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.
Only more recently has cognitive therapy been adapted for eating disorders (Vitousek, 1996). In their review of eight outcome studies, Compas et al. (1998) concluded that cognitive therapy for bulimia nervosa meets criteria for an efficacious approach, although effectiveness research suggests that on average only 55 are in full remission at follow up. A recent multi-site study has broadly replicated these findings (Agras et al., 2000). It is premature to comment on cognitive therapy for anorexia nervosa as, although several adaptations have been suggested (Vitousek, Watson & Wilson, 1998), there is very limited research attesting to its efficacy or effectiveness to date.
Anorexia nervosa, a psychiatric disease characterized by a disordered body image, severely limited caloric intake and body weight well below ideal, has been associated with elevated GH concentrations and a variable response to provocative stimuli (29). Studies using GHRH as a secretogogue demonstrate a variable GH response to food, in a manner similar to what has been observed in obese subjects, a group with unique neuroendocrine dynamics including blunted GH secretion. Subjects with fear of obesity, an eating disorder characterized by poor growth and delayed sexual development owing to caloric restriction over fear of becoming obese (30), is not associated with abnormal GH secretion. A spectrum of pituitary responsivity to stimuli was noted in nine subjects, distinct from that observed in anorexia nervosa and related to the degree of individual undernutrition (30,31).
The DSM IV provides research criteria for BED in Appendix B. The clinical picture is similar to BN, with the important absence of compensatory purging. CBT and IPT are at least as effective in treating BED as BN, and group treatment with either therapy is well accepted (Wilfley et al., 1993). However, BED is extremely common and could easily overwhelm eating disorder services. Many BED patients are overweight. Psychological approaches emphasise the benefits of stability, at whatever weight, and discourage dieting. However, medical services for obesity are more likely to urge dieting and weight reduction. Interdisciplinary dialogue is likely to be as important in the future management of obesity (with and without binge eating) as in the management of anorexia.
Bulimia nervosa appears to be a 'modern' disorder, reaching psychiatric awareness in the 1970s. It has been treated as a 'depressive equivalent' with antidepressant medication and therapies modified from antidepressant strategies. High-dose antidepressant medication (such as fluoxetine 60 mg daily) offers proven but often short-lived anti-bulimic benefit (Walsh et al, 1991) and benefits are inferior to the best psychological therapies (Agras et al., 1992). Extensive evidence supports cognitive behaviour therapy (CBT), in individual or group format, as the first-line treatment, with interpersonal therapy (IPT) a close second. Disappointingly, most individuals treated for BN do not receive evidence-based treatments (Crow et al., 1999). This may partially explain the finding (Ben-Tovim etal., 2001) that five-year outcome for BN (and other eating disorders) was independent of receiving treatment. prognosis. Those with co-morbid personality disorders, particularly the 'multi-impulsive'...
Historical and geographical studies suggest that anorexia nervosa has occurred wherever there are humans. The first formal medical account is in Richard Morton's Phthisiologia (1689). Anorexia nervosa responds to the same precipitants as bulimia but depends on a physiological capacity to tolerate extreme starvation, which may be genetic. The core psy-chopathology of anorexia nervosa is overwhelming concern about body shape and weight. Phobia of fatness increases as weight decreases. The controversial 'body image distortion' does not amount to a delusion (and is unresponsive to anti-psychotic drugs) but resembles an obsessive-compulsive conviction, attracting to itself all negative attributions generated in the course of everyday life. Current diagnostic criteria for anorexia nervosa require that This occurs either through sheer dietary restraint (restricting sub-type) or by restraint together with self-induced purging ('bulimic' subtype-although 'binges' are often simply episodes of...
Borderline personality disorder may be an example of a condition whose prevalence changes with time and circumstance because it is socially sensitive (Paris, 2003, 2004). Many socially sensitive disorders (e.g., substance abuse, eating disorders, antisocial personality, borderline personality) have externalizing symptoms and impulsive traits that are particularly responsive to social context, contained by structure and limits, and amplified by their absence.
Twenty-five years of increasingly sophisticated research suggests that cognitive therapy is effective to a clinically significant degree for a majority of patients with a variety of presenting problems in a range of populations and settings. An evidence-based conclusion is that cognitive therapy is a treatment of choice for people diagnosed with depression, generalized anxiety, panic, bulimia nervosa, psychosis and a range of somatoform disorders. More recently, preliminary outcome studies suggest cognitive therapy is a promising intervention for people diagnosed with personality disorders and substance misuse, but further research is indicated.
