ASEPTIC

1. Appearance and Behavior

2. Speech

3. Emotion (mood and affect); Perception

4. Thought content and process

5. Insight and Judgement

6. Cognition

-patient is able to open eyes, look at you, responds fully and appropriately 

-part of Level of Conciousness

-drowsy, but can open eyes, look at examiner and respond.  Falls back to sleep easily

-part of Level of Conciousness

-opens eyes when commanded to and looks at you, offers confused responses, has lack of interest in the environment

-part of level of conciousness

-Wakens only with painful stimuli.  Verbal responses slow or absent.  Falls back into unresponsive state when stimuli ceases

-part of level of conciousness

-unarousable to any stimuli

-part of level of conciousness

•What is your name?

•What is the day or date?

•Where are we now?

Orientation is assessed by asking the pt to describe the day, date, year, time, place where he or she is currently residing, his or her name and identity, and why he or she is in the hospital (clinic)

If oriented to time, place and person, write Ox3. If alert also, write A and Ox3.

If patient only gets 1 or 2 correct, document “Pt. oriented to person and place, not time”

-talkative or silent?  Does the pt speak spontaneously or only when directly questioned? 

-part of speech and language

-Too fast, too slow, just right?

-part of speech and language

-too loud, too quiet, just right?

-part of speech and language

-can you understand what the patient is saying physically?  If not, why not?

-part of speech and language

 -Is the rate, flow, melody and content of speech within normal limits?  If not, suspect an aphasia.

F is WWRRoNg- look for word comprehension, repetition, naming, reading and writing

-part of speech and language

– receptive aphasia – pts with fluent but non-sensical speech, impaired word comprehension, repetition, naming, ability to read, ability to write (location of lesion is posterior superior temporal lobe)

"Wordys aphasia" (Wernicke's aphasia- wordy, but making no sense (jibberish)) 

– expressive aphasia – slow speech, hard to speak, but what they get out makes sense.   Word comprehension is intact and they may be able to nod or shake their head appropriately.  Repetition is impaired. Reading is fair to good, writing is often impaired.  Location of lesion is posterior inferior frontal lobe.

"Broken aphasia" (Broca's aphasia-broken speech; know what to say but can’t say it) 

When pronounce “WERnicke” mouth is open so you are able to express. So, the defect is in comprehension (sensory aphasia)

When pronounce “Broca” mouth stays closed with the B, so it’s inability to express verbally (a motor aphasia)

Ask pt to follow one or two step command.

-Part of Speech Fluency

Ask the pt to repeat “No ifs, ands or buts”

-part of speech fluency

-ask the patient to name the parts of a watch

-part of speech fluency

ask the pt. to read a paragraph out loud

-part of speech fluency

-ask the pt to write a sentence

-part of speech fluency

The external expression of emotion visible to the clinician (Provider’s observation)

•Are the pts responses  and body language devoid of emotion? (Depression)

•Are their responses hyper-emotional? Manic

•Do they pts responses change dramatically through the interview? Labile – rapid-cycling bipolar or schizophrenia

•Are the responses appropriate to the patient’s situation or what they are saying? intoxication, schizophrenia, organic brain disease

•Does the pt have poor eye contact? (can be cultural/female)

To assess mood, you need to ask the patients how they are feeling (It’s what the pt says)

•“How are your spirits these days?”

•Labile (changes quickly/cycling) mood?

•Intensity of mood?

•Is the patient suicidal?

•Is the mood appropriate to the patient’s situation?

Assess the logic, relevance, organization and coherence of the patient’s thought processes.  Look for the following abnormalities of thought:Derailment or loose associations, Tangentiality, Pressured speech, Incoherence, Circumstantiality, Distractable speech, Perseveration, Clanging, Confabulation

Derailment or loose associations

      one topic to another without clear correlation and pt not realizing are unrelated

-part of thought process

Tangentiality

only partially relevant or irrelevant responses

-part of thought process

     -quickly, long answers, not finish one thought before starting another

-part of thought process

 -makes no sense at all (word salad)

-part of though process

-is rare, but when it does occur is often inschizophrenia

-delayed in reaching goal bc unnecessary detail, components properly related

-part of thought process

-seen in OCD

 – changes subject in response to something unrelated in environment

-part of thought process

 – persistent repetition of words or ideas

-part of thought process

 – words chosen based on sound they make (rhyming) not meaning

-part of though process

seen in schizophrenia

 – fabrication of facts to fill in gaps of memory

-part of thought process

-in dementia and alcoholism

– recurrent, uncontrollable thoughts or images that are unwanted and unpleasant

-part of thought content

 – repetitive behaviors or mental acts pt feels driven to perform for relief or prevent future consequences

-part of thought content

– false, fixed personal beliefs not shared by others in community

o   Persecution (paranoia), grandiosity, delusion of being controlled externally, somatic delusions (something is stuck on arm; or having HIV) , jealousy

-part of thought content

 – persistent irrational fears accompanied by desire to avoid stimulus 

-part of thought content

·      Feelings of unreality – a sense that things in the environment are unreal, strange, or remote

-part of thought content

-(mind and body detached from the world)

·      Feelings of depersonalization – a sense that the inner self has become detached from the mind or body

-part of thought content

-Mind detached from the body

·      Anxiety – fears, tensions, or uneasiness that may be focused or free-floating

-part of thought content

·      Poverty of thought/ Alogia – no depth, minimal responses, very concrete (vs. abstract)

-part of thought content

•Illusions – misperception of real external stimuli (e.g.PTSD)

-part of perception

An example of an illusion might be that someone thinks they hear their dead mother’s voice, when in reality a sister or aunt is speaking.   Or a veteran may hear a car backfire and think he is in a battle situation again.  This is common in grief, delirium, PTSD

·      Hallucinations – false perceptions.  Pt hears smells or feels something others cannot (visual, auditory, tactile, olfactory)

-part of perception

·      Delusion or Hallucination?

