Anorexia Nervosa Treatment Overview

Breaking Bulimia

Breaking Bulimia

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

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Bulimia Help Method

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Cognitive Therapy for Eating Disorders

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.

Nutritional Dwarfing Anorexia Nervosa

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).

Binge Eating Disorder

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.

Treatment A Anorexia Nervosa

Anorexia nervosa is treated through a combination of nutritional rehabilitation and psychotherapy, with the goals of weight restoration, development of healthy eating habits, improvement in moods behaviors, reduction in obsessions with thinness, and amelioration of concomitant physical and psychiatric symptoms (8). Psychotherapy may be provided individually or in groups. In younger patients with anorexia nervosa, who frequently live with their family of origin, family therapy is also used. Individual psychological therapies include cognitive behavioral psychotherapy, in which faulty cognition regarding eating and weight is examined, and psychodynamic or interpersonal psychotherapy, in which the patient's current interpersonal relationships with others are explored. Cognitive behavioral psychotherapy is described in more detail below. Medications are less often used in the treatment of anorexia nervosa than in bulimia nervosa. Few medications have proven effective in long-term studies....

Prognosis A Anorexia Nervosa

Anorexia nervosa is a condition with severe morbidity and a high mortality, estimated at up to 20 over 20 years, although most studies show considerably lower rates, closer to 5 (143-145). The major reasons for death include starvation, suicide, and cardiac arrhythmias due to fluid and electrolyte imbalance (144,145). A 10-year follow-up study of 76 severely ill anorexics found high rates of chronicity, with 41 experiencing bulimic episodes 10 years after initial treatment, and a 13-fold increase in mortality (146). Less than one-quarter of patients in that series were considered fully recovered. In a review of 14 outcome studies, Herzog et al. (144) report that 22-70 of patients were within the normal weight range at follow-up, while 15-43 were considered underweight. Overweight is not common among patients with a history of anorexia nervosa. Even when overweight is defined as 10 above ''standard'' weight, studies report a prevalence of only 2-10 (144). The same review reported that...

Bulimia nervosa

Bulimia nervosa is an eating disorder characterized by binge eating and engaging in inappropriate ways of counteracting the bingeing (using laxatives, for example) in order to prevent weight gain. The word bulimia is the Latin form of the Greek word boulimia, which means extreme hunger. A binge is consuming a larger amount of food within a limited period of time than most people would eat in similar circumstances. Most people with bulimia report feelings of loss of control associated with bingeing, and some have mildly dissociative experiences in the course of a binge, which means that they feel disconnected from themselves and from reality when they binge. Hypokalemia Abnormally low levels of potassium in the blood. Hypokalemia is a potential medical emergency, as it can lead to disturbances in of the heart rhythm. Muscle cramps and pain are a common symptom of hypokalemia in bulimic patients. Incisors The four teeth in the front of each jaw in humans. The incisors of patients with...

Eating disorders

Anorexia (loss of appetite) is usually the result of physical ill health. Excessive parental concern about food can result in anorexia, or lead the child to use food refusal or vomiting to manipulate the parents. Depression is another cause. Anorexia nervosa (see Chapter 15) occasionally affects prepubertal children but more often starts in adolescence.

Anorexia Nervosa

There is evidence that suggests zinc deficiency may be intimately involved with anorexia in humans, if not as an initiating cause, then as an accelerating or 'sustaining' factor for abnormal eating behaviours that may deepen the pathology of the anorexia (McClain et al 1992, Shay & Mangian 2000). Zinc status is compromised in anorexia nervosa due to an inadequate zinc intake, with supplementation (50 mg elemental zinc day) shown to decrease depression and anxiety, stop body weight loss and improve weight gain (Katz et al 1987, Safai-Kutti 1990). According to one randomised, double-blind, placebo-controlled trial, 100 mg of zinc gluconate doubled the rate of subjects with anorexia nervosa increasing their BMI compared to placebo (Birmingham et al 1994).

Adverse Reactions

Hypercalcaemia Increased serum calcium may be associated with anorexia, nausea and vomiting, constipation, hypotonia, depression and occasionally lethargy and coma. Prolonged hypercalcaemic states, especially if associated with normal or elevated serum phosphate, can precipitate ectopic calcification of blood vessels, connective tissues around joints, gastric mucosa, cornea and renal tissue (Wilson et al 1991).

Clinical Presentation

The presentation of Crohn's disease may be insidious or acute, with symptoms including diarrhoea, anorexia and weight loss. Various forms of fistulae (abnormal connection between two epithelial lined structures) may occur including an enterovesical fistula (between small intestine and urinary bladder) which leads to gas in the urine (pneumaturia) and repeated urinary tract infections. Enterocolic and enteroenteric (between adjacent small bowel loops) fistulae may also occur. Enterocutaneous fistulae usually only happen after previous surgery. One of the differential diagnoses of a right iliac fossa mass is Crohn's disease with a peri-intestinal abscess around the distal ileum.

Statistical Prediction

Given the shortcomings of clinical judgment for describing functional relationships, it is important to note that sequential and conditional probability analyses have been used to analyze self-monitoring data. These statistical analyses have been used to clarify the functional relationships involved in a variety of problems including smoking addiction, bulimia, hypertension, and obesity (e.g., Schlundt & Bell, 1987 Shiffman, 1993).