Particular tactics are geared to deal with the manifestation of extreme aggression in the hours, the management of affect storms, psychopathic transferences, paranoid micro-psychotic episodes, chronic sado-masochistic acting out, and the threat to the treatment by drug or alcohol abuse, eating disorders, and other psychopathologies frequently complicating severe personality disorders. Treatment tactics also involve the application of general psychoanalytic techniques as mentioned before, such as the dynamic, economic, and structural considerations regarding when, how, and what to focus upon and in what order to intervene interpretively in each session. The severity of the fragmentation of the
The functional consequence of heparin binding to platelets is subtle cell stimulation. Antibody-independent activation of platelets by heparin in vitro has been reported from many laboratories. However, the results of these studies have varied, presumably because of differences in experimental conditions. In plasma, for example, heparin alone causes slight platelet aggregation, whereas platelets suspended in laboratory buffers are reported to aggregate either briskly or not at all in response to heparin (Eika, 1972 Salzman et al., 1980 Westwick et al., 1986 Chong and Ismail, 1989). In citrate-anticoagulated plasma, heparin also potentiates platelet activation by agonists such as ADP and collagen (Holmer et al., 1980 Chen and Sylven, 1992 Xiao and Theroux, 1998 Aggarwal et al., 2002 Klein et al., 2002), and this effect is more pronounced in patients with acute illness, arterial disease, and anorexia nervosa (Mikhailidis et al., 1985 Reininger et al., 1996 Burgess and Chong, 1997).
Excessive intake of vitamin D in fortified food, over-the-counter supplements or excessive ingestion of anti-rickets pharmaceuticals can result in vitamin D poisoning. An acute toxic dose has not been established but the chronic toxic dose is more than 5O OOO IU day in adults for 1-4 months and, in children, 4OO IU day is potentially toxic. Acute toxicity effects may include muscle weakness, apathy, headache, anorexia, nausea, vomiting, and bone pain. Chronic toxicity effects include the above symptoms and constipation, anorexia, polydipsia, polyuria, backache, hyperlipidemia, and hypercalcemia. Hypercalcemia may cause permanent damage to the kidney (see http www.emedicine.com emerg topic638.htm). Arterial hypertension and aortic valvular stenosis can also result from hypervitaminosis D.
Similar findings have been obtained in relation to other problematic behaviors. For example, perceptions of the prevalence of peer use of cigarettes and marijuana predict personal cigarette and marijuana use (Graham et al, 1991 Juvonen et al, 2007). The body image and disordered eating literatures have documented disturbing relationships of perceived norms for weight and body size with unhealthy behaviors among young women. Sanderson and colleagues (2002) found that women who had greater discrepancies between their own body mass index and the perceived average body mass index of their peers were at increased risk for both experiencing an extreme desire to be thin and engaging in behaviors that are symptomatic of bulimia, such as binging and purging. Similarly, Bergstrom et al (2004) documented greater unhealthy weight loss behaviors, including vomiting, fasting, and use of laxatives and diuretics, among women who overestimated men's endorsement of overly thin women as attractive.
Dialectical behaviour therapy consists of four primary treatment stages with pre-commitment occurring prior to beginning each stage. Currently, the main body of research on DBT is on what is called Stage 1 DBT. The first stage of DBT is usually one year of treatment designed to get the client's behaviours under control. Clients in Stage 1 are usually engaging in severely out of control behaviours. They are suicidal, engaging or having the urges to engage in non-suicidal self-injurious behaviours, are substance abusing, binging and or purging, criminal behaviour, gambling, and engaging in out of control, impulsive behaviours. Once the clients' behaviours are under control, they move into Stage 2 of DBT. In Stage 2, the behaviours are under control, but the clients' level of misery is still extremely high. Usually, Stage 2 is some form of structure exposure based treatment, usually for trauma. Because the out of control behaviours that lead clients into Stage 1 DBT are usually to avoid...
Of an individual patient may often hinge on effective relief from symptoms and having each symptom treated as it arises. Symptoms may range from minor irritations to serious distress, including dysphagia, anorexia, constipation, nausea, vomiting, incontinence, hiccup, cough, breathlessness, restlessness, and confusion (Enck, 1994 Saunders & Baines, 1989). Attending to the details of each symptom is important. Indeed, it has been shown that relief of minor symptoms often goes a long way to relieve the pain accompanying any serious illness. A patient who is terminally ill with cancer and is at the same time suffering from untreated constipation is a neglected patient, however much effort is or has otherwise been extended on that patient's behalf. Such treatment may not be heroic or dramatic, but is nevertheless important. Often those who compile lists of ways of relieving symptoms are apologetic for their simplicity, but it is all of the niggling things that can detract so much from the...
