteside et al., 1984). However, the illness may be severe, resulting in dehydration. Up to 6 liters of stool output has been reported in an apparent immunocompetent host (Brandborg et al., 1970). This general pattern of illness makes this infection clinically indistinguishable from C. parvum infection. One of the notable features of I. belli infection is the ability of the parasite to cause strikingly protracted illnesses in immunocompetent hosts (Brandborg et al., 1970 Shaffer and Moore, 1989 Trier...
Women with anorexia nervosa stop menstruating. Anorexics may also have abdominal pain, constipation, and increased urination. The heart rate may be slow or irregular. Many develop downy, dark body hair (lanugo) over normally hairless areas. They may have bloating after eating and swelling of the Self-induced vomiting can lead to erosion of tooth enamel, gum abscesses, and swelling of the parotid glands in front of the ear and over the angle of the jaw. About one-third of women with bulimia have abnormal changes in their menstrual cycles. Some bulimics consume so much food in such a short period of time that their stomachs rupture. More than 75 percent of these individuals die. Use of ipecac and laxatives can lead to heart damage. Symptoms include chest pain, skipped heartbeats, and fainting, and these heart problems can lead to death. In addition, bulimics are at increased risk for ulcers of the stomach and small intestine and for inflammation of the pancreas.
One emerging theme in the field of substance addiction is the intricate relationship at a molecular level with other mental disorders. Substances of abuse modulate some of the same biochemical pathways and circuits involved in mood and anxiety disorders. It is also increasingly being appreciated that there is a strong interplay with cognitive disorders. Eating disorders can also be viewed from the perspective of a substance abuse disorder, both in aetiology and treatment. Active areas of research include substance abuse propensity and affective disorders, substance abuse as a way of self-treating affective disorders, and substance abuse and cognitive disorders. This ongoing work may have strong practical implications in terms of treatment strategies.
Acute hepatitis B develops in approximately 30-50 of adults at the time of initial infection and is characterized by anorexia, nausea, vomiting, and often jaundice. The risk of progression to chronic infection varies with age, being highest among young children and infants (30-90 ) and lowest among adolescents and adults (2-6 ) (Lok & McMahon, 2001).
Endorphins have been shown to play a role in a wide variety of body functions, including memory and learning and the control of sexual impulses. Abnormal activity of endorphins has been shown to play a role in organic psychiatric dysfunctions such as schizophrenia and depression. Deficits in endorphin levels have been observed to correlate with aggressiveness endorphin replacement therapy results in the diminishment of such behavior. Abnormal levels of endorphins in the blood have also been found in individuals suffering from behavioral disorders such as anorexia or obesity.
These symptoms last for about 3 weeks. Sore throat occurs in over 80 of cases and is usually accompanied by anorexia and nausea. The sore throat develops in the first week and subsides in the second week, rarely generating severe symptoms or massive tonsillar pharyngeal oedema. Sharply defined, red spots at the junction of the soft and hard palates are of diagnostic value. Positive throat swabs for P-haemolytic streptococci are frequently found. Bilateral, non-inflammatory cervical lym-phadenopathy is almost invariable, and inguinal and axillary lymphadenopathy is usual. The spleen is palpable in more than one-half of cases, although only occasionally does it extend to the iliac crest. These secondary lymphoid organs increase in size in the first week and subside slowly after the second week. Slight hepatomegaly and jaundice occurs in about 10 of cases. Fever is present in most cases but of no characteristic type and may be transient. A few patients develop a fine macular...
Although 'self-care' is necessary, it appears that most do seek help from health care professionals for more complex medical problems. Professional help should also be sought in cases of psychosis, severe depression, suicidal ideation, anorexia nervosa, PTSD, serious difficulties with a child (including the possibility of abuse), or any mental health problem that appears to be getting worse. Organizations could increase the potential for more effective care by fostering a culture that promotes help-seeking behaviour (MMWR, 1999).