Health Issues Affecting Lgbt Populations

Sexual orientation is not intrinsically linked to mental health problems however, stigma, homophobia, and prejudice may negatively impact the mental health of LGBT individuals (Meyer, 2003). Furthermore, estrangement from family members, adjusting to a LGBT identity, lack of support for relationships and families may be additional stressors. Unfortunately, population-based estimates of prevalence of mental disorders among LGBT people are lacking (Dean, et al., 2000). The few probability based studies that have been done found higher rates of depression, panic attacks syndrome, and psychological distress among MSM (Cochran and Mays, 2000 Cochran, et al., 2003 Mills, et al., 2004), especially among those who had experienced anti-gay harassment (Mills, et al., 2004). Lesbian and bisexual women appear to have higher prevalence of general anxiety disorder compared to heterosexual women (Cochran, et al., 2003). HIV (Bing, et al., 2001 Dickey, et al., 1999) as well as the stress of caring...

Cholinesterase Inhibitors

McKeith and colleagues (McKeith, Del Ser, et al., 2000) performed a randomized, placebo-controlled, double-blind trial using rivastigmine to treat behavioral disturbances in DLB. This was a large multicenter trial involving 120 patients. Nearly 63 in the treatment group showed at least a 30 improvement on the Neuropsychiatric Inventory (NPI Cummings et al., 1994). Functionally, this equated to less apathy, less anxiety, and fewer delusions and hallucinations. Cognitive improvements, in particular, in measures of attention and memory also occurred. Cholinergic side effects (nausea, vomiting, and anorexia) were reported in some patients. Grace et al. (2001) reported on a smaller pilot trial of open-label treatment with rivastigmine in 29 DLB patients who were followed over a period of 96 weeks. No detectable declines in cognition as measured by the MMSE

Nonidiosyncratic Heparininduced Platelet Activation

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).

Clinical classification of depression

Severe depression is characterized by a pervasive depression of mood, which has a different quality from ordinary sadness, cannot be expressed by tears even if the patient wants to cry, and is unrelated to external circumstances. Somatic symptoms (early morning waking, diurnal variation of mood, anorexia, and weight loss) are often prominent, and psychotic features (delusions and or hallucinations) may be present. Severe episodes usually respond best to physical methods of treatment (see below) rather than psychological therapies alone.

Clinical evaluation of premenstrual syndrome

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

In Obesity Prevention Programs

Large energy deficit, usually in excess of 500 kcal (2000 kJ) per day, which needs to be sustained for the period of weight loss. This usually involves moderate change in current diet and physical activity patterns, but is often achieved with more radical change. In contrast, the prevention of weight gain may only require very minor but long-term energy adjustments in the region of 50 kcal or less a day to avoid the accumulation of excess energy over time and prevent an increase in body fat stores. Thus the most effective prevention strategies may not necessarily be based on what makes the biggest contribution to the development of energy imbalance. Instead effective prevention strategies will need to focus on changes that are achievable, sustainable, simple, relevant to a large proportion of the target population, and capable of contributing to increased energy expenditure or decreased energy intake or both. Changes that may only result in a small reduction in energy intake or small...

Causes and symptoms

There is considerable evidence that OCD has a biological component. Some researchers have noted that OCD is more common in patients who have suffered head trauma or have been diagnosed with Tourette's syndrome. Recent studies using positron emission tomography (PET) scanning indicate that OCD patients have patterns of brain activity that differ from those of people without mental illness or with some other mental illness. Other studies using magnetic resonance imaging (MRI) found that patients diagnosed with OCD had significantly less white matter in their brains than did normal control subjects. This finding suggests that there is a widely distributed brain abnormality in OCD. Some researchers have reported abnormalities in the metabolism of serotonin, an important neurotransmitter, in patients diagnosed with OCD. Serotonin affects the efficiency of communication between the front part of the brain (the cortex) and structures that lie deeper in the brain known as the...

Structuring The Treatment In

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...

Difficulties In Distinguishing Psychopathology From Culturerelated Conditions

Second, assuming that clinicians agree that it is important to consider the impact of cultural variables upon the assessment of multicultural groups, a crucial question would be Why such variables are not currently emphasized by clinicians in their clinical practices At least two answers may be proposed (Paniagua, 1998). First, current standard clinical ratings such as the Minnesota Multiphasic Personality Inventory, the Child Behavior Checklist, the Zung Depression Scale, and the Schedule of Affective Disorders and Schizophrenia (Rut-ter, Tuma, & Lann, 1988) and diagnostic instruments such as the DSM-IV (1994) do not require an assessment of cultural variables that might lead to the identification of culture-bound syndromes (e.g., Table I) or disorders associated with specific cultural contexts (e.g., ADHD, Anorexia Nervosa, etc.). Thus, in clinical practice one would not be concerned with the fact that a given mental health practitioner does not include a screening of cultural...

Abdominal Pain and the Acute Abdomen

Associated Symptoms Fever, chills, nausea, vomiting (bilious, feculent, blood, coffee ground-colored material) vomiting before or after onset of pain jaundice, constipation, change in bowel habits or stool caliber, obstipation (inability to pass gas) chest pain, diarrhea, hematochezia (rectal bleeding), melena (black, tarry stools) dysuria, hematuria, anorexia, weight loss, dysphagia, odynophagia (painful swallowing) early satiety, trauma.

Physical Examination

Differential Diagnosis Inadequate caloric intake, peptic ulcer, depression, anorexia nervosa, dementia, hy-per hypothyroidism, cardiopulmonary disease, narcotics, diminished taste, diminished olfaction, poor dental hygiene (loose dentures), cholelithiasis, malignancy (gastric carcinoma), gastritis, hepatic or renal failure, infection, alcohol abuse, AIDS.