In some patients, especially those with comorbid conditions associated with platelet activation (burns and anorexia nervosa), heparin treatment can result in a transient decrease in platelet count (Burgess and Chong, 1997 Reininger et al., 1996) (see Chapter 4). Unfractionated heparin (UFH) activates platelets directly (Salzman et al., 1980), an effect observed less frequently with low molecular weight heparin (LMWH) (Brace and Fareed, 1990). Known as nonimmune heparin-associated thrombocytopenia (nonimmune HAT), this direct proaggregatory effect of heparin occurs predominantly in patients receiving high-dose, intravenous (iv) UFH therapy. Typically, platelet counts decrease within the first 1-2 days of treatment and then recover over the next 3-4 days. There are no data indicating that these patients are at increased risk for adverse outcomes, including thrombosis. Indeed, it is possible that inappropriate discontinuation of heparin for nonimmune HAT could increase the risk for...
Clinical presentation is determined by the site of tumour within the bowel (Table 13.2). Transient changes in bowel function are common as a result of GI infection and functional bowel disease such as irritable bowel syndrome. However, persistence of bowel symptoms for more than 6 weeks is of concern, particularly in those over 40 years of age malignant disease should be excluded in this group. As a generalisation, cancers of the left colon and rectum present with change in bowel habit and or bleeding whereas right colon cancers cause anaemia and small bowel obstruction. General malaise, anorexia and weight loss, and uncommon features of bowel cancer generally reflect the presence of metastatic disease.
Many of the cardiovascular trials reported side effects of garlic use, with the most frequently reported being GI symptoms and garlic breath. In addition, rash and prolonged oozing from a razor cut were reported in one of these studies (86). Other commonly described side effects associated with garlic use include GI effects such as abdominal pain, fullness, anorexia, and flatulence.
Radiation therapy provides an important role in the management of HGG. Nursing care provided by the radiation oncology nurse begins at the initial consult visit and continues into the early post-radiation phase. Patients and families must be educated regarding treatment schedules and expected effects and side effects. Options available to patients include conventional regional radiation, whole brain radiation, stereotactic radiosurgery such as gamma knife or photon beam, brachytherapy, and hyperthermia (31). It is often difficult to assess if symptoms are being caused by the radiation therapy itself, tumor growth, or other concurrent therapies. Acute symptoms occur within the first few weeks to months and are usually self-limiting. These include nausea but rarely vomiting, anorexia, impaired taste, fatigue, increased seizures, increased neurologic deficits, skin changes, hair loss, and impaired wound healing. Some patients whose radiation fields lie near the ear can experience hearing...
Type 2 diabetes is a heterogeneous syndrome both in terms of aethiopathogenetic mechanisms and phenotypic aspects. Type 2 diabetes is the primary result of either insulin resistance or deficiency in insulin secretion, each having a completely different clinical perspective and presentation is usually characterized by a mixture of the two. A genetic predisposition is the most important aspect environmental factors (eating disorders, reduced physical activity, overweight, obesity) precipitate and favour progression of the disease. It is very difficult to determine the incidence of type 2 diabetes because many recent onset cases of diabetes go undiagnosed owing to the absence of overt symptoms. However, current studies have shown that incidence varies from 1 case per 1000 year in the industrialized world to 25 cases per 1000 year in the Pima Indians. The observed differences among populations and ethnic groups reinforces the relevance of genetic and environmental factors.
Severe chronic stress and HPA axis activation results in suppression of the hypothalamic-pituitary-gonadal axis at all levels (hypothalamus, pituitary, gonads) and a decrease in reproductive activity in general. In women, stress-induced secondary hypothalamic amenorrhea due to glucocorticoid hypersecretion has been observed in melancholic depression, chronic alcoholism, and eating disorders (Chrousos and Gold, 1998 Kyrou et al, 2006). In men, severe stress in real life, i.e., exposure to war, to an earthquake or to a critical life event may lead to impaired sperm quality (Abu-Musa et al, 2008 Fukuda et al, 1996 Gollenberg et al, 2010). Interestingly, a psychological profile of being an active, competitive person may coincide with a low sperm count, possibly through activity-induced activation of the SNS and a deficiency of testicular blood flow. Behavioral therapy focusing on relaxation strategies appear to increase sperm counts and reproductive success in these men (Hellhammer and...