·                  1. A voice is telling you someone is planning to hurt you

·                  2. You are fearful of the coat-rack on entering the clinic

·                  3. Sensation that bugs are crawling all over your skin

·                  4. Belief that you smell so bad that no one wants to be around you

·                  1. A voice is telling you someone is planning to hurt you- Hall

·                  2. You are fearful of the coat-rack on entering the clinic- Delusion

·                  3. Sensation that bugs are crawling all over your skin- Hall

·                  4. Belief that you smell so bad that no one wants to be around you- Delusion

Affective blunting – limited range of expression

-part of behavior

Rigidity – resists movement

-part of behavior

Waxy flexibility – maintains a posture once placed there

-part of behavior

Inappropriate affect – the patient’s expression does not match the situation, e.g. laughing while speaking of a sad subject

-part of behavior 

Physical anergia/ psychomotor retardation – limited physical movement

-part of behavior

   – can patient learn something new and repeat it back

o   3 words

-aspect of memory

·      Recent memory – correctly remember things that happened today (ask 5 mins later)

·      Remote memory – remember things that happened a long time ago

-part of memory testing

·      Attention – focus enough to be able to perform tasks

o   Serial sevens, spell world backwards

-part of cognition

·      Information and vocabulary – apparent intelligence by degree to which are informed, vocabulary

- part of cognition test

·      Abstract thinking

o   Proverbs – interpret a commonly used proverb

o   Similarities – tell how two things are alike

§  Judgment – ability to evaluate a situation and form an appropriate response

·      Propose solution to current situation

·      Propose solution to hypothetical situation – stamped and addressed envelope

§  Insight – ability to understand and acknowledge illness or situation

o   Axis I: Syndrome

§  Major domains – psychotic, cognitive, affective, anxiety, substance related,

§  Somatoform, paraphilias, sleep disorders, impulse control disorders, dissociative disorders

·      Childhood vs. adult

·      Abnormal vs. normal based on functional impairment

§  Limited hierarchies of exclusion: can rule IN by further history; rarely rule OUT; comobird dz common thus “Consider also”

§  Memorizing criteria is not enough

§  Categorical (abnormal vs normal) not dimensional

o   Axis II: Personality Disorders, Mental Retardation

§  Fixed, maladaptive qualities rather than problems acquired by otherwise “normal” people  (acquired early in life and persist)

§  Categorical (abnormal vs normal) not dimensional

o   Axis III: Medical Conditions

§  Recognition of secondary disorders

§  May limit treatment/affect outcome

§  PMH may be related psychologically or pathophysiologically

o   Axis IV: Stressors

§  Psychological factors, causal

§  May complicate/constrain treatment

o   Axis V: Global Assessment of Function

§  Quantitative

§  If in hospital almost always <50

·      Describe some of the of the advantages and disadvantages of the DSM approach

o   Advantages: helps to recognize common things and consult literature (improved reliability of diagnosis; clarified the diagnostic process and facilitated history taking; clarified and facilitated the process of differential diagnosis)

o   Disadvantages: doesn’t tell motivation, genes, role, environmental role, personal factors, quality of thinking, meaning pt attaches to symptoms, resources/strengths (the increased precision sometimes gives clinicians and researchers a false sense of certainty about what they are doing; may sacrifice validity for reliability; encourage clinicians to treat diagnosis as no more than a checklist and forget about the pt as a person)

o   DSM IV assumptioms: Same syndrome may have many causes. Different causes may produce similar syndromes; High reliability, variable validity; A valid diagnostic scheme would relate symptoms and behaviors to : Neurological pathways, Etiology, Genetics

o   Assessment Beyond Diagnosis:

o   Risk (danger to self or others)

o   Psychosocial (formulation of causes, pathways, significance, resources as well as deficits)- describe though process

o   DSM is a starting point, not an end

o   This course teaches both diagnosis and formulation which bridges biology, psychology and culture/environment

·      Discuss concepts of evolutionary biology used to validate the dimensions of psychiatric disorders

o   Depression is an adaptive strategy to elicit nurturing behavior from other members of your species

·      Evolutionary Biopsychosocial Formulation:

·      Separates fixed and malleable elements

·      Biological psychological and social elements all may be fixed or modifiable

·      Interactive, dynamic

·       

o   Biological influence – neurobiology, function, structure, genetics, infectious influences

§  Interaction of multiple genes with environmental factors

§  No gene is equivalent to fate for mental illness

§  Stressful life situations cause depression in some people who are prone

§  Infectious influences – HIV/AIDS, schizophrenia from exposure to infectious agents in utero

o   Psychosocial influence – psychodynamic theories, behaviorism and social learning theory, family, culture

§  Psychodynamic theories

·      Freud – behavior is the product of underlying conflicts

·      Unconscious mental processes – ex. Defense mechanisms

·      Role of past experiences

·      Object relations and self psychology

·      Behaviorism and social learning

o   Classical conditioning – pairing a neutral (conditioned) stimulus with one that evokes a response (unconditioned stimulus) such that the neutral stimulus eventually comes to evoke the response

o   Operant conditioning – learning occurs as a consequence of action; behavior is reinforced or rewarded

·      Culture – socioeconomic status, cultural identity, idioms of distress, ethnopsychopharmacology 

·      List the common symptoms of depression.

·       

o   SIG E CAPS

o   Sleep disorder – insomnia as an iatrogenic (things that make pt come to you) cause, rumination (mind won’t shut down), different from other causes of insomnia by asking about other depressive symptoms

o   Interest deficit (anhedonia) – feeling down? No feelings? Sad? Irritable?