Toward Ethical Guidelines Of Terminal Care

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...

Iinonimmune Heparinassociated Thrombocytopenia

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...

Jaundice and Hepatitis

History of the Present Illness Dull right upper quadrant pain, anorexia, jaundice, nausea, vomiting, fever, dark urine, increased abdominal girth (ascites), pruritus, arthralgias, urticarial rash somnolence (hepatic encephalopathy). Weight loss, melena, hematochezia, hematemesis.

Adverse Effects and Toxicity

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.

Role Of Mutual Empathy In The Therapeutic Process

Painful consequences of these symptoms (the startle response, affective lability, inauthenticity, lack of trust, self-harm, substance abuse, and eating disorders) are the deepening sense of isolation, shame, and helplessness. These symptoms make the possibility of reparative connection even more elusive.

Diagnostic Characteristics

Anorexia nervosa is characterized by refusal to maintain a normal body weight, along with a fear of gaining weight. Diagnostic criteria for anorexia nervosa are shown in Table 1. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (1) criteria divide anorexia into the restricting and binge-eating purging subtypes. Approximately 50 of patients with anorexia nervosa experience binge eating and or purging at some point in their illness (3). Bulimia nervosa is characterized by frequent episodes of binge eating accompanied by emotional distress, plus the presence of frequent compensatory behaviors to avoid weight gain (Table 1) (1). The DSM-IV further classifies patients as belonging to the purging or nonpurging subtypes. Purging is common in bulimia nervosa, and Table 1 Diagnostic Criteria for Eating Disorders Anorexia nervosa Bulimia nervosa Binge eating disordera E. The binge eating is not associated with the regular use of inappropriate compensatory...

Pathophysiology A Individual and Familial Factors

A number of psychological factors have been described in patients with eating disorders, including difficulties in self-esteem and self-regulation, along with a sense of ineffectiveness and helplessness. Eating disorders, in this view, represent the attempt of the patient to gain control in the arena of eating and weight. Girls who are conflicted about maturation and sexuality are felt to be particularly prone to the development of anorexia nervosa. There are limitations in determining the pre-morbid psychological factors that may predispose to the development of eating disorders, primary among which is that this information has generally been obtained retrospectively, after the eating disorder has developed. A community-based study found that nonspecific risk factors such as adverse childhood experiences, negative comments about weight and shape, parental depression, and a predisposition towards obesity increased the likelihood of developing BED (31).

Affective Disorders

Affective disorders are common among patients with eating disorders, leading some researchers to postulate that eating disorders are a variant of affective disorders. Comorbid major depression is frequent among patients with eating disorders (42,43), occurring in over half of all patients in some series. In addition, family history of affective disorders is often more frequent among patients than controls. The response of symptoms to antidepressant treatment, in both bulimia nervosa and binge eating disorder, has been proposed as further evidence of this link. However, it is unknown if the depression seen in bulimia nervosa and binge eating disorder is primary, secondary to the eating disorder, or due to an underlying common pathogenesis. Dysfunction of the serotonergic pathways, which could affect both appetite and mood, has been postulated as one such possible mechanism (44). While depression is common in patients with anorexia nervosa, at least some of these symptoms may be...

Other Comorbid Psychiatric Conditions

Obsessive-compulsive disorder is reportedly more frequent in both anorexia nervosa and bulimia nervosa (46,47), and some researchers have speculated that disturbances in neurally active substances, such as 5HIAA, brought about by starvation, binge eating, or purging, may contribute to the perpetuation of compulsive behaviors in patients with these disorders (46-49). Among individuals with binge eating disorder, no increase in either obsessive-compulsive disorder or obsessive-compulsive personality disorder has been noted (50). Other anxiety and related disorders, such as generalized anxiety disorder and phobias, are also common in eating disorders (51,52). Personality disorders involving impulsivity (including borderline personality disorder) are found more frequently in those with eating disorders involving binge eating than among controls, across the weight spectrum. For example, one study found that obese individuals with binge eating disorder have a 14 prevalence of borderline...

Recommended dosage

Culty, the dosage may be increased to 3 mg twice a day after at least two weeks at the lower dosage. Some people are unable to tolerate nausea, vomiting, anorexia, and weight loss that occur with higher dosages. If the drug does not cause significant adverse effects, the dose may be increased to 4.5 mg two times per day, followed by 6 mg two times per day. The dosage should be increased slowly, at two-week intervals. If side effects occur and cannot be tolerated, the drug may be stopped for several doses. When the drug is started again, the same dosage or the next lower dosage may be tried. The maximum daily dosage is 6 mg two times per day.

Chemoradiation Effects on Qualityof Life

Despite the potential survival benefits for patients with locally advanced pancreatic cancer receiving radiation therapy and chemotherapy, these gains are modest. With rare exception, all patients will ultimately succumb to their disease. In spite of this, significant palliative benefit can be achieved by chemoradiation. Pain, anorexia, fatigue, and clinical wasting are relatively common symptoms, which significantly impact on the patient's quality of life. Although poorly documented in many studies, using the aforementioned techniques (including IORT), reports from larger series indicate that complete pain relief can be obtained in as much as 50 to 80 of patients (71). Using EBRT alone with or without chemotherapy, approximately 35 to 65 of patients will experience pain resolution as well as some improvement in wasting and obstructive symptoms (53,72,73). Definite but less dramatic improvements in performance status and anorexic symptoms may be observed as well (72,73). Because of...