In critically ill patients, the low T3 syndrome has been considered a predictor for mortality (Chopra, 1997). In patients with anorexia nervosa, the low T3 syndrome as well as a smaller volume of the thyroid gland has been observed, which are both reversible after weight gain (Munoz and Argente, 2002). In PTSD and major depression, both hyper- and hypoactivity of the hypothalamic-pituitary-thyroid axis have been described (Boscarino, 2004 Newport and Nemeroff, 2000).
During childhood or adolescence may result in chronic GH suppression and subsequently, psychosocial short stature. However, with amelioration of environmental conditions during development, this may be reversed (Gohlke et al, 2004). Also Anorexia nervosa coincides with dysreg-ulation in GH-IGF-1 functioning and, given a prepubertal disease onset, may result in diminished final body height (Munoz and Argente, 2002).
Secular trends suggest that improved nutrition, hygiene, and health care are associated with an earlier age of menarche over the past 300 years (Eveleth and Tanner, 1990 Tanner, 1962 Worthman, 1999). However, even within human populations within the same region there is considerable variation in the age of sexual maturation that associates with nutritional status only when there is considerable disparity in the availability of energy resources (reviewed in Ellis, 2004). Thus, in studies with human as well as nonhuman populations (Kirkwood and Hughes, 1981), nutrition and age of female sexual maturation are related only under conditions that involve severe dietary restrictions. Likewise, extreme levels of physical activity that place demands on metabolic resources or states of anorexia also delay menarche (Brooks-Gunn and Warren, 1988 Georgopoulos et al., 1999). These are the more extreme cases. Variations in diets within adequately nourished...
Social relationships are intimately tied to well-being and mental health (Sullivan, 1953). The close association between mental health and social interpersonal processes is highlighted by the pervasiveness of severely impoverished social networks and deficits in social skills of persons with schizophrenia, depression, social anxiety, and eating disorders for example. Primary assumptions embedded in social and interpersonal perspectives in behavioral medicine are that interpersonal disturbances may function as (1) causally disruptive phenomena in the development of mental illness, (2)
The second problem with glaucoma medications in younger patients is a greater frequency of, or sensitivity to, psychological and sexual side effects. These can include depression, anxiety, confusion, sleep disturbances, drowsiness, weakness, fatigue, memory loss, disorientation, emotional lability, loss of libido, and impotence. Central nervous system side effects of CAIs have been primarily associated with their systemic use and can be described as a complex consisting of general malaise, fatigue, weight loss, depression, anorexia, and loss of libido. Once again, careful instruction on nasolacrimal occlusion can result in reduced dosages of medications and decreased systemic absorption. This is especially important when topical medications are prescribed for pregnant or lactating women.
The first, large, randomized trial of intraventricular GDNF was published in 2003. In this trial, 50 patients underwent placement of pumps and intraventricular catheters. The patients were randomized to receive either carrier alone or one of several concentrations of recombinant GDNF. At six to eight months, none of the GDNF groups had demonstrated improvements over placebo and several of the groups had worsened (39). Additionally, adverse effects were noted in 100 of patients receiving GDNF. These included nausea, anorexia, and shock-like sensory symptoms resembling Lhermitte's phenomena. It was suggested that the relative size of the human brain makes the transependymal diffusion of GDNF insufficient to create the necessary concentrations to produce an effect (40). A series of trials were also underway to evaluate the effects of intrastriatal microinfusion of GDNF. A phase I safety study published by Gill et al. reported that microinfusion in five parkinsonian patients produced no...
General symptoms include fever, sweats, malaise, anorexia, weight loss and apathy. Tachycardia and elevated temperature are consistent with a patient who is toxaemic. Local features are pain relieved by rest, swelling of the affected limb, immobility of associated joints, paralysis in the chronic situation and tenderness in the region of the epiphyseal region of the long bones.