Many symptomless patients are detected through the finding of a raised mean corpuscular volume (MCV) on a routine blood count. The main clinical features in more severe cases are those of anaemia. Anorexia is usually marked and there may be weight loss, diarrhoea or constipation. Other particular features include
Oral carbonic anhydrase inhibitors (CAIs) have already been in clinical use for 50 years in the treatment of increased IOP (Sugrue, 1989). The currently used oral CAIs include acetazolamide and methazolamide. However, patient compliance with systemic CAI medication is poor, due to side effects such as hypokalemia, fatigue, depression, gastrointestinal disturbances, and anorexia (Epstein and Grant, 1977 Lichter et al., 1978). Because the topical administration of CAIs was clinically ineffective, researchers started to explore other methods of drug delivery, including the prodrug approach (Sugrue et al., 1985 Grove et al., 1988 Woltersdorf et al., 1989) and cyclodextrin-technology (Javitt et al., 1994 Loftsson et al., 1994) to increase the topical activity of CAIs. The prodrug approaches, described below, were undertaken before the advent of topical dorzolamide solution and brinzolamide suspension in the 1990s (Sugrue, 2000). These compounds are CAI analogs, however, and not prodrugs.
Hypereosinophilic syndrome is characterized by sustained eosinophilia of 30-70 of total leucocyte count ( 1.5 X 109 L) for longer than 6 months, absence of other underlying causes of eosinophilia and evidence of organ dysfunction due to eosinophilic tissue infiltration. Presenting features include anorexia, weight loss, fever, sweating, thromboembolic episodes, heart failure, splenomegaly, and skin and central nervous system disease. Peripheral blood eosinophils have a variety of cellular abnormalities and bone marrow eosinophils are increased (3060 ), but myeloblasts are usually not. It has been difficult to assess the clonality of the hypereosinophilic syndrome, but some cases are clonally derived, as demonstrated by clonal karyotypic abnormalities and X-inactivation assays.
Patients with this form of anovulation suffer from hypothalamic amenorrhea. Patients will have low estrogen levels, low gonadotropin levels (FSH and LH), normal prolactin levels and will not bleed after a progesterone challenge. The classic patients seen with this disorder are those that suffer from anorexia nervosa, or athletes with a low BMI (
Particularly impressive evidence for a cultural perspective comes from the fact that different types of disorders appear in different cultures. Anorexia nervosa, which involves self-starvation, and bulimia nervosa, which involves binge eating followed by purging, primarily strike middle- and upper-class women in Westernized cultures. In Western cultures, women may feel particular pressure to be thin and have negatively distorted images of their own bodies. Amok, a brief period of brooding followed by a violent outburst that often results in murder, strikes Navajo men and men in Malaysia, Papua New Guinea, the Philippines, Polynesia, and Puerto Rico. In these cultures, this disorder is frequently triggered by a perceived insult. Pibloqtoq, a brief period of extreme excitement that is often followed by seizures and coma lasting up to twelve hours, strikes people in Arctic and Subarctic Eskimo communities. The person may tear off his or her clothing, break furniture, shout obscenities,...
Eating disorders such as anorexia, bulimia, and compulsive overeating provide evidence of the complex relationship between the physiological and psychological components of hunger. Obesity has also been examined using medical and psychological models. The etiology of hunger's relationship to eating disorders has provided insight, if not consensus, by investigating the roles of hereditary factors, social learning, family systems, and multigenerational transmission in hunger as well as the socially learned eating patterns, food preferences, and cultural ideals that can mediate the hunger drive. Body image, eating restraint, and eating attitudes have been assessed by various methods. The focus of much of the research on hunger beyond the early animal experiments has been eating disorders. The findings confirm that hunger is more than a physiological need and is affected by a multitude of variables.
A GHRH stimulation test has also been developed and employed in depressed patients. Two groups have shown a blunted GH response to GHRH in depressed patients 129-131 . However, Krishnan et al. 126,132 found minimal differences in serum GH response to GHRH between depressed and control patients. A comprehensive review of GHRH stimulation tests in depression, anorexia nervosa, bulimia, panic disorder, schizophrenia and Alzheimer's disease concluded that the results of this test are not consistent and in some cases are contradictory 133 . Factors including the variability of GHRH-stimulated GH among controls, lack of standard outcome measures, and age and gender-related effects may account for some of this variability. Further studies using GHRH will help develop a standard stimulation test to clarify further the response to GHRH in depression and other psychiatric disorders.