Measurement of Effect and Response

Associated with beryllium exposure (Chapter 21) or the weakness, fatigue, and anorexia associated with mercury-vapor exposure (Chapter 33). In this group of effects, we can also include subjective psychological changes, mood changes, and annoyance reactions to dust, skin irritation, and smell. Data may be collected through standardized interviews or self-completed questionnaires. When interviews are carried out, it is important to avoid observer bias caused by, for example, different interviewers in the exposed group and the reference group. The way questions asked may affect the answers. Ideally, the interviews should be blind (i.e., the interviewer should not know to which group a particular person belongs). In a double-blind study, neither the interviewer nor the person studied knows the exposure status of this person.

Personality Disorders And Social Sensitivity

Mental disorders whose prevalence changes with time and circumstance can be described as being socially sensitive. Disorders that have a stable prevalence across cultures and time can be described as being socially insensitive. Many of the socially sensitive disorders (e.g., substance abuse, eating disorders, antisocial personality, borderline personality) have externalizing symptoms. Impulsive traits, which tend to be contained by structure and limits and amplified by their absence, are particularly responsive to social context. At the same time, disorders characterized by internalizing symptoms (e.g., unipolar depression, anxiety disorders) are also socially sensitive. Anxious and depressive traits can be either contained or amplified by social supports.

Identification And Definition

Sensitive (24) because of the great concern of psychosocial dysfunction associated with the diagnosis of overweight and the high prevalence of eating disorders among certain subsets of the pediatric population, such as adolescent girls. Thus, clinicians are likely to favor a measure that minimizes false positives, even if it does not detect all children who are overweight.

Psychiatry of adolescence

Schizophrenia, affective disorders, neuroses, eating disorders, substance misuse, and deliberate self-harm may all begin during adolescence, and personality disorders may become clearly evident at this time. Drug misuse and completed suicide in adolescents are becoming increasingly common.

Cholangiocarcinoma Involving the Proximal Bile Ducts Hilar Cholangiocarcinoma Clinical Presentation

The early symptoms of hilar cholangiocarcinoma are nonspecific, with abdominal pain, discomfort, anorexia, weight loss, and or pruritus seen in about one-third of patients (7,16,35,36). Most patients come to attention because of jaundice or abnormal liver function tests. Although most patients eventually become jaundiced, this may not be present in cases of incomplete biliary obstruction (i.e., right or left hepatic duct), which may go unrecognized for months. These patients are often further evaluated and diagnosed because of an elevated alkaline phos-phatase or gamma glutamyltransferase. Pruritus may precede jaundice by some weeks, and this symptom should prompt an evaluation, especially if associated with abnormal liver function tests. Patients with papillary tumors of the hilus may give a history of intermittent jaundice. Small fragments of tumor may detach from a friable papillary tumor of the right or left hepatic duct and pass into the common hepatic duct. Physical exam...

Chronic Renal Failure

History of the Present Illness Oliguria, current and baseline creatinine and BUN. Diabetes, hypertension history of pyelonephritis, sepsis, heart failure, liver disease peripheral edema, dark colored urine, rashes or purpura. Hypovolemia secondary to diarrhea, hemorrhage, over-diuresis glomerulonephritis, interstitial nephritis. Excessive bleeding, flank pain, anorexia, insomnia, fatigue, malaise, weight loss, paresthesias, anemia.

Chronic liver disease

Chronic liver disease may present with features of impaired synthetic function, such as oedema, bruising, jaundice or pruritus, with features of portal hypertension, such as asci-tes, abdominal pain or variceal haemorrhage, or with general malaise, fatigue and anorexia. Alternatively the underlying aetiology, such as excess alcohol consumption, may bring the problem to light or it may be discovered incidentally during routine blood testing.

Phenotypic variation in human female reproductive development

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...

Deficiency Signs And Symptoms

Beriberi is the classic thiamine deficiency state. General early deficiency signs and symptoms include fatigue, irritability, poor memory, sleep disturbances, chest wall pain, anorexia, abdominal discomfort and constipation. Primary deficiency is caused by inadequate dietary intake of thiamine, particularly in people subsisting mainly on highly polished rice (de Montmollin et al 2002) or unfortified grain products. Insufficient intake may also occur in anorexia and in people receiving TPN without supplemental thiamine.

Intracerebral Drug Infusion Glial Cell Line Derived Neurotrophic Factor

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...

Other Special Situations

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.

Insulinlike Growth Factor1 Igf1

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).

NonNHS healthcare facilities

Although most psychiatric services are provided by the NHS, some care is purchased from other providers. For example, there are private psychiatric hospitals, including some set up for profit, and some non-profit-making institutions. The NHS often purchases services from both types in areas where it cannot itself meet demand. 'Difficult-to-manage' patients, especially the acutely psychotic and potentially violent those suffering the chronic effects of brain injury and special groups such as patients with eating disorders or puerperal illnesses, are among those most frequently placed in the private sector. Many private wards offer higher levels of staffing and tighter physical security than most modern NHS facilities.

Side Effects Of Hormonal Therapy Similarities And Differences

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.

Reactive Lymphocytosis In Common Disease States

Reactive Lymphocytes Pics

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...

Symptom Distress in Patients with Advanced Cancer

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

Cognitive Therapy for Different Populations and in Different Settings

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.