The numerous projects that have been completed examined patient populations with a variety of advanced malignancies, requiring readers to extrapolate a generalized advanced-cancer experience to the subset of patients in which they are interested. The common symptoms reported in the advanced-cancer population include fatigue, pain, anxiety, and anorexia, each with prevalence rates reported to be greater than 50 .20-28 In addition, most patients with advanced cancer experience a multitude of symptoms simultaneously.21,24,26 It is important to note that the majority of studies have focused on physical symptoms such as pain or anorexia rather than on psychological symptoms such as anxiety and depression. Studies that included the examination of psychological symptoms found such symptoms to be common in patients with advanced malignancy.24,29-33
There are well established efficacious ESTs for anxiety, depression, bipolar disorder, schizophrenia, tobacco addiction, obesity, anorexia, cocaine abuse, and more. No treatment for personality disorder is listed as well established efficacious, but treatments for avoidant (social skills training) and borderline personality disorder (dialectical behavior therapy) have made it to the list of probably or possibly efficacious approaches (Chambless & Ollendick, 2001, Table 2).
Hormonal therapy for prostate cancer eventually produces decreases in libido and potency in virtually all patients regardless of the modality used.34,124 Additional side effects include lethargy, depression, anorexia, breast swelling with or without tenderness, hot flashes, anemia, and osteoporosis with potential for pathological fracture.14,125-130 Most side effects, including impotence and infertility, are slowly reversible with cessation of therapy. However, reduced bone mineral density often does not reverse after prolonged hormonal suppression. There is a consensus that irreversible changes occur more often after suppression of longer than 18-24 months.
Dietary prevention of chronic heart failure CHF the role of micronutrients dietary fatty acids and reduced sodium intake
There is not room here to fully explore the present knowledge in this field. Nevertheless, if we restrict our comments to human data, the situation can be summarised as follows. Cases of hypocalcaemia-induced cardiomyopathy (usually in children with a congenital cause for hypocalcaemia) that can respond dramatically to calcium supplementation have been reported.67 Hypomagnesaemia is often associated with a poor prognosis in CHF,68 and correction of the magnesium levels (in anorexia nervosa for instance) leads to an improvement in cardiac function. Low serum and high urinary zinc levels are found in CHF,69 possibly as a result of diuretic use, but there are no data regarding the clinical effect of zinc supplementation in that context. In a recent study, plasma copper was slightly higher and zinc slightly lower in CHF subjects than in healthy controls.58 As expected, dietary intakes were in the normal range and no significant relationship was found between dietary intakes and blood...
It is normal for young children between the ages of 1 and 4 to have a relative lymphocytosis. The white cell differential in this age group will show a reversal in the number of lymphocytes to segmented neutrophils from the adult reference range. The lymphocytes, however, will have normal morphology (Fig. 10.11). By far the most common disease entity displaying variation in lymphocytes is infectious mononucleosis. This is viral illness caused by the Epstein-Barr virus (EBV), a member of the human herpes virus family, type 4. Although young children may become infected with EBV, the virus has a peak incidence at around 20 years of age. Most adults have been exposed to EBV by midlife, and this is recognized by demonstratable antibody production whether or not they have had an active case of infectious mononucleosis. The virus is found in body fluids, especially saliva, and is frequently passed through exchanges such as kissing, sharing food utensils, or drinking cups. The virus, which...
Overall, the nitrogen-retaining effects of rhIGF-1 in metabolic ward studies did not consistently attain levels seen with rhGH (30), whereas the increases in REE were comparable to those seen with rhGH. Moreover, the insulin-like effect of IGF-1 poses a potential obstacle to its use in patients with HIV-associated wasting, many of whom may be at increased risk of hypoglycemia because of limited energy stores, anorexia, malabsorption, or increased insulin sensitivity (54,55).
Substantial concern has been expressed that for children and adolescents, at least, the media contribute to health problems including violence, sex, drugs, obesity, and eating disorders (Strasburger, 2009). Both correlational and experimental research support these claims. Perhaps the most mature area of research among these problems is on youth media exposure and violence. Conclusions include an increasing likelihood of aggressive behavior in younger
Behcet's disease (BD) is a rare disorder of unknown etiology that affects mucocutaneous tissues, the eyes, and the genitourinary system. The classic triad of oral aphthous ulcers, uveitis, and genital ulcers is pathognomonic for BD. It may progress to involve the GI, pulmonary, renal, and central nervous systems, as well. Symptoms include malaise, fever, anorexia, and weight loss. Sore throat, dysphagia, and odynophagia are often present at acute presentation. BD is commonly misdiagnosed as pharyngitis or tonsillitis at initial presentation, resulting in a delay in appropriate treatment. Please refer to Chapter 3 for discussion of the epidemiology, pathogenesis, diagnosis, treatment, and prognosis of BD.
