intro to behavioral med (all packets)

Bulimia Nervosa

What is the more common eating disorder?

How do you feel about your weight/body?

What is the general screening question for eating disorders?

EAT-26 Eating Attitudes Test, others

What are objective screening tools for eating disorders?

Patient's can be frustrating for family; history can be unreliable from patient as they don't see anything as wrong, so have to get some history from family

Why can the history be hard?

- Current and past weight

- Current and past feelings about weight

- Current and past feelings about food

- Current and past patterns of eating

- Unusual eating rituals

- History of dieting

- Episodes of binge-eating

- Self-evaluations, self-esteem

- Relationships between weight and self-esteem

- Medical illnesses/medications

- Psychiatric/substance use history

- FMHx eating disorder/psych illness

- Menustration

What should you get when taking the history of a patient with a possible ED?

- Psychological- self-esteem, personality traits like perfectionism (anorexia)

- Biological- genetic/family history, cortisol is increased, serotonin/norepinephrine

- Social- females more at risk, sometimes following trauma or because of a sport

What is the Etiology for EDs?

Ballet, gymnastics, cheerleading, wresting and horse-racing for males; coaches play a role in some of these

What are sports that can make someone more likely to develop an eating disorder and who can influence this?

- Depression

- Anxiety and OCD features

- Personality disorders- borderline personality disorder with bulimia

- Substance abuse

What are comorbid conditions with eating disorders?

Anorexia Nervosa

are hungry, but willfully don't eat

1. Restriction of energy intake relative to requirements -> leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health

What is the first criteria for someone with anorexia nervosa?

Weight that is less than minimally normal or expected (normal low BMI is 18, anorexia BMI is usually around 15)

What does "significantly low body weight" refer to?

Intense fear of gaining or becoming fat, or persistent behavior that interferes with weight gain, even though underweight

What is the second criteria for anorexia (why do they have such a low weight)?

Disturbance in the way in which one's body weight or shape is experienced, self-evaluation influenced by body weight/shape or denial of the seriousness of the current low body weight

What is the third criteria for anorexia (why do they fear becoming fat)?

- Loss of muscle mass/subcutaneous fat -> Cachexia (term for skeletal appearance)

- Dry skin or cyanosis (turn blue from lack of oxygen)

- Lanugo (fine downy baby hair to keep them warm)

- Hair loss elsewhere

- Bradycardia (low heart rate) and hypotension

- Hypothermia/cold intolerance

- Headaches

- Dizziness/fainting

- Muscle aches/cramps

- Abdominal pain

- Constipation

- Amenorrhea- absence of menstrual cycle in females

What are the objective and subjective findings of anorexia nervosa?

- Leukopenia/anemia

- Sinus bradycardia, arrhythmias

- Cardiac muscle loss

- Thyroid dysfunction

- Impaired renal function

- Osteoporosis

- Electrolyte disturbances (can cause arrhythmias, which can cause death)

What are medical complications with anorexia nervosa (come from starvation)?

- Unusual eating habits (won't eat in public)

- Overuse of laxatives or diuretics

- Poor self-esteem

- Extreme physical activity (hours and hours)

- Social isolation/intolerance of others

- Moodiness/irritability

- Resist change in routine/inflexible thinking

- Oversensitivity to criticism/perfectionism

- Suicidal ideation

- Extreme concern about appearance

What are other common features of anorexia nervosa?

In our society, as we value thinness; females

Where and who is anorexia nervosa more prevalent?

Mid- to late-adolescence

When is the typical onset of anorexia nervosa?

Electrolyte imbalances or suicide

What can death from anorexia nervosa occur from?

Recurrent episodes of binge-eating

What is the first criteria for Bulimia Nervosa?

High caloric/fatty food

What kinds of food do people typically eat in binges?

Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar period of time/under similar circumstances

What occurs in recurrent episodes of binge-eating?

Recurrent inappropriate compensatory behavior in order to prevent weight gain

What is the second criteria for bulimia nervosa?

Self-induced vomiting (most common), purging (laxatives, diuretics, enemas), fasting exercising

What are examples of compensatory of behaviors that people with bulimia nervosa use to prevent weight gain?