Early in the 20th century, body image concepts and studies had a tendency to focus on neurologically impaired patients. Although this brought the area of body image into the domain of scientific study, little attention was paid to the psychological aspects of body experience. More recently this has changed and in the past 20 years, much of the research on body image has emanated from a burgeoning interest in clinical eating disorders. Indeed much has been gained from this marriage of body image and eating disorders research but there have also been detrimental consequences (Cash & Brown, 1987). Body image has tended to become synonymous with either distorted body width estimates or a general emphasis on
Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis or Anorexia Nervosa. Many psychiatric disorders present with marked anxiety, and the diagnosis of specific phobia should be made only if the anxiety is unrelated to another disorder. For example, specific phobia should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack.
Obsessive-Compulsive Disorder, Specific Phobia, Hypochondriasis, or Anorexia Nervosa. Anxiety symptoms are common to many psychiatric disorders such as depression and the anxiety disorders. The diagnosis of social phobia should be made only if the anxiety is unrelated to another disorder. For example, social phobia should not be diagnosed in panic disorder if the patient has social restriction and excessive anxiety about having an attack.
Following treatment for thyroid cancer, patients are required to undergo regular monitoring of their disease status for the rest of their lives. The morbidity associated with lifetime surveillance is highlighted in a number of studies 13,19,20 . Surveillance generally involves thyroid hormone withdrawal followed by body scanning. The induced hypothyroid state results in symptoms of fatigue sleep disturbance impaired psychomotor skills reduced ability to concentrate anorexia pain and fluid retention 19 . As is true for survivors of other types of cancer, the process of monitoring generally raises patients' concerns about the threat of recurrence.
Extension of cognitive therapy Beck was cautious in extending his cognitive model of depression to other mental disorders he has always been a methodical researcher, careful to restrict his claims to demonstrable results. For example, his first book on the treatment of depression recommended limiting cognitive therapy to nonpsychotic patients with unipolar depression who had not responded to or refused to take antidepressant medication. After the 1970s, however, the cognitive model was successfully applied by Beck's followers to a wide range of problems, including anxiety disorders, substance abuse, marital conflict, eating disorders, and anger management. One study reported that the interest in cognitive therapy among mental health care professionals increased 600 in the 16 years between 1973 and 1989. In the 1990s, cognitive therapists published outcome studies that reported success in treating psychotic disturbances and personality disor-ders historically regarded as the most...
Abstract Acute mountain sickness (AMS) is a syndrome of headache, anorexia, nausea and fatigue, which commonly occurs with rapid ascent to high altitudes. The pathogenesis of AMS remains incompletely understood. A leading theory has been that AMS could be an early stage manifestation of high altitude cerebral edema, which sometimes complicates AMS and is of poor prognosis. There has indeed been recent reports of magnetic resonance imaging (MRI) evidence of hypoxia-induced reversible brain edema in healthy volunteers. Interestingly, in these studies, brain edema was both vasogenic and cytotoxic but with only the MRI cytotoxicity signals correlated to AMS symptomatology. Studies in volunteers exposed to normobaric or hypobaric hypoxic conditions have disclosed a hypoxia-induced alteration of the autoregulation of cerebral blood flow in proportion to the severity of oxygen deprivation and to AMS symptoms. The alteration of cerebral autoregulation contributes to breathing instability...
Patients with eating disorders such as anorexia nervosa and bulimia nervosa often present with excessive concerns about their cutaneous body image in addition to concerns about their weight and shape (Gupta & Gupta, 2001a). The eating disorders can be associated with a wide range of dermatological (Gupta et al., 1987 Gupta & Gupta, 2000) complications related to starvation, bingeing and purging, abuse of laxatives and other related symptoms (American Psychiatric Association, 1994). Acne has a peak incidence during mid-adolescence, a life stage that is associated with a high incidence of eating disorders. In some vulnerable adolescents even mild acne may exacerbate or precipitate an eating disorder such as bulimia nervosa (Gupta et al., 1987 Gupta & Gupta, 2000). The endocrine changes associated with binge eating may cause a flare-up of acne (Gupta et al., 1992), which is frequently observed in patients with eating disorders (Gupta & Gupta, 2000). In these patients the disfigurement...