Chris Freeman is a consultant psychiatrist and psychotherapist based at the Cullen Centre in the Royal Edinburgh Hospital and is also a senior lecturer in the Department of Psychiatry at the University of Edinburgh. He established the South of Scotland Training Programme in Cognitive Behaviour Therapy and has published widely in the areas of eating disorders and psychological therapies.
We predict that the period to 2030 will see a range of exciting developments in cognitive therapy research and practice. In the area of outcome research, the most obvious area for advancement is where promising initial research suggests that cognitive therapy may prove to be an evidence-based approach personality disorders, anorexia nervosa and substance misuse. Here efficacy and effectiveness research is urgently needed to establish whether people with these complex mental health problems can be helped through cognitive therapy. Similarly, psychotherapy outcome research is needed to examine how cognitive therapy fares when it is adapted to different populations (for example, older adults) and to different service settings (such as primary care).
The success of IPT in treating unipolar mood disorders has led to its expansion to treat other psychiatric disorders. Frank and colleagues in Pittsburgh have been assessing a be-haviourally modified version of IPT as a treatment adjunctive to pharmacotherapy for bipolar disorder. Further, IPT is increasingly being applied for a range of non-mood disorders. There are intriguing applications of IPT as treatment for bulimia (Agras et al., 2000 Fairburn et al., 1993 Wilfley et al., 1993, 2000) and anorexia nervosa social phobia (Lipsitz et al., 1999), posttraumatic stress disorder, borderline personality disorder and other conditions. Life events, the substrate of IPT, are ubiquitous, but how useful it is to focus on them may vary from disorder to disorder. There have been two negative trials of interpersonal therapy for substance disorders (Carroll, Rounsaville & Gawin, 1991 Rounsaville et al., 1983), and it seems unlikely that an outwardly focused treatment such as IPT would be useful...
Liver toxicity occurs usually early during therapy (within 18 weeks of starting). If liver enzymes levels increase to 3.5 times upper limit of normal (ULN) during treatment, nevirapine should be stopped immediately. If liver enzymes return to baseline values and if the patient has had no clinical signs or symptoms of hepatitis, rash, constitutional symptoms or other findings suggestive of organ dysfunction, it may, on a case-by-case basis, be possible to reintroduce nevirapine. However, frequent monitoring is mandatory in such cases. If liver function abnormalities recur, nevirapine should be permanently discontinued. If clinical hepatitis (anorexia, nau
Although our culture does not view being underweight as a particularly serious problem, many young women with anorexia nervosa suffer from malnutrition and thereby become more susceptible to disease. Interestingly, research has demonstrated that sharply reducing caloric intake while keeping the intake of proteins, vitamins, and minerals at recommended levels can assist in the avoidance of many diseases and slow the aging of various body systems (Weindruch & Walford, 1988).
The main, and often only, symptom of an early gastric cancer is dyspepsia. As the cancer becomes more advanced symptoms include anorexia, weight loss, vomiting, and anaemia. Unfortunately, dyspepsia is a very common symptom, and is often treated by patients and doctors alike with a variety of ant-acid therapies. Guidelines have been produced to encourage referral of patients with dyspepsia who - Anorexia Dyspepsia with risk factors
Patients with ulcers have a variety of symptoms, including epigastric pain, anorexia, vomiting, and weight loss. Epigastric pain may be relieved by food, or associated with anorexia, and radiates through to the back. Some patients are asymptomatic. Examination is often unremarkable, except for melaena when there has been bleeding, or a succussion splash with gastric outlet obstruction. The diagnostic investigation is upper GI endoscopy, which allows visualisation of ulcers as well as
Endometriosis in captive colonies of female rhesus monkeys can occur in relatively high incidence ( 26 ). The causes of endometriosis appear to be varied and range from surgery to radiation exposure (Fanton and Golden, 1991). One of the major issues of endometriosis, especially in rhesus macaques, is diagnosis at a treatable stage of the disease. As observed by a number of laboratories, endometriosis is difficult to diagnose until relatively advanced (Rippy et al., 1996). Use of indicators, such as plasma levels of CA-125, have been examined as a possible indicator of endometriosis (Rippy et al., 1996). The condition is accompanied by lesions, cyst formation, adhesions to organs, anorexia, and abdominal masses
Although many of these studies were done in adults, the results are applicable to children. Exercise increases GH levels in normal subjects, an effect inhibited by naloxone, atropine and oral glucose administration (23). Elevated plasma GH levels are seen following acute trauma, major surgery, and electroconvulsive therapy, with mild increases observed following venipuncture (20). Twenty-four-hour GH secretory profiles during severe illness are characterized by higher basal levels of GH and reductions in serum IGF-1, but no differences in mean GH concentration or number of GH pulses (24). The dissociation between GH and IGF-1 is similar to that seen in catabolic states including prolonged fasting, nutritional dwarfing and anorexia nervosa.
