Eating Disorders, Somatoform Disorders, and Factitious

Factitious Disorders

-"Munchausen syndrome" -"Munchausen syndrome By Proxy" -Fake illness -Primarily for a secondary gain -Unknown prevalence, estimated 1% -2/3 male -20 - 40 years -Comorbidity +Comorbidity *mood disorders *personality disorders *substance-related disorders (**Munchausen syndrome" and "Munchausen syndrome By Proxy" are not medical disorders. They ARE feigning.)

Bulimia Nervosa: Facts

-15 percent—have multiple comorbid impulsive behaviors, +Substance abuse, and +Lack of ability to control themselves in such diverse areas as money management (resulting in impulse buying and compulsive shopping) +Sexual relationships (often resulting in brief, passionate attachments and promiscuity) +Self-mutilation +Chaotic emotions +Chaotic sleeping patterns. +They often meet criteria for borderline personality disorder and other mixed personality disorders +Bipolar II disorder. -Better prognosis than Anorexia Nervosa (bc eating food allows a person to be physiologically healthier than starvation.)

Bulimia Nervosa: Prevalence

-2 - 4% -More common in women -Men 1/10 that of females -A bit later in adolescence than Anorexia -20% of women experience transient sxs in college -Usually normal weight, but may have hx of obesity (or family hx of obesity) -High achievers, social pressure to be thin -Parents neglectful or rejecting -Alcohol dependence, shoplifting, and emotional lability (including suicide attempts) are associated with bulimia nervosa. -May feel discomfort from sxs and more readily seek tx

Somatoform Disorders

-7 disorders 1) somatization disorder, characterized by many physical complaints affecting many organ systems; (2) conversion disorder, characterized by one or two neurological complaints; (3) hypochondriasis, characterized less by a focus on symptoms than by patients' beliefs that they have a specific disease; (4) body dysmorphic disorder, characterized by a false belief or exaggerated perception that a body part is defective; (5) pain disorder, characterized by symptoms of pain that are either solely related to, or significantly exacerbated by, psychological factors; (6) undifferentiated somatoform disorder, which includes somatoform disorders not otherwise described that have been present for 6 months or longer; and (7) somatoform disorder not otherwise specified, which is the category for somatoform symptoms that do not meet any of the somatoform disorder diagnoses mentioned above

Eating Disorders: Three

-Anorexia Nervosa -Bulimia Nervosa -Eating Disorder NOS

Anorexia Nervosa: Treatment

-Behavioral, interpersonal, cognitive -Inpatient is often necessary, recommended if 20% below expected weight -30% below expected weight require 2 - 6 months inpatient

Bulimia Nervosa: Facts

-Concerned about their body image -Concerned about their appearance, -Worry about how others see them, and are -Concerned about their sexual attractiveness. -Most are sexually active, compared with anorexia nervosa patients, who are not interested in sex. -Pica (eating non-food items) and struggles during meals are sometimes revealed in the histories of patients with bulimia nervosa. -Those with bulimia nervosa who do not purge tend to be obese. -Purging type at risk for hypokalemia (low potassium) from vomiting or laxative abuse and hypochloremic (low chloride) alkalosis

Bulimia Nervosa: Facts

-Defined as binge eating combined with inappropriate ways of stopping weight gain. -Abdominal pain or nausea—terminates the binge eating, -Followed by feelings of guilt, depression, or self-disgust. -Unlike patients with anorexia nervosa, those with bulimia nervosa may maintain a normal body weight.

Anorexia Nervosa: Etiology Hypotheses and Social Factors

-Etiology Hypotheses +Underlying psychological disturbance in young women with the disorder include conflicts surrounding the transition from girlhood to womanhood. +Psychological issues related to feelings of helplessness and difficulty establishing autonomy have also been suggested as contributing to the development of the disorder. -Social Factors +Patients with anorexia nervosa find support for their practices in society's emphasis on thinness and exercise. +Close, but troubled, relationships with their parents +Participation in strict ballet schools increases the probability of developing anorexia nervosa at least 7 x +Wrestling is associated with a prevalence of full or partial eating-disordered syndromes during wrestling season of approximately 17 percent +A gay orientation in men is a proved predisposing factor (**Girls who are in ballet are 7 times more likely. -Strained relationships with parents makes it more likely.)