§  May initially complain of physical problems

§  Loss of interest in “usual activities” (ask what are)

o   Guilt – feeling overly responsible for current or past errors; misinterpreting trivial or neutral events as personal failures; feelings of worthlessness; may be delusional

o   Energy deficit – fatigue without exertion (“can’t get out of bed", small tasks require excessive effort, reduced efficiency

o   Concentration deficit – easily distracted (Distractibility) ; memory problems; difficulty making decisions; difficulty performing complex tasks that require focused attention (serial 7s)

o   Appetite disorder – generally decreased interest in food; may have increased appetite and food cravings (sweets and carbs); significant weight loss or gain

o   Psychomotor retardation/agitation – agitation, inability to sit still; slowed movement and/or speech; changes in vocal volume, inflection, quantity or variety of content

o   Suicidality

·      Describe the depressive syndromes defined by the DSM

o   Major depressive disorder – for at least 2 weeks (or more) at least 5 depressive symptoms are present one of which is either depressed mood or loss of interest/pleasure; (ask them about things they used to be interested in e.g. sex, recreational activities); Can diagnose major depressive disorder with one major depressive episode

(NOT on Notes: “Major depression”  connotes syndrome of mood, ideation, vegetative signs and behaviors which are dimensions of disorder reflecting different brain/environmental determinants)

§  Along with 3-4 (nearly daily):

·      Significant weight loss without dieting

·      Insomnia or hypersomnia

·      Psychomotor agitation or retardation

·      Feelings of worthlessness or guilt

·      Decreased concentration

·      Recurrent thoughts of death or suicide

§  Symptoms do not meet criteria for a mixed episode (when both depresion and Mania are occurring at same time)

-(ALWAYS ask Pt about MANIC episode e.g. felt had a lot of energy that couldn’t sleep at all)

§  Symptoms cause significant impairment in social, occupational or other important functions

§  Symptoms are not due to a substance (can’t really diagnose if SA b/c it’s mixed in)

§  Symptoms not better explained by bereavement (Not diagnosed if major life event e.g. death)

§  Stressful Life Events (SLEs) and Major Depression:

§  SLEs precede the onset of major depression more frequently than expected by chance.  This relationship is probably causal.

§  However, humans display wide variation in response to adversity.

§  Some individuals are stress-sensitive and prone to depression in response to modest stressors, while others are stress-      resistant, remaining symptom free after adversity.

§  Gene x Environment Interaction: Serotonin Transporter Gene and SLEs

§  Serotonin is a neurotransmitter implicated in the pathogenesis of depression.

§  The serotonin transporter (5-HTT) gene codes for the protein in neurons that recycles serotonin after it has been       secreted into the synapse.

§  Since the most widely prescribed class of antidepressants act by blocking this transporter protein, the gene has been a       prime suspect in mood and anxiety disorders.

§  Serotonin Transporter Gene and SLEs

§  Caspi et al (2003): People with a genetic vulnerability to stress are more than twice as likely to develop depression       after a traumatic event as those with a version of the same gene that appears to confer protection.

§  Study has been replicated by Kendler et al (2005): Variation at the 5-HTT moderates the sensitivity of individuals to the       depressogenic effects of even mild SLEs

o   Major depressive episode – same as MDD except symptoms must just be present for a two week period.  Recurrent with 2 month symptom free period between MDEs. 

o   Dysthymic disorder – depressed mood most days for 2 yrs (1 for children and adolescents, may be irritable rather than depressed)- not quite major depressive episode

§  Two or more:

·      Poor appetite or overeating

·      Insomnia or hypersomnia

·      Low energy or fatigue

·      Low self-esteem

·      Poor concentration

·      Feelings of hopelessness

§  No two month period within the two years without these symptoms and no MDD

·      Describe the interplay of risk factors for depression.

o   Genetics – 10% risk for first degree relatives

o   Stress – ex. Poverty, unemployment, divorce, marital adversity

o   No racial or ethnic variation

o   Female:male ratio of 2:1

o   More common in men over age 55

o   Higher in elderly (especially if have physical problems)

-personal or family history of depression

o   Multiple medical problems – especially if life threatening/debilitating

o   Unexplained physical complaints

o   Chronic pain

o   Overutilization of medical services

Contributory Factors

Older age

Comorbidities

o   Social isolation

o   Drug/alcohol misuse

o   Other psychiatric diagnoses 

·      Evaluate a potentially suicidal patient for risk factors, thoughts, plans, intent, support, and comorbidity

8th most common cause of death among adults, second leading cause ages 15-24 in the U.S., 1% of the U.S. population commits suicide

o   Rate for men peaks at age 75, for women in 40s and 50s

o   Less common among married (support)

o   10-15% of those who have been hospitalized for depression commit suicide

o   If there is a plan, immediately hospitalize 

-suicide is psychiatric EMERGENCY

·      Describe the epidemiology, medical relevance of anxiety

·       

o   Perception – travels from periphery to frontal cortex

o   Evaluation – subcortical structures (amygdale, hippocampus)

o   Reaction – brain centers that regulate motor and autonomic activity (hypothalamus, locus ceruleus)

§  Cortical interneurons

§  Neural networks linking central structures

§  Critical peripheral organs: heart, lungs, muscle, adrenal glands

o   Paroxysmal anxiety – SNS activation, PNS deactivation, cortisol production, regulation by serotonin

o   Persistant anxiety – low grade SNS elevation (c. low cortisol), cortical interneurons GABA/glutamate activity

o   Fight/flight response – mobilize lipids, stimulate then inhibit urination/defecation, raise pain threshold, enhance immune activity, inhibit insulin activity

o   Termination of anxiety – cortisol reduces central NE, negative auto feedback, modulated by GABA and serotonin, cortical modulation (thought/defenses)