Sociocultural Factors

It has been proposed that''dieting disorders'' is a more proper term than ''eating disorder'' because the underlying essential feature of anorexia nervosa, bulimia nervosa, and associated conditions is the ''inappropriate and excessive pursuit of thinness'' (32). For individuals with either anorexia nervosa or bulimia nervosa, attempts at weight loss and dietary restriction (often severe) almost invariably precede the development of the significant symptoms of disordered eating. The current cultural milieu, in which thinness, fitness, and body shapes that are impossible for most women to obtain are prized, no doubt contributes to the dissatisfaction with body size and shape that is normative among women. While most women have tried to lose weight, relatively few develop eating disorders, leading some investigators to suggest that dieting may be a ''necessary, but insufficient'' condition for the develop- 5 ment of eating disorders (33). The relationship between dietary restraint and...

Biological Predisposition

Family and twin data suggest that there may heritable factors that predispose to susceptibility for developing eating disorders (58,59). While there appear to be familial factors involved in the development of anorexia and bulimia nervosa, further study is necessary to sort out the magnitude of additive genetic factors with those of shared environment (60). Studies are currently in progress to identify genetic factors contributing to the pathogenesis of anorexia and bulimia nervosa (61). Although abnormalities in numerous neuroendocrine and metabolic systems have been described in eating disorders, it is often difficult to sort out the effects of semistarvation or purging behaviors from disturbances that might be primary (62). While many of the metabolic abnormalities seen with eating disorders normalize after recovery, suggesting a state, rather than trait, component (63), some researchers have found persistent abnormalities after recovery from anorexia or bulimia nervosa (46,64,65)....

Inflammatory Autoimmune

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.

Zyprexa see Olanzapine

May occur with panic disorder Amenorrhea (loss of menstrual periods) anorexia nervosa bulimia nervosa Amnesia (memory loss) acute stress disorder Alzheimer's disease dissociative amnesia dissociative fugue dissociative identity disorder post-traumatic stress disorder vascular dementia Wernicke-Korsakoff syndrome Anxiety bulimia nervosa Bizarre behavior schizotypal personality disorder Blood pressure changes substance abuse substance intoxication Body image issues anorexia nervosa bulimia nervosa Body temperature, raised sleep terror disorder substance abuse substance intoxication Bowel movements, in inappropriate places encopresis brief psychotic disorder major depressive disorder schizophrenia schizophreniform disorder Cold hands and feet anorexia nervosa Communication. See language anorexia nervosa

Acute seroconversion illness

At least 50 of patients have an acute illness associated with seroconversion. The illness usually occurs within 6 weeks of infection and is characterised by fever, night sweats, malaise, severe lethargy, anorexia, nausea, myalgia, arthralgia, headache, photophobia, sore throat, diarrhoea, lymphadenopathy, generalised maculoerythematous rash and thrombocytopenia. Neurological manifestations including meningoencephalitis and peripheral neuritis are commonly observed. Acute HIV infection should be considered in the differential diagnosis of illnesses resembling glandular fever. This illness is self-limiting and usually revolves within 1 to 3 weeks. However, chronic lethargy, depression and irritability may persist after the acute illness. Non-specific viraemic sequelae such as mucosal ulceration, desquamation, exacerbation of seborrhoea and recurrences of herpes simplex may occur (see Fig. 24.1).

Health Outcomes Of Stressful Life Events

Life Events Theory Health Psychology

Only a small number of studies focus explicitly on selected stressors in relation to a specic disease (e.g., Jacobs & Bovasso, 2000, on early loss and breast cancer Matsunaga et al., 1999, on sexual abuse and bulimia nervosa). In most studies, either stress (often measured by a life event checklist) or health outcomes (assessed by symptom checklists) are unspecic. Moreover, methodological inequalities make it dif'cult to compare research ndings directly. Therefore, it is not surprising that research has produced conicting results. The following example on ulcers illustrates one of the problems, namely, the differences in the time span between stress occurrence and health impairment.

Prevalence Of Personality Disorders In Contemporary Society

The finding that about half of those receiving mental health treatment are compromised in their personality functioning, enough to warrant a personality disorder diagnosis, underscores the importance of acknowledging the contribution of personality to relational disturbances such as marital dysfunction, spousal abuse, domestic violence, child abuse, as well as the most common clinical syndromes such as anxiety, depression, eating disorders, and addictions. The prevalence rates for personality disorders vary greatly. In a review of six studies, Mattia and Zimmerman (2001) found that the rates documented ranged from as low as 6.7 to as high as 33.3 . These findings are suggestive of a greater problem than is being acknowledged. There are few epidemiological studies that have investigated the prevalence of childhood and adolescent personality disorders. Bernstein et al. (1993) indicate that the rate of personality disorders between the ages of 9 and 19 is high. They found that...

Radiation Oncology Nurse

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...

Argentina Biosurveillance

Anorexia, fever, dyspnea, cough, and nasal discharge. Clinical signs not always present. May remain subclinical. Sudden onset of fever, Culture of agent from blood anorexia, birth of weak stillborn animals. (early) or urine. Serology No clinical disease in wild animals. Anorexia, nausea, vomiting, diarrhea. Followed by fever, muscle pain, swollen eyelids, headache and chills. Muscle pain may last several months.

Night Eating Syndrome

In the current climate of managed care, inpatient treatment is increasingly being replaced by less expensive and less intensive therapies, including outpatient care and partial hospitalization (91). One randomized study has shown good outcomes in anorexic patients assigned to outpatient treatment (92). However, many experts believe that inpatient treatment is preferable for all but the most mild forms of anorexia nervosa (8). While anorexia nervosa is the diagnosis most likely to require hospitalization, there are indications for hospi-talization in patients with any of the eating disorders (Table 2) .