The major causes of morbidity and mortality in these adolescents are unintentional injuries, many of which are related to alcohol and drug use. Other causes of morbidity include unintended pregnancy, sexually transmitted diseases, eating disorders, and depression (Eaton et al., 2006). These factors are not easily discernable from the traditional patient provider model of health interviewing. An alternative model, the HEADSS Model, was developed in 1972 by Dr. Harvey Berman of Seattle and refined by Dr. Eric Cohen and Dr. John M. Goldenring. An acronym for Home, Education Employment, Activities, Drugs, Depression, Safety, and Sexuality, this model can be particularly useful in the juvenile justice system as health care practitioners explore the complex forces affecting an adolescent's behavior and health outcomes (Goldenring & Cohen, 1988).
Classic presentation ( 50 of cases) Abdominal pain (usually 72 h), initially diffuse, periumbilical and colicky (visceral pain lasting a few hours). The pain becomes sharp and localised to the RIF (somatic pain as parietal periton- eum involved). Anorexia (the most constant symptom) and nausea are
The clinical features of dengue haemorrhagic fever are characterised by fever, rash and anorexia lasting 3-5 days, followed by hepatomegaly, hypotension and a haemorrhagic diathesis. The dengue shock syndrome is due to decreased plasma volume following increased vascular permeability, and is associated with a significant mortality of up to 10 , but which can be as high as 40-50 if untreated. Diagnosis in returning travellers may be difficult. Serological diagnosis is based on haema-gglutination-inhibition and IgM antibody-capture ELISA. Definitive diagnosis is by way of virus isolation and PCR-based techniques.
The transplant psychiatrist evaluates for any psychiatric disorders that may interfere with the transplant. He or she should also screen for self-destructive behaviors, compliance with medical treatment and the transplant workup itself, and any personality traits or disorders that may prove to be maladaptive. Psychotic disorders may make the patient unacceptable for a transplant if he or she becomes paranoid and noncompliant. However, a diagnosis of schizophrenia alone should not be an absolute contraindication to transplantation if the patient has a history of compliance with medication and is stable both psychiatrically and socially. Recurrent depressive disorders with multiple suicide attempts or failure to take care of one's needs would also be considered a contraindication. Even severe conditions such as borderline personality disorder could interfere with the ability of a patient to comply with the transplant protocol. Rapid shifts in mood, inability to sustain a positive...
Visceral leishmaniasis is the most serious form of this infection. It is typically caused by Leishmania donovani, L. infantum (which mainly affects young children) or L. chagasi. The disease has a typical incubation period of 2-6 months and is accompanied by a low-grade fever however, onset may be delayed for many years. Cells of the reticuloendothelial system are invaded and the patient presents with weight loss, malaise, anorexia, left hypochondrial discomfort, shivering and chills. On clinical examination the patient is cachectic and anaemic hepatosplenomegaly and lymphadenopathy may be present. The symptoms and signs are due to the effects of chronic cytokine release TNFa is known to have anorectic and catabolic effects (Pearson et al., 1992). Uncontrolled activation of the immune system results in inability to
The selective serotonin reuptake inhibitors (SSRIs) are generally safer choices than the older tricyclic medications, since the anticholinergic side effects may cause delirium or tachycardia. The tricyclics can cause blood pressure changes as well. The SSRIs do cause side effects such as gastrointestinal (GI) disturbances and headaches. Monoamine oxidase inhibitors (MAOIs) are best avoided because of the risk of hypertension. Ritalin can be another option, however. We have not found that it causes anorexia. Indeed, it may promote an increased appetite in some patients.
As folate is only loosely bound to plasma proteins, it is easily removed from plasma by haemodialysis or peritoneal dialysis (in contrast, cobalamin is not removed from plasma by dialysis as it is firmly protein bound). The amount of body folate that can be removed in this way is relatively small. Nevertheless, in patients with anorexia, vomiting, infections and haemolysis, folate stores may become depleted and megaloblastic anaemia can supervene. Routine folate prophylaxis is now given.