Thyrotropin-releasing hormone (TRH) stimulates GH secretion in a variety of conditions including acromegaly, anorexia, and depression (20,66 see ref. 66 for a more complete list). The mechanism for this paradoxical GH response to TRH is unclear, but may also reflect the presence of TRH receptors on pituitary somatotropes or impaired hypothalamic control of GH secretion (66). TRH by itself does not affect GH secretion in humans, yet pretreatment with TRH decreases the mean peak GH response to dopam-ine, while augmenting peak GH levels when administered after dopamine infusion. Pretreatment with triiodothyronine (T3) blocks this inhibitory effect of TRH (67). Thus, TRH appears to work at a different level when GH concentration is elevated (i.e., acromegaly, following dopamine infusion) compared to physiologic states with lower GH concentration.
Y is a 30-year-old, African American female with a college education who had been in psychotherapy for three months at the time the treating clinician described her. The clinician gave her an Axis I diagnoses of dysthymic disorder and eating disorder NOS and a GAF score of 50, indicating moderate impairment. As part of the assessment, the clinician completed a randomly ordered checklist of all of the symptoms comprising Axis II. When we applied DSM-IV diagnostic algorithms, the patient met criteria for borderline, histrionic, and dependent PDs. We also asked the clinician to rate this patient on each of the empirical prototypes of the Cluster B PDs using the rating system described earlier. The clinician rated the patient as meeting criteria for borderline PD (a rating of 5) and having significant features of histrionic PD (a rating of 3). She gave the patient ratings of 2 and 1, respectively, for narcissistic and antisocial PD. On a questionnaire that addresses developmental and...
The fact that more women than men are treated in mental health clinics and psychiatric hospitals would lead one to believe that the rate of mental illness is higher among women than among men. This appears to be the case with respect to some, but certainly not all, mental disorders. Women tend to be more vulnerable to anxiety disorders, depression, and eating disorders, and they probably have a higher rate of attempted suicide than men. On the other hand, boys are more likely than girls to stutter, to be hyperactive, and to develop other conduct or behavioral disorders (Myers, 1995). As adults, they are more likely to become alcoholics and or substance abusers and to develop antisocial personalities (Unger, 1979). Men also commit more crimes than women, and crimes of violence in particular (U.S. Department of Justice, 1996). Finally, substantially more men than women, and especially older white men, succeed in committing suicide (Singh et al., 1996).
After an incubation period of 1 to 4 weeks the clinical presentation is with nonspecific flu-like symptoms, including fever, chills, headache, fatigue, and anorexia. Other less common symptoms are nausea, diaphoresis, depression, photophobia, myalgias, arthralgias, dark urine, emotional lability, and hyperesthesias. Unlike Lyme disease, rash is not a feature of the illness. Splenomegaly is present on exam in patients. More severe disease occurs in splenectomized patients. The diagnosis is established by examination of thick and thin Giemsa-stained blood smears. Characteristic intra-ery-throcytic forms may be present.
Such as malaise, anorexia and weight loss may be present, due to disseminated disease or paraneoplastic syndrome. Haematuria following direct trauma to the renal tract will be evident from the history, but bleeding following minimal trauma should be investigated carefully as there may be some underlying pathology. Patients on anticoagulants who develop haematuria also require full investigation, as a lesion in the urinary tract may be unmasked by the anticoagulants.
In this chapter we treated the major neuroendocrine systems and their role in health and stress-related disorders, such as depression, PTSD, infertility, or eating disorders. It becomes evident that neuroendocrine systems are tightly intertwined with each other and perturbations in one system may cause multiple dysregulations in the others. Environmental events, and stress in particular, have profound effects on proper neuroendocrine functioning and may thus affect disease onset, maintenance, or progression.