Body dysmorphic disorder

BDD is characterized by an unusually exaggerated degree of worry or concern about a specific part of the face or body, rather than the general size or shape of the body. It is distinguished from anorexia nervosa and bulimia nervosa, to the extent that patients with these disorders are preoccupied with their overall weight and body shape. For example, an adolescent who thinks that her breasts are too large and wants to have plastic surgery to reduce their size but is otherwise unconcerned about her weight and is eating normally would be diagnosed with BDD, not anorexia or bulimia. As many as 50 of patients diagnosed with BDD undergo plastic surgery to correct their perceived physical defects.

An Integrated Etic Emic Approach

Integration of the etic and emic approaches involves learning about the general clinical principles but, at the same time, viewing the clinical method as fundamentally personal. Any relevant information is applied with regard to the uniqueness of the cultural context and the personal situation of the client. There are at least two aspects of the clinical issue that need to be considered. First, the issues presented by a client are fundamentally personal to the client, irrespective of whomever else may share the problem. For example, an adolescent girl suffering from anorexia nervosa will grapple with issues surrounding weight gain and body image. Despite the fact that many other young women may be facing these same issues, the problem is unique within this adolescent's own personal experiences. The second aspect concerns the client's specific life context or situation. How does the clinician define the context or gain understanding of the situation from the client's perspective In the...

Female Reproductive System

The most common cause of secondary amenorrhea is pregnancy, which can be determined by assaying urine human chorionic gonadotropin (hCG). Other pathologic causes of secondary amenorrhea include hypothalamic pituitary malfunction (e.g., anorexia nervosa), ovarian disorders (e.g., ovariectomy), and end-organ disease (e.g., Ash-erman syndrome, in which the basal layer of the endometrium has been removed by repeated curettages). Anorexia nervosa

Polycystic kidney disease

Peritoneal Dialysis Nurses History

Polycystic kidney disease is inherited in an autosomal dominant manner in which gradually enlarging renal cysts are associated with progressive renal impairment. It may present with chronic renal failure or be found during screening of relatives of patients with the disease. More unusually it can present with an abdominal mass, with hypertension or with rupture of an associated intra-cranial Berry aneurysm causing a subarachnoid haemorrhage. The renal failure most commonly manifests in middle age and might present with vomiting, nausea, anorexia, itching, fatigue, polyuria, etc. The cysts can bleed producing haem-aturia, become infected or be painful. There is an increased incidence of cardiac disease including valvular abnormalities, herniae and diverticular disease. It has a prevalence of 0.1 .

About the Editors

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.


Amoxapine is used primarily to treat depression and to treat the combination of symptoms of anxiety and depression. Like most antidepressants of this chemical and pharmacological class, amoxapine has also been used in limited numbers of patients to treat panic disorder, obsessive-compulsive disorder, attention-deficit hyperactivity disorder, enuresis (bed-wetting), eating disorders such as bulimia nervosa, cocaine dependency, and the depressive phase of bipolar (manic-depressive) disorder. It has also been used to support smoking cessation programs.


Initial assessment usually includes a careful interview and history (clinical evaluation). A weight history, menstrual history, and description of daily food intake are important during initial evaluation. Risk factors and family history are also vital in suspected cases. Laboratory results can reveal anemia (low red blood cell count in the blood), lowered white blood cells, pulse, blood pressure, and body temperature. The decreased temperature in extremities may cause a slight red-purple discoloration in limbs (acrocynanosis). There are two psychological questionnaires that can be administered to aid in diagnosis, called the Eating Attitudes Test (EAT) and Eating Disorders Inventory (EDI). The disadvantage of these tests is that they may produce false-positive results, which means that a test result may indicate that the test taker has anorexia, when, actually, s he does not.

Bias and Base Rates

As for epidemiological notions, examiners may be consciously or inadvertently influenced in the conclusions they draw by how they view the nature and incidence of various conditions. Those who believe that borderline personality disorder is widespread are likely to diagnose this condition more frequently than those who think this diagnostic category lacks precision and is used too frequently. Those who believe that attention-deficit hyperactivity disorder (ADHD) occurs mainly in boys, and adolescent anorexia mainly in girls, are relatively unlikely to diagnose ADHD in girls and anorexia in boys. In all such instances of possible influence derived from demographic, environmental, and epidemiological expectations, the challenge for assessment psychologists is to recognize their personal biases and prevent them as much as possible from exerting inappropriate influence on the conclusions and recommendations they derive from their assessment data. On the other hand, the previous examples...

Volume Preface

Eating disorders were classified as a disorder of childhood and adolescence in earlier diagnostic nomenclatures, but it is now recognized that eating disorders can have an onset into young adulthood. Eating disorders have been recognized since the beginning of medicine and are among the more frequently diagnosed and treated mental disorders. Howard Steiger, Kenneth R. Bruce, and Mimi Isra l include within their chapter not only the well established disorders of anorexia nervosa and bulimia nervosa but also the burgeoning literature on binge eating disorder. They provide a compelling integrated conceptualization for these disorders that considers developmental, cognitive, social, dynamic, and neurophysiological contributions to their etiology and pathology.

Future Directions

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).