The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months

What is the third criteria for bulimia nervosa?

- Dental enamel loss

- Chipped, ragged teeth

- Cavities

- Enlarged salivary glands- parotid (because they are constantly producing saliva to balance out acid)

- Hand callouses/scars from induced vomiting (bite down on hand)

- Bloating, fullness

- Lethargy

- GERD sx

- Abdominal pain

- Sore throat

What are objective/subjective findings with bulimia nervosa (tied to self-induced vomiting)?

Halitosis (bad breath), Abrasions on knuckles, Negative gag reflex (lose ability to stimulate gag reflex), Dentition (poor dental health)

What is the HAND pneumonic for remembering findings of bulimia nervosa?

- Electrolyte imbalance (from vomiting)

- Cardiac arrhythmias

- Esophageal tears

- Seizures

- Menstrual irregularities (don't get thin enough to fully develop amenorrhea)

- Pancreatitis

What are medical complications associated with bulimia nervosa?

At or slightly above normal weight, makes it harder to spot any issues

What does the weight of patients of bulimia nervosa look like and what does this mean?

Attempt to conceal; go to bathroom after meal for purging

What do people with bulimia nervosa do during their binge episodes and purging?

Low, anxious mood

What are binge episodes triggered by?

Multidisciplinary (might need family therapy, nutritional counseling)

What is the treatment like for eating disorders?

- inpatient or outpatient

- Therapy- Cognitive Behavioral Therapy, Maudsley Therapy

- Pharmacotherapy (use fluoxetine for bulimia nervosa)

What are different options for treatments of eating disorders?

See if it develops

Eating disorder behaviors can be common, so what do we need to do as clinicians?

chronic, brain

Substance use disorders are __________ diseases of the ___________

Dopamine (pleasure motivator)/reward pathways; when people who are prone to substance use disorders use once, brain is hardwired to want more

What is disrupted in substance use disorders?

Tolerance

the requirement of an increased dose to acheive the same effect, (or, markedly diminished effect with continued use of the same amount)

With drug of abuse

When does tolerance occur?

Withdrawal

generally the opposite of the intoxication symptoms; once a patient gets addicted and doesn't use

Substance Use Disorder

a problematic pattern of substance use, leading to clinically significant impairment or distress, over a 12-month period

1. Impaired Control (substance taken in larger amounts, or over a longer period of time than intended; persistent desire or unsuccessful effort to cut down or control the use; great deal of time spent obtaining or using the substance, or recovering from effects; craving)

2. Social Impairment (failure to fulfill major role obligations at work, school, or home; continued use despite persistent social or interpersonal problems; important social, recreational, or occupational activities are given up or reduced)

3. Risky Use (recurrent use in situations in which it is physically hazardous; continued use despite knowledge of physical/psychological problem due to substance)

4. Pharmacological Criteria (Tolerance; Withdrawal)

What are atleast two of the following symptoms one must have to have substance use disorder?

Craving

intense desire or urge to use drug

- Most common (marijuana is, with alcohol and tobacco in second place)

- Males are afflicted more than females

- 1/10 Americans

- 1/2 trillion dollars

What is the epidemiology and prevalence like for substance use disorders?

- Alcohol and CNS Depressants (downers)

- Cocaine and Psychostimulants/Amphetamines (Speed and uppers)

- Opiates

- Cannabis

- Anabolic Steroids

- Nicotine

What are the different categories of drugs?

Alcohol and CNS Depressants

Downers that sedate and calm us

Alcohol, benzodiapines, barbiturates

What are examples of CNS Depressants?

Alcohol and CNS Depressants (Downers)

What category of substance has intoxication that looks like this: disinhibition (filter comes off), (includes inappropriate sexual or aggressive behavior) somnolence, impaired memory, judgement, slurred speech, incoordination, unsteady gait, stupor?

Alcohol and CNS Depressants (Downers)

What category of substance has withdrawal that looks like this: anxiety or psychomotor agitation, tremor, tachycardia (heart rate increases), HTN (blood pressure increases), diaphoresis (sweating), craving, nausea/diarrhea?

Tremors

What is a big sign of alcohol withdrawal?