§  Pathological anxiety often due to hypersensitivity, hyper-reactivity or undue persistence of anxiety, failure of timely inhibition

·      Describe the common elements of all anxiety disorders (pathophysiology)

o   Anticipation – of danger (cognitive process)

o   Arousal- physiological response

o   Avoidance – motor behavioral

o   Panic Disorder –

Not just panic attacks; Requires FEAR of attack and AVOIDANCE of places where the attack might occur

-can explain to pt that the rxn is to protect them from danger 

-resembles heart attack (requires medical attention)

-3As: Anticipation (Expect to be attacked or embarrased);Arousal (Heart attack symptoms);Avoidance of fear cause

uncued panic, catastrophic interpretationofphysical sensation, anticipation and agoraphobic avoidance

§  Rely on full symptom picture, demographics, family history

§  Agoraphobic avoidance and relational behavior

§  Panic and depression together malignant suicide predictor!!

§  DSM IV criteria – PAGE 169-171

o   Social Phobia –

-3As: Anticipation (expect humiliation, scorn, scrutiny; dread of encounter);Arousal (Panic plus blushing; tremor is most common; same as panic attacks); Avoidance (isolation from desired relationship, inhibition of ambition)

-most common anxiety disorder besides simple phobia; very common in medical training

-at high risk of developing alcohol abuse

-Risk Factor: being criticized heavily during development; being rejected or not having a peer group

-panic and blushing, expectationof humiliation or hurt, yearning and social isolation

§  Sensitizing social experiences

§  Discipline through humiliation

§  Rejection by peers

§  Disfigurement

§  Interpersonal victimization or trauma

§  More common in men than women (may just seek treatment more)

§  Risk factor for alcohol abuse

§  DSM IV criteria – PAGE 182

-Acute Stress Disorder (ASD); requires trauma (threatening event that evokes fear, helplessness and horror; can involve SELF or OTHERS; usually sudden

-Risk factor: TRAUMA

--seen in combat, rape, natural disasters, accidents

-3A’s: Anticipation: Intrusions in nightmares, flashbacks, forced recollection aka don’t  want t think about it; Persistent Arousal (sleep disorder, startle, irritability, poor concentration, hypervigilance); Avoidance (numbing, forgetting, isolation, loss of future orientation, loss of interest aka apathetic)

-NON Criteria Symptoms:

H/A, teeth grinding, back pain; nausea, anorexia, gas, diarrhea, constipation (IBS); Abdominal pain; Chest pain or pressure; MUPS – multiple unexplained physical symptoms

o   PTSD

§  Triad of intrusive (worry/think about), numbing, and arousal symptoms

§  Symptoms often less patterned

·      MUPS – multiple unexplained physical symptoms

§  Inquire about stress and trauma especially if functional symptoms

§  Specific symptom inquiry – nightmares, forced recollection, amnesia, distance, loss of future orientation, startling, irritability, disrupted sleep

§  DSM IV criteria – PAGE 194-5

o   Generalized Anxiety Disorder

-3A’s: Anticipation/appraisal (EVERYTHING including health, money, appearance, rejection); Persistent Arousal (increased muscle tension, heart rate, H/A, backache, IBS, HTN, mobilize triglyceride); Avoidance (inhibition of curiosity, social activity)

Risks:

-Most common in older adults

-Common in diabetics

§  Persistent arousal – tension, disrupted sleep, appetite and GI disturbance, aches and pains, sighing, jumipness

§  Promiscuous worry – everything is threatening, catastrophic interpretations

§  Negative expectations

§  Helplessness

§  High comorbidity with depression

§  Panic not prominent

§  May be constitutional or post traumatic

§  More common in women

§  DSM IV criteria – PAGE 178

3A’s:

Anticipation (Intrusion by obsessions of esp contamination, danger, offending those in power b/c think they’ll do something sexual, violent or blaspheme)

Arousal (triggered by obsessions)

-Avoidance (compulsive, ritualistic neutralizing behaviors such as washing, counting, checking, praying)

-Risk:

Strong genetic influence in early onset patients; Male>Female; OC symptoms also occur in depression, psychosis, Tourett’s disorder

§  DSM IV criteria – PAGE 187

·      Describe the rational for treatment approaches to anxiety disorders

Treatment:

-CBT and Drugs & EXPOSURE

-CBT educations to control arousal (breathing, meditation, exercise), control threat and problem solving; Group support; Spirituality

-Drugs: antidepressentant (SSRIs and MAOIs)

-EXPOSURE

o   Panic Disorder, Social Phobia, PTSD

§  Education, reinterpretation of phenomena as understandable

§  Demonstration of competence to help

§  Psychotherapy – cognitive or modified psychodynamic

§  Medications – regulate SNS (antidepressants, blockers)

§  Exposure – facilitate relearning of inhibitory responses

o   Generalized anxiety disorder

§  Medications: target interneurons or rheostats rather than specific pathways

§  Enhance sense of control, confront catastrophic thinking, extend range of function

§  Psychotherapy and support

 -UNCONCIOUS Bodily distress without organ pathology (physiological); Overfocus on physical experience, medical care seeking and may recognize role of stress or emotion, but discount it (Psychological) UNCONCIOUS

-It’s hard to classify b/c they are based on “ruling out” diseases; leaves pt in limo with overreliance on “rule out” strategies that are expensive and cause real damage

-Epi and Risk:

More in Women; may be estrogen/progesterone modulated; prejudicial of women as  medical care seekers; it’s RARE

-Criteria:Hx of many physical complaints before age 30 resulting in looking for medical treatment or significant impairment in social, occupation; At least 8 unexplained symptoms including four pain, 2 GI, 1 sexual, 1 pseudoneurological; CANNOT be explained by a know medical condition; are NOT intentionally made up

o   Somatization disorder

§  Multiple complaints in multiple organ systems beginning early in life with no demonstrable, adequate medical causes