Palliative Surgery

The role of surgery in palliating symptoms of gastric cancer has declined in recent years as the results of nonsurgical treatments have improved. The main problem symptoms in patients with advanced gastric cancer are pain, vomiting, bleeding, and anorexia. Gastrectomy will not correct anorexia, but it can deal with the other three symptoms on occasion. Intractable pain from gastric cancer is relatively rare, and often associated with very widespread unresectable disease. Operation should therefore only be undertaken when there is good evidence that a resection is feasible and nonsurgical measures have failed to relieve the pain. Chronic hemorrhage from gastric cancer commonly leads to anemia, which can often be dealt with by top-up transfusions. As the life expectancy of these patients is extremely limited, surgery is often not required. Persistent vomiting from gastric cancer commonly arises either from pyloric stenosis, paralysis of the gastric tube due to widespread infiltration,...

Other Applications

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...


History of the Present Illness Quantify the amount of blood, acuteness of onset, color (bright red, dark), character (coffee grounds, clots) dyspnea, chest pain (left or right), fever, chills past bronchoscopies, exposure to tuberculosis hematuria, weight loss, anorexia, hoarseness.


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).

Binge eating

While binge eating is a symptom of bulimia nervosa, it differs from this disorder in that behaviors intended to get rid of the food (fasting, excessive exercise, or using laxatives or inducing vomiting to purge the food from the system) are present among those with bulimia, but are generally absent among binge eaters. Binge eating may also occur in anorexia nervosa. The clinician's diagnostic handbook, the Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revised, published in 2000) subsumes binge eating under the diagnosis of eating disorders not otherwise specified. Binge eating disorder is, however, under consideration as a separate diagnostic category, pending further study. While people who binge eat are clearly at high risk for becoming overweight, there are important differences between simple obesity and binge eating. People who binge eat are far more likely to report significant mood problems, especially depression, and to report greater...


Liver toxicity occurs usually early during therapy (within 18 weeks of starting). If liver enzymes increase to > 5x upper limit of normal (ULN) during treatment, nevi-rapine 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, nausea, jaundice, etc.) occurs, nevirapine must be stopped immediately and never readminis-tered.


The diagnosis of bulimia nervosa is made on the ia basis of a physical examination, a psychiatric assess- n ment, the patient's eating history, and the findings of lab- v oratory studies. Patients who do not meet the full criteria S for bulimia nervosa may be given the diagnosis of sub-syndromal bulimia or of eating disorder not otherwise specified (EDNOS). Patients suspected of having bulimia nervosa should be given a complete physical examination because the disorder has so many potential medical complications. In addition, most bulimics are close to normal weight or only slightly overweight, and so do not look outwardly different from most people of their sex in their age group. The examination should include not only vital signs and an assessment of the patient's height and weight relative to age, but also checking for such signs of bulimia as general hair loss, abdominal soreness, swelling of the parotid glands, telltale scars on the back of the hand, petechiae, edema, and teeth...

Masked depression

The classic affective features of depression are masked by a complex of somatic complaints. Such symptoms include fatigue anorexia weight loss menstrual changes unusual sensations in the abdomen, chest or head bodily aches and pain dry mouth and difficulty in breathing. If depression is not considered many fruitless, expensive and distressing investigations may be performed. According to Davies, 2 nearly half of patients with depressive illness report to the doctor with complaints that suggest physical illness. The family doctor has to suspect masked depression in a patient with a multitude of physical complaints or with complaints that do not fit any definite pattern of organic disease.

Figure 61

Muscle Cells

The recent discovery of the leptin (ob) gene, which encodes a fat-specific mRNA and leptin, has given some insight into the mechanism of energy homeostasis. Human leptin gene expression occurs in mature adipocytes and is highly regulated. Studies of obese individuals show that levels of leptin mRNA in adipose tissue as well as serum levels of leptin are elevated in all types of obesity, regardless of whether it is caused by genetic factors, hypothalamic lesions, or increased efficiency of food utilization. Studies of individuals who have lost weight and those with anorexia nervosa show that leptin mRNA levels in their adipose tissue and serum levels of leptin are significantly reduced. In experimental animal models, the addition of recombinant leptin to obese, leptin-deficient ob ob mice causes them to reduce their food intake and lose about 30 of their total body weight after 2 weeks of treatment.

Case Example Joyce

Joyce is a 38-year-old woman who has been married for 8 years. She presents with a long, intermittent history of bulimia and other features consistent with obsessive-compulsive spectrum disorder. Her bulimic symptoms responded rather readily to an exposure-based cognitive behavioral treatment strategy. Over the course of therapy she gradually was able both to cease purging and to expose herself to foods she had previously restricted and to situations she had avoided.


History of the Present Illness Rate of onset, duration, frequency. Volume of stool output (number of stools per day), watery stools fever. Abdominal cramps, bloating, flatulence, tenesmus (painful urge to defecate), anorexia, nausea, vomiting, bloating myalgias, arthralgias, weight loss.

Matrimonial Disputes

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).


Desipramine is known principally as an antidepressant drug used to promote recovery of depressed patients. It also has therapeutic uses in panic disorder, pain management, attention-deficit hyperactivity disorder (ADHD), sleep attacks (narcolepsy and cataplexy), binge eating (bulimia), and in cocaine craving in the treatment of addiction.

Stress Illness

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.


History of the Present Illness Constant, dull, boring, mid-epigastric or left upper quadrant pain radiation to the mid-back exacerbated by supine position, relieved by sitting with knees drawn up nausea, vomiting, low-grade fever, rigors, jaundice, anorexia, dyspnea elevated amylase.


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

Thyroid Hormone

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.