A 47-year-old man was referred to our hospital on December 29, 1997 because of an exacerbation of fulminant myocarditis after undergoing steroid pulse therapy with methylprednisolone and plasma apheresis for acute hepatitis and acute myocarditis at another hospital. About two weeks earlier, he presented with a low-grade fever, general fatigue, cough, anorexia, and nausea. On December 20, 1997, he was admitted to a hospital because the symptoms worsened. A physical
However only three (criticality, hostility and overinvolvement) were found to be clinically meaningful and are elicited through a two to two-and-a-half hour standardised Camberwell Family interview (Vaughn & Leff, 1976a). Brown & Birley (1968) showed that relapse in schizophrenia was preceded by both pleasant and unpleasant events in the weeks before the episode. Subsequently, Vaughn and Leff found that patients with more than 35 hours per week of face-to-face contact with relatives with high expressed emotion were highly likely to relapse over a nine-month period - even if they were on drug therapy - compared with those who were exposed to less than 35 hours per week of the same or to relatives with low expressed emotions (Vaughn & Leff, 1976b). In this study high EE-exposed patients were more likely to relapse compared to low EE patients who were not on medications. An aggregate analysis of 25 studies (Bebbington & Kuipers, 1994) confirmed the role of EE in schizophrenia outcome...
Cat-scratch disease is caused by a systemic infection with Bartonella henselae, a bacteria colonizing cat saliva. The infection typically presents as a skin lesion at the site of a cat scratch with ensuing local lymphadenopathy. Infection is manifested by lymphadenopathy, but infected individuals may display fever, fatigue, anorexia, or headaches. It is most commonly a pediatric disorder, affecting individuals usually younger than 21 years of age. Neurologic involvement is estimated to affect 2 to 3 of patients, presenting as encephalopathy, seizures, cerebellar ataxia, hemiparesis, myelitis, or cranial neuropathies. Curiously, neurologic involvement has an increased incidence in adult patients. Facial nerve involvement is considered rare (65).
In a review by Smith (17), the safety and tolerability of rHuIL-11 administered sc at the recommended dose of 50 g kg d was compared with placebo in two phase 2 studies. The dataset included 308 patients, ranging from 8 mo to 75 yr of age, who received up to eight sequential 1-28-d courses of oprelvekin. In this group, aside from complications associated with underlying malignancy or cytotoxic chemotherapy, most adverse events were of mild or moderate severity and were reversible after cessation of the growth factor. The incidence and type of adverse events were similar between patients who received oprelvekin and those who received placebo. Edema, dyspnea, tachycardia, conjunctival injection, palpitations, and pleural effusion occurred more frequently in the oprelvekin-treated patients. Adverse events that occurred in 10 of patients and were observed in equal or greater frequency among patients receiving placebo included asthenia, pain, chills, abdominal pain, infection, anorexia,...
The effectiveness of psychological interventions for anxiety disorders, depression and anorexia nervosa will be considered in this section. Anorexia The prevalence of anorexia nervosa - a syndrome where the central feature is self-starvation - among teenage girls is about 1 (World Health Organization, 1992 American Psychiatric Association, 1994). Wilson & Fairburn (1998) in a recent extensive literature review concluded that family therapy and combined individual therapy and parent counselling with and without initial hospital-based feeding programmes are effective in treating anorexia nervosa (for example, Crisp etal., 1991 Eisler etal., 1997 Le Grange etal., 1992 Hall & Crisp, 1987 Robin&Siegal, 1999 Russell etal., 1987). They also concluded that inpatient refeeding programmes must be supplemented with outpatient follow-up programmes if weight gains made while in hospital are to be maintained following discharge. Key elements of effective treatment programmes include engagement of...
Clinical manifestations of mononucleosis vary considerably from patient to patient. Constitutional symptoms including fever, myalgia, malaise, and anorexia are initial complaints. Acute exudative pharyngotonsillitis is accompanied by tender cervical lymphadenopathy, especially in the posterior cervical chain. Hepatosple-nomegaly is a part of the systemic presentation.
There seems to be general agreement that children under 5, when a parent leaves, particularly if it was the main carer, are those most at risk of long-term effects (Smith, 1999). Primary and secondary school children can be troubled long term, with anger, distress and poor concentration at school. Older children can react with risk-taking behaviour, staying out, cutting themselves, and eating disorders. The conflicting feelings about themselves, their identity and self-esteem is linked to their conflicting feelings about their parents (Zimmerman et al., 1997). Harter (1999) suggests self-esteem depends on the competence and the adequacy of the young person, and approval from significant others particularly where there is a long-term supportive relationship. Where there has been domestic violence there is considerably more trauma to the child (Hemmings et al., 1997).
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