§  Presumed result of abnormal learning, genetic predisposition

§  Hard to confirm in medical setting

-type of somatoform disorder

-Affects voluntary motor or sensory function that suggest a neurological or general medical condition (NOT PAIN); it is not made up; preceded by stressors; cannot by medically explained; may coexist with neuropathology esp pseudoseizures

-sedative interview or hypnosis

o   Conversion disorder

§  Focal symptoms resolving unconscious conflict

§  Classically: neurological symptoms that violate known anatomy (gait, paralysis, sensory symptoms, pain, pseudoseizures, globus hystericus)

§  Actual and symbolic link to identifiable stress

§  Relieved by hypnosis or insight

§  Often misapplied as diagnosis of exclusion

-type of somatoform disorder

-CONSCIOUS Intentional production (feigning) of physical or psychological symptoms. Have no external incentive (economic gain); motivated by UNCONSCIOUS desire to play sick role

§  “Munchhausen’s syndrome” 

-focus of ATTENTION or TREATMENT; NOT a MENTAL ILLNESS

o   Factitious disorder

§  Self inflicted for “primary” (unconscious) gain

§  Health care professionals

§  Rarely by proxy

o   Malingering

-CONSCIOUS production of symptoms due to CONCIOUS motivation (compensation)

§  Common in military and prison populations, antisocial Personality Disorder, plaintiffs

-focus of ATTENTION or TREATMENT; NOT a MENTAL ILLNESS

§  Feigned illness for “secondary” (conscious) gain

§  Escape, disarm aggression, prevent abandonment, elicit care, compensation, drug seeking

§  Common in military and prison populations

§  Often very antisocial

§  Regulation is psychological and physical

§  Look for physiological developmental and psychological commonalities between various patterns of symptoms expression

-Mispercetion of a body part as disfigured; constant preocupation (acknowled her concerns are exaggerated); Can be included in anorexic/bulimic differential

-type of somatoform disorder

-Pain in the absence of injury; pain grossly in excess of expected from dz; pain in one or more anatomical sites is the predominant focus and is severe enough to seek medical attention

-type of somatoform disorder

·      Define personality disorders

PD’s like personality DON’T CHANGE

-Divides into normal and abnormal (unlike AXIS I which divides by dz state)

o   An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable overtime, and leads to distress and impairment.

o   Characteristics: inflexible and pervasive, maladaptive, stable over time, causes distress or impairs fxn, not accounted as consequence of another mental disorder, not due to direct physiological effects of substance (drug, alcohol, meds), egosyntonic (consistent with one's ideal self-image), distresses friends/family

o   Pattern is manifested in two or more of the following areas:

§  Cognition- Think

§  Affectivity- Feel

§  Interpersonal functioning- Interact

§  Impulse control- Act

o   Coded on Axis II

·      Describe the various etiologic factors involved in personality disorders

-Cause is UNKNOWN, but

-Influences include:

1. Developmental- early life events (e.g. child abuse/maltreatment- borderline & antisocial PD)

2. Genetic- schizophrenia related to schizotypal; 

3. Neurobiological- abnormal brain structure and function associated with borderline and antisocial PD)

4. Cultural-high family cohesion in China, Jewish decreases risk for antisocial

o   Some personality disorders may reflect disease

o   Variability in personalities has advantages for species

o   Genetic behavioral traits – aggressiveness, altruism, assertiveness, constraint, empathy, harm avoidance, impulsivity, leadership, nurturance, persistence, physicality, reward dependence, social closeness, sociability, traditionalism, well-being

o   Early trauma, parenting, illnesses, etc play role in development

4 MAIN Theories of Psychodynamic:

o   Defense mechanisms – (ego manages anxiety) unconscious role of the ego in managing anxiety or conflict

§  Immature (Projecting) defenses – denial, projection, acting out, splitting (More common in PD)

§  Intermediate (Not Thinking about it OR Doing more than needs to) or neurotic defenses – repression, dissociation, intellectualization, displacement, reaction formation

§  Mature defenses – altruism, humor, sublimation, anticipation

o   Transference – patient’s experience of the doctor as though he is a significant person for their past (e.g. pt sees provider as his mother)

o   Contertransference – how your interaction interacts with pt (e.g. provider has issue with being abandoned and gets sexually involved with HPD pt;  doctor’s emotional reactions to a patient may be particularly stron when dealing with PD patients

·      Describe the DSM cluster A and clinical presentations, differentiating between the disorders

·       

o   Cluster A – odd or eccentric

§  Paranoid PD –  SUSPICIOUSNESS e.g. being persecuted, military unwarranted suspiciousness and a tendency to misinterpret the actions of others as threatening or deliberately harmful, stereotype of hate group

·      < 1% lifetime risk

§  Schizoid PD –ISOLATED BUT LIKE IT (don’t suffer e.g. Computer hacker) detached from others, a restricted range of emotional expression and lack of interest in activities, stereotype of socially awkward

·      < 1% lifetime risk

·      May be prepsychotic stage of schizophrenia

§  Scizotypal PD – WEIRD RELATIONSHIPS (Schizophrenia, psychotic spectrum e.g. believing in UFO) deficits in interpersonal relationships and distortions in both cognition and perception, the clairvoyant mystic

·      2-3% lifetime risk

·      Chronic low form of psychosis

·      Describe the DSM cluster B and clinical presentations, differentiating between the disorders

o   Cluster B – Dramatic, emotional or erratic (overlap among them)

§  Narcissistic PD – MEN “I DON’T CARE; IT’S ALL ABOUT ME (e.g. Boss)” grandiosity, lack of empathy and a need for admiration, wealthy realestate tycoon who enjoys firing people