Bariatric surgery is currently the most successful approach to rescuing patients with severe obesity and reversing or preventing the development of several diseases associated with obesity. There are an increasing number of surgeries being performed for the treatment of obesity. This rise in procedures can be attributed to the increased population of extreme obesity as well as the failure of diet, exercise and medical therapies. Another factor could be the ability to perform the surgery laproscopically. Surgery can be an additional treatment option for patients with a BMI 40 who failed lifestyle changes with or without medication supplementation and have obesity-related comorbid conditions. Surgery alone will not correct any underlying psychological eating disorders. Additionally, reduction of cardiovascular morbidity and mortality does not occur due to weight loss through surgery alone. The Swedish Obese Subjects (SOS) Study, which was an observational study, did show that the...
Symptoms, such as diarrhea, cramps, anorexia and malaise. Therapy with metronidazole and dilox-anide furoate is recommended for symptomatic individuals. The trophozoite form of E. polecki resembles that of E. histolytica and E. coli, and differentiation from these and other protozoa rely on identification of the cyst stage of the organism, which is characteristically uninucleate with a large karyosome (Ravdin, 1986 Leber 1999).
Women constitute 90 percent of people diagnosed with eating disorders eight million adolescent and young adult women in the United States alone. The majority of these are Caucasian (95 percent) and from middle- to upper-middle-class backgrounds. Research in the latter part of the twentieth century indicated that adolescent and young adult women were most likely to be affected however, these disorders are now found in girls as young as nine and in older women. By the end of the twentieth century, eating disorders were also increasingly identified in women from other ethnic and socioeconomic groups. These disorders are most likely underreported in men and seem to affect gay men disproportionately. Also at risk are men with certain professions or avocations such as jockeys, dancers, body builders, and wrestlers, in which weight and body shape are an issue.
The personality disorders have been the subject of criticism by researchers because of the difficulty in diagnosing them reliably. Individuals with a personality disorder often display symptoms of other personality disorders. For example, researchers have debated about the distinction between schizoid personality disorder and avoidant personality disorder, as both disorders are characterized by an extreme in social isolation. Individuals with personality disorders are more likely than the general population to suffer from other psychological disorders, such as depression, bulimia, or substance abuse. This overlap of symptoms may lead to difficulty with diagnostic reliability. The personality disorders occur so frequently with other types of psychological disorders that it is challenging to sort through symptoms to determine what is evidence of each disorder. It is difficult to estimate the prevalence of personality disorders in the United States, as individuals with these disorders do...
Bupropion is appropriate for patients who have been unsuccessful using nicotine replacement. Bupropion reduces withdrawal symptoms and can be used in conjunction with nicotine replacement therapy. The treatment is associated with reduced weight gain. Bupropion is contraindicated with a history of seizures, anorexia, heavy alcohol use, or head trauma.
Clinically, patients acutely experience diarrhea, abdominal pain, nausea and vomiting, anorexia, and malaise. The symptoms subside with the pathologic effects and, typically, spontaneously disappear 2 6 weeks after the completion of radiation therapy56 However, there is evidence to suggest that patients who develop acute small intestine toxicity may be at risk for chronic effects.57 Chronic effects include malabsorption and diarrhea, with more rapid transit times occurring in the affected bowel. This chronic malnutrition may be severe, resulting in anemia and hypoalbuminemia. There can be bleeding from ulceration and pain and bloating from strictures, as well as fevers from abscess. The clinical syndrome is progressive with worsening symptoms and effects with time.
Flutamide was originally used in a number of phase II trials, notably that by Whitmore and Sogani16, in patients with advanced metastatic prostate cancer. It showed a subjective response in over 70 and an objective response of just under 50 . It was also noted that there were some good subjective responses where patients had been previously surgically castrated. Unlike the steroidal antiandrogens, the non-steroidal anti-androgens appear to exert no cardiovascular side effects. Flutamide does, however, cause gastrointestinal side effects in approximately a quarter of patients, most noticably diarrhea in between 17 and 23 of patients plus nausea, anorexia and depression in a further 15 . In addition, hepatotoxicity has been shown in between 3 and 8 of cases. Two different dosage schedules have been employed in phase II studies and one small phase III study 250 mg 3x day and 1500mg day. The side effects are noticebly worse in the higher dosages and there appeared to be no additional...