Ovarian cancer

Ovarian cancer has the highest mortality rate of all the gynaecological cancers because the majority of patients present in the late stage of the disease. It is usually asymptomatic prior to the development of metastases. Epithelial tumours are the most common of malignant ovarian tumours. They are uncommon under 40 years of age and the average age of diagnosis is 50 years. 3 The most common presentation is abdominal swelling (mass and or ascites). Non-specific symptoms, which may be present for a long time before diagnosis, include abnormal uterine bleeding, weight loss, abdominal discomfort, reduced capacity for food, anorexia, nausea and vomiting.

Dual diagnosis

Dual diagnosis is a term that refers to patients who have both a mental health disorder and substance use disorder. It may be used interchangeably with co-occurring disorders or comorbidity. According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), an estimated 10 million people in the United States will have a combination of at least one mental health and one substance abuse disorder in any twelve-month period. Substance abuse is the most common and significant co-occurring disorder among adults with such severe mental illnesses as schizophrenia or bipolar disorder. It may also be observed in individuals with mental health diagnoses that include depression, anxiety, post-traumatic stress disorder, or eating disorders. The term substance abuse refers to substance use disorders that range along a continuum from abuse to dependence or addiction. Abuse of alcohol or other drugs may occur in persons with eating disorders in an effort to deal with guilt,...

Short Term Toxicity

Mucositis is often severe, requiring narcotic analgesics and intravenous alimentation. This is especially the case after thioTEPA-containing regimens and in patients with prior spinal irradiation. Patients receiving thioTEPA may also develop generalized skin erythema and desquamation, secondary to the excretion of thioTEPA in sweat. Acute neurological dysfunction, including hallucinations, coma, seizures, headaches, ataxia-tremor-dysarthria syndrome, anorexia, and nausea syndrome are reported in

Postnatal depression

Clinical features are not distinct from other depressive illnesses, and may include depression of mood, anxiety, panic attacks, fatigue, loss of libido, anorexia, and insomnia. Some of these symptoms are difficult to distinguish from the inevitable changes in sleep, eating pattern, and sexual function brought about by giving birth and caring for a child. Thoughts of hating or wishing to harm the baby are common, and should always sensitively be asked about the mother will feel very guilty about any thoughts of this kind, and may be much helped by talking about them, and understanding that she is not alone in experiencing them. Actual harming of the baby is rare unless the mother is psychotic. The illness may last for months or years, especially if, as is often the case, it goes undetected and untreated. This chronic ill health in the mother is believed to hinder cognitive and emotional development in the child.


Anorexia nervosa, as categorized by the DSM-IV, is relatively uncommon, affecting 0.5-1 of adolescent and young adult women (8,9), although a much larger percentage experience subthreshold symptoms. Approximately 10 of patients with anorexia nervosa are male (9). There is some evidence that the incidence of anorexia nervosa is increasing among adolescents, but not among adults (10,11). Although most individuals with anorexia nervosa are adolescents or young adults, onset has been reported in prepubertal children and postmen-opausal women (12). It is more common in industrialized societies where food is plentiful and thinness is valued, but anorexia nervosa is found in individuals from all cultures and social strata (13,14). The prevalence of bulimia nervosa has been estimated at 1-3 of high school and college-age women (8,9), although a much greater percentage engage in bulimic behaviors, such as binge eating and or purging, that are not of sufficient frequency or duration to meet...

Mental Disorders

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).

Sexual Abuse

The contribution of sexual abuse to the development of eating disorders remains controversial. While some authors have cited sexual abuse as a major causal factor in eating disorders (66), others have found that the prevalence of sexual abuse is no greater in eating disordered patients than in patients being treated for other psychiatric disorders (67). It has been suggested that some types of sexual abuse, such as earlier and more persistent abuse, may predispose to eating disorders (68), and that it is binge eating, rather than dietary restriction, that is associated with sexual abuse (69,70). Although sexual abuse may play a direct role in the development of eating disorders for some patients, it appears to be a risk factor for psychiatric disorders in general, rather than specific for eating disorders (68).


Addiction has been postulated to play a role in disordered eating, with some individuals addicted to certain foods or combinations of foods. Although substance abuse and other impulse control disorders are associated with binge eating in some studies, there is no evidence that ''addiction'' to foods such as refined flour, simple sugars, or carbohydrates occurs or triggers binge episodes (71). An interesting finding, however, is that both lean and obese female binge eaters, women with binge eating disorder, who prefer to binge on foods that are both sweet and high in fat, may decrease their intake of these foods selectively when given naloxone (72). The role of h-endorphins and other endogenous opioids in the development or maintenance of binge eating, while unknown, is intriguing.


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.

Case report

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

Mesenteric adenitis

This presents a difficult problem in differential diagnosis with acute appendicitis because the history can be very similar. At times the distinction may be almost impossible. In general, with mesenteric adenitis localisation of pain and tenderness is not as definite, rigidity is less of a feature, the temperature is higher, and anorexia, nausea and vomiting are also lesser features. The illness lasts about five days followed by a rapid recovery. Comparisons between the two are presented in Table 30.5 but if in any doubt it is advisable to consider the problem as acute appendicitis and perhaps proceed to laparotomy. Anorexia, nausea, vomiting

Cat Scratch Disease

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).


Randomized, controlled trials have shown that CBT is effective in mild to moderate depression (Butler et al., 2006). Other trials have shown it to be effective for anxiety disorders (Bisson, 2006 Gale and Browne, 2006 Kumar and Browne, 2006), bulimia nervosa (Hay and Bacaltchuk, 2006), and possibly somatoform disorders, and even psychotic disorders. As well as treating an index episode, this therapy may have prophylactic value in preventing future episodes (secondary prevention).