·      < 1% lifetime risk, men 3x more likely than women

§  Anitisocial PD – EXPLOITS OTHERS- DON’T Respect others’ rights (e.g. dumb criminal) guiltless, exploitative and irresponsible behavior with the hallmark being conscious deceit of others, stereotype of the cold and callus criminal

·      3% lifetime risk in males, 1% in females (90% pts are Male)

§  Histrionic PD – WOMEN DRAMATIC TO BE THE CENTER OF ATTENTION; excessive emotional expression and attention seeking behavior

·      <3% lifetimerisk

§  Borderline PD – SENSE OF SELF NOT STABLE & feel ABANDONED;pervasive instability in moods, interpersonal relationships, self-image, and behavior, often disrupts family and work life, long-term planning, and the individuals sense of self identity.  Often impulsive, risky behavior, vollitile relationships, suicidal behavior

·      2% lifetimerisk

High rate of completed suicide after many attempts

·      Describe the DSM cluster C and clinical presentations, differentiating between the disorders

o   Cluster C – anxious or fearful

§  Obsessive compulsive PD – rigidity, perfectionism, orderliness, decisiveness, interpersonal control and emotional constriction

·      1% lifetime risk; more common in males; ·      Do not usually act on obsessions. 

As opposed to OCDisorder which has INTRUSIONS, OBSESSION & RITUAL e.g. unable to shake hand

§  Avoidant PD – inhibition, introversion and anxiety in social situations (EARLY FORM OF SOCIAL PHOBIA); highly sensitive to criticism; want to have relationships

·      1% lifetime risk

§  Dependent PD – submissive behavior and excessive needs for emotional support (e.g. MARRIAGE; Culturally sensitive)

·      < 1% lifetime risk

·      Discuss neuropsychiatric and genetic factors involved in personality disorders

·       

o   Behavioral activation – tendency to imitate exploratory behavior, be curious about novel stimuli e.g. novelty seeking

§  Dopamine – reward/pleasure system

o   Behavior inhibition – harm avoidance; tendency to inhibit behavior when faced with novelty, punishment, or nonrewarded e.g.social anxiety

§  Serotonin – fight/flight system

o   Behavioral maintenance – reward dependence; tendency to be conditioned andtomaintain behaviors associated with reward and non-punisment

§  Norepinephrine – homeostasis system

-part of anxiety disorder

A discrete period of intense fear or discomfort, in which four (or more) of the following Sx developed abruptly and reached a peak within 10 minutes:

•   1.palpitations and accelerated heart rate

•   2.sweating

•   3.trembling or shaking

•   4.SOB or smothering (difficulty breathing)

• 5.Choking   

-6.Chest Discomfort or pain 

•   7.Nausea or abdominal distress

•   8.Dizzyness, unsteady feelings, or faintness

•   9.Derealization (feelings of unreality) or depersonalization (being detached from oneself)

•   10.Fear of losing control or going crazy

•   11.Fear of dying

•   12.Paresthesias (numbness or tingling sensations)

•   13.Chills or flushes

Generalized Anxiety Disorder

-part of anxiety disorder

A.  Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B.  Person finds it difficult to control the worry

C.  Anxiety and worry are associated with three (or more) of the following six Sx (w/at lease some Sx present for more days than not for the past 6 mo)

•   relentlessness or feeling keyed up or on edge

•   being easily fatigued

•   difficulty [ ] or mind going blank

•   irritability

•   m. tension

•   sleep disturbance (diff falling or staying asleep, or restless unsatisfying sleep)

D.  Focus of the anxiety and worry not confined to features of an Axis I disorder disorder and the anxiety and worry do not occur exclusively during PTSD

E.  Anxiety, worry, or physical Sx cause clinically significant distress or impairment in social, occupational, or other imp areas of functioning.

F.   Disturbance not d/t direct physiological effects of a substance or a general medical condition and does not occur during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

-Part of anxiety disorder

Social Phobia

A.  A marked and persistent fear of one or more social or performance situations in wh the person is exposed to unfamiliar people or to possible scrutiny by others.  The individual fears that he or she will act in a way (or show anxiety Sx) that will be humiliating or embarrassing.

B.  Exposure to the feared social situation almost invariably provokes anxiety, wh may take the form of a situationally bound or situationally predisposed Panic Attack.

C. The person recognizes the fear is excessive or unreasonable.

D.  The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

E.  The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic functioning), or social activities or relationships, or there is marked distress about having the phobia.

F.   In indiv under 18 yrs, the duration is at least 6 months.

G. The fear of avoidance is not d/t the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder.

H.  If a general medical condit or another mental disorder is present, the fear in Criteria A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s dz...

Specify if:

Generalized: if the fears include most social situations (also consider dx of Avoidant PD)

Obsessive-Compulsive Disorder

-part of anxiety disorder

A.  Either obsessions or compulsions:

            Obsessions are defined by:

•   recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

•   the thoughts, impulses, or images are not simply excessive worries about real-life problems

•   the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

•   person recognizes that the obsessional thoughts, impulses, or images are a product or his/her own mind (not imposed from w/out as in thought insertion)

            Compulsions are defined by:

•   repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

•   behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

B.  At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than one hour/day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D.  If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it

E.  The disturbance is not d/t the direct physiological effects of a substance or a general medical condition.

With poor insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable

Posttraumatic Stress Disorder

-part of anxiety disorder 

A.  The person has been exposed to a traumatic event in which both of the following were present:

•   the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

•   the person’s response involved intense fear, helplessness, or horror

B.  The traumatic event is persistently reexperienced in one (or more) of the following ways:

•   recurrent and intrusive distressing recollections of the event, including images, thoughts or perceptions