A 75-year-old man comes to your office with anorexia and nausea. Five years ago he was found to have congestive heart failure that responded to treatment with a thiazide diuretic and an angiotensin-converting enzyme inhibitor. Three years ago digoxin was added to the regimen in a dose of 0.25 mg day. This morning he omitted his digoxin dose. On hospital admission,
The bone marrow trephine shows the fat replacement of marrow with or without the remaining islands of cellularity (Figure 13.1b and c). Non-haemopoietic cells remain, sometimes giving the impression of a chronic inflammatory infiltrate. Reticulin is not increased. The most common mistake in the diagnosis of aplastic anaemia is to make the diagnosis on the basis of a bone marrow aspirate in the presence of pancytopenia without obtaining adequate trephine specimen. Other conditions that can also present with pancytopenia and a hypocellular bone marrow include hypocellular myelodysplastic syndrome, hypo-cellular acute myeloid leukaemia, hypocellular acute lympho-blastic leukaemia, hairy cell leukaemia, lymphoma, myelofibrosis, mycobacterial infections and anorexia nervosa or prolonged starvation, emphasizing the importance of careful examination of not only the bone marrow but also a well-stained peripheral blood film.
The interface between psychiatry and dermatology is multidimensional and begins in early development. The skin is a vital organ of communication and the earliest social interactions between the infant and its caregivers occur via the body, especially through touch. A disruption in tactile nurturance, for example, as a result of a skin disorder during infancy or due to childhood abuse and or neglect can be associated with serious psychiatric morbidity in later life including major depressive disorder, body image pathologies, a tendency to self-injure and dissociative states when there is significant psychological trauma present in association with the neglect. The importance of the skin in social communication is further exemplified during adolescence when the development of a cosmetically disfiguring skin disorder such as acne can be associated with depression, suicidal ideation and body image disorders including eating disorders. The role of the skin as an organ of communication...
All patients with delayed puberty should have a TSH, total T4 (more robust assay than the problematic free T4), and serum prolactin, and detailed psychosocial history. Hypothyroidism (central, rather than primary) hyperprolactinemia, and hypothalamic disorders (eating disorders stress exercise) may occur in patients who are eugonadal or hypogonadal depending upon the duration of the process. In the absence of a tumor, strong consideration must be given to the history and physical exam with particular attention to BMI, eating and exercise patterns, and stress. Eating disorders such as anorexia nervosa or bulimia must be sought because of the significant morbidity and mortality. A history of extreme exercise such as prolonged running or ballet must also be elicited, as should a history of stress. Morning cortisol levels are elevated in patients with eating disorders, and reverse T3 levels may be elevated (preferential conversion of T4 to rT3 instead of the more active T3). Correction of...
Thus, there are both internal cues and external cues that define hunger and lead an individual to know when to eat and how much to eat. External cues as a motive for eating have been studied extensively, particularly in research on obesity and eating disorders such as binge behavior and compulsive overeating. External cues include enticing smells, locations such as restaurants or other kinds of social settings, and the social environment what other people are doing. When external cues prevail, a person does not have to be hungry in order to feel hungry.
Eating disorders were identified as early as ancient Roman times, when banqueters gorged themselves, then induced vomiting. Some of the early Christian saints were anorexic. However, eating disorders only emerged as an area of social and medical concern in the second half of the twentieth century. Persons with eating disorders have a distorted body image and unrealistic ideas about weight. Although such disorders are found primarily among young, middle- to upper-middle-class, well-educated Caucasian women, eating disorders increasingly affect and may be overlooked in men, older women, and persons of color. No single factor appears to be the cause of eating disorders, with social, cultural, psychological, genetic, biological, and physical factors all playing a part. Treatment may include hospitalization for nutritional monitoring and for stabilization in persons with serious medical complications or who are at risk for suicide. Regardless of the setting, treatment is best carried out...
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