Anorexia Nervosa: Facts

-Half restrict food intake -Half restrict food intake AND binge and purge -Course can be a spontaneous recovery or chronic until death +Mortality 5 - 18% +Poor relationships, depression, and restrictive vs. binge/purge are associated with poorer outcomes -Comorbidity +65% Depression +34% Social Phobia +26% OCD

Anorexia Nervosa

-Health Consequences +Amenorrhea +Abnormal reproductive hormone functioning +Hypothermia +Bradycardia +Orthostasis +Leukopenia +Lanugo +Severely reduced body fat stores -Other features +Passion for collecting recipes and for preparing elaborate meals for others. +Eating binges occur secretly and often at night and are frequently followed by self-induced vomiting. +Patients abuse laxatives and even diuretics to lose weight, +Ritualistic exercising, extensive cycling, walking, jogging, and running are common activities. +Hiding food all over the house +Frequently carrying large quantities of candies in their pockets and purses. +Disposing of food in their napkins or hide it in their pockets. +Cutting their meals into very small pieces and spend a great deal of time rearranging the pieces on their plates. +If confronted, they often deny that their behavior is unusual or flatly refuse to discuss it. +Poor sexual adjustment (**Just bc they have an aversion to gaining weight, doesn't mean that they have one towards food. They may cut it into tiny pieces or cook for others.)

Somatoform Disorders: Facts

-Lifetime prevalence 1 -2% -5:1 female to male ratio -Before age 30, usually in teens -Estimated that 5 - 10% of general practitioner pts meet criteria for Somatization Disorder -2/3 have other mental disorders

Anorexia Nervosa: Prevalence

-Prevalence +Up to 4% in adolescents/young adults +More common in females (10 - 20 times) +Usually begins in adolescence (5% in 20s)

Anorexia Nervosa

-Three major criteria 1. self-induced starvation to a significant degree; 2. relentless drive for thinness or a morbid fear of fatness; 3. presence of medical signs and symptoms resulting from starvation. -Characterized by +refusal to maintain a minimally normal weight, +intense fear of gaining weight +significant misinterpretation of their body and its shape

Somatization Disorder

A. A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning. B. Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: 1. four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination) 2. two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods) 3. one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy) 4. one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting) C. Either (1) or (2): 1. after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) 2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings D. The symptoms are not intentionally produced or feigned (as in factitious disorder or malingering).

Factitious Disorder by Proxy

A. Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care. B. The motivation for the perpetrator's behavior is to assume the sick role by proxy. C. External incentives for the behavior (such as economic gain) are absent. D. The behavior is not better accounted for by another mental disorder.

Factitious Disorder

A. Intentional production or feigning of physical or psychological signs or symptoms. B. The motivation for the behavior is to assume the sick role. (**IMPT. It's for the attention) C. External incentives for the behavior (such as economic gain, avoiding legal responsibility, or improving physical well-being, as in malingering) are absent. -Code based on type: +With predominantly psychological signs and symptoms: if psychological signs and symptoms predominate in the clinical presentation +With predominantly physical signs and symptoms: if physical signs and symptoms predominate in the clinical presentation +With combined psychological and physical signs and symptoms: if both psychological and physical signs and symptoms are present but neither predominates in the clinical presentation

Undifferentiated Somatoform Disorder

A. One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints). B.Either (1) or (2): 1. after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication) 2. when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The duration of the disturbance is at least 6 months. E. The disturbance is not better accounted for by another mental disorder (e.g., another somatoform disorder, sexual dysfunction, mood disorder, anxiety disorder, sleep disorder, or psychotic disorder). F. The symptom is not intentionally produced or feigned (as in factitious disorder or malingering).

Pain Disorder

A. Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention. B. The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain. D. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). E. The pain is not better accounted for by a mood, anxiety, or psychotic disorder and does not meet criteria for dyspareunia. -Code as follows: +Pain disorder associated with psychological factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of pain disorder is not diagnosed if criteria are also met for somatization disorder. -Specify if: +Acute: duration of less than 6 months +Chronic: duration of 6 months or longer +Pain disorder associated with both psychological factors and a general medical condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain. The associated general medical condition or anatomical site of the pain (see below) is coded on Axis III. -Specify if: +Acute: duration of less than 6 months +Chronic: duration of 6 months or longer Note: The following is not considered to be a mental disorder and is included here to facilitate differential diagnosis. +Pain disorder associated with a general medical condition: a general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. (If psychological factors are present, they are not judged to have a major role in the onset, severity, exacerbation, or maintenance of the pain.) The diagnostic code for the pain is selected based on the associated general medical condition if one has been established or on the anatomical location of the pain if the underlying general medical condition is not yet clearly established—for example, low back, sciatic, pelvic, headache, facial, chest, joint, bone, abdominal, breast, renal, ear, eye, throat, tooth, and urinary.