•   recurrent distressing dreams of the event

•   acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, incl those that occur on awakening or when intoxicated)

•   intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

•   physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), indicated by three (or more) of the following:

•   efforts to avoid thoughts, feelings, or conversations associated with the trauma

•   efforts to avoid activities, places, or people that arouse recollections of the trauma

•   inability to recall an important aspect of the trauma

•   markedly diminished interest or participation in significant activities

•   feeling of detachment or estrangement from others

•   restricted range of affect

•   sense of a foreshortened future

D.  Persistent Sx of increased arousal (not present before the trauma), as indicated by two (or more of the following):

•   difficulty falling or staying asleep

•   irritability or outbursts of anger

•   difficulty [ ]

•   hypervigilance

•   exaggerated startle response

E.  Duration of the disturbance (Sx in B, C, and D) is more than one month

F.   The disturbance causes clinically significant distress or impairment in social, occupational, or other imp areas of functioning.

Specify if:

Acute: if duration of Sx is less than 3 months

Chronic: if duration of Sx is 3 months or more

Specify if:

With Delayed Onset: if onset of Sx is at least 6 mo after the stressor

Paranoid PD:

-part of Cluster A: the ‘eccentric’ disorders

Schizoid PD:

-part of Cluster A: the ‘eccentric’ disorders

A.  A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning in early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

•   neither desires nor enjoys close relationships, including being part of a family

•   almost always chooses solitary activities

•   has little, if any, interest in having sexual experiences with another person

•   takes pleasure in few, if any, activities

•   lacks close friends or confidants other than first-degree relatives

•   appears indifferent to the praise or criticism of others

•   shows emotional coldness, detachment, or flattened affectivity

B.  Does not occur exclusively during the course of SCZ, a Mood Disorder With Psychotic Features, or another Psychotic Disorder, or a Pervasive Developmental Disorder and is not d/t the direct physiological effects of a general medical condition.

Schizotypal PD:

-part of Cluster A: the ‘eccentric’ disorders

A.  A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•   ideas of reference (excluding delusions of reference)

•   odd believes or magical thinking that influences behavior and is inconsistent with subcultural norms

•   unusual perceptual experiences, including bodily illusions

•   odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped)

•   suspiciousness or paranoid ideation

•   inappropriate or constricted affect

•   behavior or appearance that is odd, eccentric, or peculiar

•   lack of close friends or confidants other than first-degree relatives

•   excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgements about self

B. Does not occur exclusively during the course of SCZ, a Mood Disorder With Psychotic Features, another Psychotic Disorder or a Pervasive Developmental Disorder. 

Antisocial PD:

-part of Cluster B: the ‘dramatic’ disorders

A.  There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

•   failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest

•   deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure

•   impulsivity or failure to plan ahead

•   irritability and aggressiveness, as indicated by repeated physical fights or assaults

•   reckless disregard for safety of self or others

•   consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations

•   lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

B.  The individual is at least 18 yrs of age.

C. There is evidence of Conduct Disorder with onset before age 15 years.

D.  The occurrence of antisocial behavior is not exclusively during the course of SCZ or a Manic Episode.

Borderline PD:

A.  A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•   frantic efforts to avoid real or imagined abandonment

•   a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

•   identity disturbance: markedly and persistently unstable self-image or sense of self

•   impulsivity in at least two areas that are potentially self-damaging  Note: do not include suicidal or self-mutilating behavior covered in next criterion

•   recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

•   affective instability d/t a marked reactivity of mood

•   chronic feelings of emptiness

•   inappropriate, intense anger or difficulty controlling anger

•   transient, stress-related paranoid ideation or severe dissociative Sx

Histrionic PD:

-part of Cluster B: the ‘dramatic’ disorders

A.  A pervasive pattern of excessive emotionality and attention seeking, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•   is uncomfortable in situations in which he or she is not the center of attention

•   interaction with others is often characterized by inappropriate sexually seductive or provocative behavior

•   displays rapidly shifting and shallow expression of emotions

•   consistently uses physical appearance to draw attention to self

•   has a style of speech that is excessively impressionistic and lacking in detail

•   shows self-dramatization, theatricality, and exaggerated expression of emotion

•   is suggestible, i.e., easily influenced by others or circumstances

•   considers relationships to be more intimate than they actually are

Narcissistic PD:

-part of Cluster B: the ‘dramatic’ disorders

A. A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•   has a grandiose sense of self-importance

•   is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

•   believes that he or she is ‘special’ and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

•   requires excessive admiration

•   has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

•   is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

•   lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

•   is often envious of others or believes that others are envious of him or her

•   shows arrogant, haughty behaviors or attitudes

Avoidant PD:

-part of Cluster C: the ‘anxious’ disorders

A.  A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning in early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

•   avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection

•   is unwilling to get involved with people unless certain of being liked

•   shows restraint within intimate relationships because of the fear of being shamed or ridiculed

•   is preoccupied with being criticized or rejected in social situations

•   is inhibited in new interpersonal situations because of feelings of inadequacy

•   views self as socially inept, personally unappealing, or inferior to others

•   is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Dependent PD:

-part of Cluster C: the ‘anxious’ disorders

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning in early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

•   has difficulty making everyday decisions without an excessive amount of advice and reassurance from others

•   needs others to assume responsibility for most major areas of his or her life

•   has difficulty expressing disagreement with others because of fear of loss of support or approval  Note: Do not include realistic fears of retribution.