Can be life-threatening (seizures and death can occur)

Why does withdrawal from Alcohol and CNS Depressants (Downers) have to be treated?

Benzodiapines; helps replace the neurotransmitter effects, there is regulated protocol with withdrawal

What is used to treat withdrawal from Alcohol and CNS Depressants (Downers)?

- Usually supplement patients with multivitamins and thiamine

- Legal BAC is 0.08%

- Takes one hour to metabolize one drink (depends on weight, food in stomach, gender)

What are some other factors about alcohol?

Gastritis, peptic ulcer disease, diarrhea, cirrhosis, pancreatitis, HTN, elevated triglycerides, increased rates of cancer

What are some complications of Alcohol and CNS Depressants (Downers) use?

Only from alcohol, not the pills

What are stomach issues with use of Alcohol and CNS Depressants (Downers) from?

Cocaine and Psychostimulants/Amphetamines

Speeds and uppers

Caffeine, methamphetamine, crack, bath salts

What are examples of Cocaine and Psychostimulants/Amphetamines?

ADHD, narcolepsy

What are Psychostimulants/Amphetamines prescribed for?

Cocaine and Psychostimulants/Amphetamines (speed and uppers)

What category of substance has intoxication symptoms that look like this: euphoria, energy, anxiety, agitation/aggressive behavior, tachycardia (elevated heart rate), cardiac arrhythmias, anorexia (decrease of appetite), pupils dilate (mydriasis)?

Ringing of ears, paranoia, hallucinations

What can higher does of Cocaine and Psychostimulants/Amphetamines lead to?

Hyperthemia (body temp gets too high)

What can cause people to die when using ectasy?

Cocaine and Psychostimulants/Amphetamines

What category of substances does withdrawal look like this: depression, fatigue, increased appetite, vivid dreams?

Cocaine

What specifically causes the withdrawal symptom of depression?

Caffeine

What specifically causes the withdrawal symptom of a headache commonly?

Nasal mucosa damage (cocaine because of snorting), vasospasm, arrhythmias (abnormal heart rhythms), MI, respiratory disease

What are complications with using Cocaine and Psychostimulants/Amphetamines?

Pain

What are opiates used for?

Heroin, codeine, morphine, (also methadone and fentanyl)

What are examples of opiates?

Opiates

What category of substances have intoxication symptoms that look like this: Rush or Nod depending on timing or dose, warmth/flushing, slurred speech, impaired judgement or memory, pupils constrict (miosis), constipation, respiratory depression, coma, death?

Opiates

What category of substances have withdrawal symptoms that look like this: piloerection (goosebumps, hairs on end), pupils dilate (mydriasis), lacrimation or rhinorrhea (runny nose), nausea/vomiting/diarrhea, tachycardia, HTN, fever, aches, yawning, insomnia, depression and anxiety?

- When intoxicated, backed up (constipated)

- When going through withdrawal, everything runs (nose, diarrhea)

What is a way to remember the intoxication and withdrawal symptoms for opiates?

Respiratory depression

What can lead to death during opiate INTOXICATION?

No

Will withdrawal of opiates kill someone?

Intoxication can kill because of respiratory depression; so we use Narcan to treat that

What is an issue involved with the intoxication of opiates and how can it be treated?

Methadone and suboxone; when patients want to be done, these meds can help with gradual withdrawal

What drugs are used for maintenance of opiates and what does that mean?

Respiratory arrest and skin abscesses (complication of IV heroin drug use)

What are complications of opiate use?

Some medical conditions like in sickness from chemo and seizures in children, but it is never indicated first-line for anything

What is Cannabis/Marijuana used for?

CBD

What is the portion of Marijuana that doesn't have any psychoactive effects?

Cannabis/Marijuana

What category of substance has intoxication effects that look like this: euphoria/inappropriate laughter, drowsiness or sedation, slowed reaction time, auditory or visual DISTORTIONS, paranoia, anxiety/dysphoria, conjunctivital injection (eyes becomes irritated and red), dry mouth, increased appetite, tachycardia, impaired memory/judgment?