Body Dysmorphic Disorder

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

Hypochondriasis

A. Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms. (**Not of delusional intensity as in Delusional Disorder, and not just of the body like in Body Dysmorphic Disorder.) B. The preoccupation persists despite appropriate medical evaluation and reassurance. C. The belief in Criterion A is not of delusional intensity (as in delusional disorder, somatic type) and is not restricted to a circumscribed concern about appearance (as in body dysmorphic disorder). D. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. E. The duration of the disturbance is at least 6 months. F. The preoccupation is not better accounted for by generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, a major depressive episode, separation anxiety, or another somatoform disorder. -Specify if: +With poor insight: if, for most of the time during the current episode, the person does not recognize that the concern about having a serious illness is excessive or unreasonable (**Sometimes they think it's the same illness, other times they think it's anything or have multiple ailments.)

Bulimia Nervosa

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances 2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. -Specify type: +Purging type: during the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas +Nonpurging type: during the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

Binge-Eating Disorder

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances 2. a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) B. The binge-eating episodes are associated with three (or more) of the following: 1. eating much more rapidly than normal 2. eating until feeling uncomfortably full 3. eating large amounts of food when not feeling physically hungry 4. eating alone because of being embarrassed by how much one is eating 5. feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least 2 days a week for 6 months. Note: The method of determining frequency differs from that used for bulimia nervosa; future research should address whether the preferred method of setting a frequency threshold is counting the number of days on which binges occur or counting the number of episodes of binge eating. E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.

DSM-IV-TR Diagnostic Criteria for Anorexia Nervosa

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though underweight. C. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) -Specify type: +Restricting type: during the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas) +Binge-eating/purging type: during the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

Eating Disorder NOS

A. The eating disorder not otherwise specified category is for disorders of eating that do not meet the criteria for any specific eating disorder. Examples include 1. For females, all of the criteria for anorexia nervosa are met except that the individual has regular menses. 2. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range. 3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months. 4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.

Anorexia Nervosa

Differential Diagnosis -Depressive Disorder +Decreased appetite, whereas a patient with anorexia nervosa claims to have normal appetite and to feel hungry +Only in the severe stages of anorexia nervosa do patients actually have decreased appetite. +In contrast to depressive agitation (anxiety), the hyperactivity seen in anorexia nervosa is planned and ritualistic. +The preoccupation with recipes, the caloric content of foods, and the preparation of gourmet feasts is typical of patients with anorexia nervosa, but is absent in patients with a depressive disorder. +In depressive disorders, patients have no intense fear of obesity or disturbance of body image. -Schizophrenia +Delusions about food being poisons, not fear of being overweight -Somatization +No irrational fear of becoming overweight. Loss of menses for over 3 months is unusual -Bulimia Nervosa +Weight is maintained. Seldom lose 15% of body weight. However, two disorders commonly coexist (**so what you're really looking for is which one it is, but sometimes it's hard to determine so it's an NOS.)

Conversion Disorder

Paralysis, blindness, and mutism are the most common conversion disorder symptoms. A. One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder. -Specify type of symptom or deficit: +With motor symptom or deficit +With sensory symptom or deficit +With seizures or convulsions +With mixed presentation (**Common in ppl who have history of trauma and personality disorders.)

Factitious Disorder Not Otherwise Specified

This category includes disorders with factitious symptoms that do not meet the criteria for factitious disorder. An example is factitious disorder by proxy: the intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual's care for the purpose of indirectly assuming the sick role. (**Usually of children or spouse in order to get attn of another person. Want to be in the role of the martyr.)

Somatoform Disorder Not Otherwise Specified

This category includes disorders with somatoform symptoms that do not meet the criteria for any specific somatoform disorder. Examples include 1. Pseudocyesis: a false belief of being pregnant that is associated with objective signs of pregnancy, which may include abdominal enlargement (although the umbilicus does not become everted), reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. Endocrine changes may be present, but the syndrome cannot be explained by a general medical condition that causes endocrine changes (e.g., a hormone-secreting tumor). 2. A disorder involving nonpsychotic hypochondriacal symptoms of less than 6 months' duration. 3. A disorder involving unexplained physical complaints (e.g., fatigue or body weakness) of less than 6 months' duration that are not due to another mental disorder.