•   has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy)

•   goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant

•   feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself

•   urgently seeks another relationship as a source of care and support when a close relationship ends

•   is unrealistically preoccupied with fears of being left to take care of himself or herself

Obsessive-compulsive PD:

- part of Cluster C: the ‘anxious’ disorders

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning in early adulthood and present in a variety of contexts, as indicate by four (or more) of the following:

•   is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

•   shows perfectionism that interferes with task completion

•   is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

•   is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

•   is unable to discard worn-out or worthless objects even when they have no sentimental value

•   is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

•   adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

•   shows rigidity and stubbornness

-straight asking:

have you had thought of hurting yourself or others?

“With all the depression you've been dealing with, have you ever had the thought that you'd be better off dead?”

The answer may be dismissive but question further

“Have you had any thoughts that life is not worth living?”

Just talking with your patient helps

Counseling, various types

Medication

SSRIs (Serotonin Reuptake Inhibitor)- take a while to work

Various types with some idiosyncratic responses in patients

SEs –feeling dissociated; suicidality; insomnia or sedation; loss of libido; nausea

Note:

Be sure to rule out bipolar before treating depression with medication

Start at a low dose and increase slowly

Inform patients that the meds will take several weeks to work

If it is not working, increase the dose (rather than switching meds)

When in doubt, get a consult

-most common psychiatric disorder (normally trivial)

-Blood/injury/injection phobia is unique (noncortical response to sight of bloody things); M>F; causes fainting

-Belief one has a particular condition despited evidence to the contrary

-Fear of having a SERIOUS disease (e.g. cancer, HIV); occurs in medical students

-Role of attention

-non localized or falsely localized physical symptoms

-negative interpretations of experience

-related to past and current stress

-response to tx (antidepressants, psychotherapy that explains, alters meaning, build moral and changes behavior by EXPOSURE and exercise)

-Severe disturbance of eating behavior; due to maladaptive behavior

-3 ways to classify them:

1. Behavioral (binging, purging, food restriction)

2. Psychological (Overvalued beliefs)

3. Medical (Starvation Syndrome, Multisystem abnormalities)

Anorexia Nervosa

A. Refusal to maintain body weight at or

above a minimally normal weight for age and

height; or failure to meet expected weight gain

during growth period (the suggested guideline

≤ 85% of normal for age and height, or BMI

≤ 17.5 17.5)

B. Intense fear of gaining weight or becoming

ntense fat, even though underweight

C. Disturbance in the way in which one

MORE (than other ED) DISCUST and SHAME of binging; guilty; eat alone

OBSESSED with WEIGHT and BODY IMAGE (Don’t recognize they are thin)

Anorexia Nervosa

Anorexia Nervosa (AN)

Anorexia nervosa is deliberate and sustained weight lossdriven by a fear of weight gain, coupled with a distorted body image.

Do not confuse with anorexia, which is a general loss of appetite or disinterest in food

-Bulimia nervosa is a cyclical and recurring pattern of binge eating (uncontrolled bursts of overeating) followed by:

Guilt and inappropriate compensatory behaviors such as:

1. crash diets, vomiting, laxative and diuretic use
2. vigorous exercise and purging to compensate for the excessive caloric intake 

-Increasign in prevalence

-Higher SES and not present in poor countries

-Anorexia starts during adolescence; 76% age 11-20

-10% mortality rate; death due to suicide, electrolyte imbalance, startvation

-Comorbid with depression, anxiety and PDs

-In BULIMICS, BORDERLINE PD associated with poor tx OUTCOMES

-AN affects 0.5% of young adult females

-BN affects 1-3% of young adult females

-90% of AN and BN cases are female

-Binge eating disorder is the most prevalent eating disorder

-BED has a 3:2 male female ratio

-10 million people with eating disorders

-FOOD OBSESSION (don’t purge as much); in older 20-30s

  Compulsive eating disorder (CED), also called binge eating disorder(BED) is characterized by subjective and behavioral indicators of uncontrolled eating or bingeing. Patients: May continue to eat even after becoming uncomfortably full. The binge is typically followed by a period of guilt and/or depression.

   Unlike bulimia, those with BED typically do not purge themselves with vomiting, laxative use, or excessive exercise to the same degree.

-Recurrent episodes of binge eating;

-Binge episodes are associated with 3 or more of the following: 

1. Eating too fast

2. Eating large amounts of food when not hungry

3. Eating alone b/c of embarrassment of the amount of food intake

4. Feeling disgusted with self, depressed or very guilty after eating

-Marked distress regarding binge is present

-Binge eating occurs on avg 2 days/week for 6 mos

-Binge is not regularly associated with compensatory menchanisms and does not occur only during the course of AN or BN

-Classified as Eating Disorder NOS (do not meet the specific criteria of AN or BN

Sociocultural:

1. Chronic family disfucntion (overcontrolling, unaffectionate and critical parents)

-Relationship failure with MOTHERS causes overdependece in environment mening FOOD and DRUGS

2. Occupation (wrestling, modeling, dancing)- “thinner the better"

3. Trauma or SLE

4. Racial/Ethnic (High SES, white)

5. Media

Genetic

1. High episodes of Bulimia among relatives of bulimics

Biological thru SEROTONIN pathway with 2 metabolites:

1. Abnormal levels of 5HT in AN

2. Abnormal high levels of 5-HIAA (impulse)

-SCOFF:

1. Do you make yourself SICK because you are uncomfortably full?

2. Do you worry you have lost CONTROL over how much you eat

3. Have you lost more than ONE stone (14lbs) in past 3 months

4. Do you believe yourself to be FAT when others believe you are thin

5. Would you say FOOD dominates your life

-Behavioral:

1. Weight monitoring

2. Teaching self monitoring

3.ID Maladaptive behavior cues

-Psychological:

1. Address emotional conflicts

2. CBT-MOST EFFECTIVE

3.Pharmacotherapy- only helpful if depressive in anorexia

-Medical:

1. Weight restoration- MAIN GOAL

2. Fix Electrolyte 

3. Vitamins supplement