Cannabis/Marijuana

What category of substances has withdrawal symptoms that look like this: Tremor, diaphoresis (sweating), nausea, change in appetite or sleep (appetite is lost), restlessness, irritable/anxious mood, anger or aggression?

Learning difficulties, respiratory problems, chronic cough, hyperemesis, amotivation, suppression of immunological function and testosterone/LH hormones

What are complications of Cannabis/Marijuana use?

Anabolic Steroids

readily available substances that are not benign

Anabolic Steroids

What category of substances has intoxication symptoms that look like this: Initial sense of well-being/euphoria, then with continued use- lack of energy, irritability, dysphoria, violence "roid rage"

Anabolic Steroids

What category of substances has withdrawal symptoms that look like this: depression, insomnia, suicidal ideation and fatigue?

Acne, jaundice, gynecomastia (overdevelopment of breast tissues in males), atrophy of testicles/prostate, liver, heart damage

What are the complications of anabolic steroids?

Nicotine

What category of substances is the single most preventable cause of disease/death?

Cigarettes, cigars, pipes, smokeless tobacco (snuff and chewing tobacco)

What are the different forms of nicotine?

involuntary (passive or second-hand smoking)

Nicotine can be ______________________

Nicotine

What category of substances has withdrawal symptoms that look like this: Dysphoria/depressed mood, insomnia, irritability, anxiety, increased appetite/weight gain?

Begin within a few hours, peak 1-4 days, and residual symptoms improve in 3-4 weeks

When do withdrawal symptoms of nicotine begin, peak, and reside?

- Cancer (lung, larynx, esophagus, pancreas, leukemia, bladder and kidney, cervix and uterus and ovaries, oral from snuff)

- COPD

- Cardiovascular disease (coronary artery disease, CVA, subarachnoid hemmorrhage)

What are medical complications of nicotine use?

PATIENT EDUCATION

- Set a quit date, rid supply, plan ahead, support group

- National quit line- 1 800 QUIT NOW, websites

- Replacement therapy: patch, gum, lozenge, inhaler, nasal spray

- Reading directions is VITAL

- Prescriptions: Chantix (varenicline), Zyban (bupropion)

- Need to learn new behavior, not just quit

What is the treatment for patients who use nicotine?

Potential sign of use disorder

- Abrupt changes in work/school attendance, quality of work, output, grades, discipline

- General attitude changes and/or irritability

- Withdrawal from responsibility

- Deterioration of physical appearance and grooming

- Wearing of sunglasses or long sleeves at inappropriate times

- Association with known substance users

- Unusual borrowing of money from friends, co-workers, parents/selling possessions

- Stealing small items from employer, home, or school/legal involvements

- Secretive behavior; poorly concealed attempts to avoid attention and suspicion such as frequent trips to storage rooms, closets, restrooms, basements

- Lost prescriptions, requests for refills, asking for meds by name, resist other tx alternatives

What is the first thing you should look for when assessing the patient?

History- administer the CAGE questionnaire

What is the second part of the assessment of the patient?

- Have you ever felt you out to Cut down on your drinking or drug use?

- Have people Annoyed you by criticizing your drinking or drug use?

- Have you ever felt bad or Guilty about your drinking or drug use?

- Have you eve had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hang-over (Eye-opener)?

What are the questions of the CAGE questionnaire?

Consider conducting a longer inquiry

What should you do with any patient who scores a 1 or higher on the CAGE questionairre?

A physical exam

What is the third part of assessing the patient?

- general appearance- anxious, tremors, gait

- Nutritional status- body habitus (skinny)

- Skin- jaundice from alcohol use or anabolic steroids, track marks from needles

- HEENT- sclera for cannabis use, pupils in opiates and amphetamines

- Chest- many produce tachycardia and hypertension

- Abdomen- liver, gastritis

- Mental Status Exam

What things should you look for in the physical exam?

Diagnostic tests

What is the fourth part of assessing the patient?

What is appropriate for that patient, depending on use

What should you order for the patient diagnostic test wise?

Toxicology screening- urine is most common, then hair and blood

What is the biggest screen for substance abuse and how can you obtain samples?

Marijuana (up to one month), and people positive for marijuana have to use and aren't exposed

What can be seen for the longest time in toxicology screening?