Somatic symptom and

related disorders
Earlier it was called somatoform disorders
• While nearly every psychiatric syndrome may include some somatic signs or
symptoms, a specific group of syndromes has been traditionally defined as somatic
symptom disorders . This group of disorders is distinguished by certain key features:
• prominent reporting of somatic symptoms
• concern about medical illness, and frequent presentation to general medical providers.
• As in other categories of mental disorder, the boundaries between individual
syndromes are more distinct in our systems of classification than they are in nature.
Understanding that various somatoform disorders often overlap, this review is
organized according to the major categories of er described in the ICD and DSM
classification systems.
• Gender and race a major factor
Somatic symptom and related disorders
Somatic symptom disorder – diagnostic
criteria
• A - One or more somatic symptoms that cause distress or result in significant disruption of daily
life
• B - Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated
health concerns mandated by one of the following
• Disproportionate and persistent thoughts about the seriousness of the symptom.
• Persistently high level of anxiety about health or symptoms
• Excessive time and energy devote to these symptoms or health concerns
• C – Although any one somatic symptom may not be consistently present, the state of being
symptomatic is present for over 6 months.
• Specify if with predominant pain is a feature or symptom is persistent (severe symptoms, marked
impairment or long duration)
• Specify current severity – mild (one symptom from B, moderate (two from B) or severe > 2 from
section B plus multiple somatic complaints.
• Diagnosis is based on positive symptoms and signs (distressing
somatic symptoms plus abnormal thoughts, feelings and behaviors in
response to these symptoms)
• It is no longer based on absence of medical explanations of these
symptoms)
• A distinct characteristic of these disorders is not the somatic
symptoms per se, but the way they present and interpret them.
• To incorporate affective, cognitive and behavioral components
 Characteristics of these disorders
• Prominence of somatic symptoms associated with significant distress
and impairment -
• Encountered in primary care and medical settings
• Less in psychiatric and mental health settings
Negative symptoms

Blunting of affect,
Poverty of speech and thought,
Apathy,
Anhedonia,
Reduced social drive,
Loss of motivation,
Lack of social interest,
Inattention to social or cognitive input.
Thoughts, feelings and behavior of somatic symptom
disorder
• Constant worry about potential illness
• Viewing normal physical sensations as a sign of severe physical illness
• Fearing that symptoms are serious, even when there is no evidence
• Thinking that physical sensations are threatening or harmful
• Feeling that medical evaluation and treatment have not been adequate
• Fearing that physical activity may cause damage to your body
• Repeatedly checking your body for abnormalities
• Frequent health care visits that don't relieve your concerns or that make them worse
• Being unresponsive to medical treatment or unusually sensitive to medication side
effects
• Having a more severe impairment than is usually expected from a medical condition
• Major depressive disorders, panic disorders, anxiety disorders may
accompany somatic symptoms. Mind body relationship
• Medical comorbidity among somatizing individuals.
• Somatic symptoms and related disorders can arise spontaneously and
their causes remain obscure.
 Causation
• Genetic and biologic vulnerability (increased sensitivity to pain)
• Early traumatic experiences (violence, abuse deprivation)
• Learning (attention obtained from illness, little reinforcement for non
somatic expressions of distress)
• Cultural, social norms that devalue and even stigmatize psychological
suffering as compared to physical suffering
• Somatic presentation as expressions of personal suffering inserted in
a cultural and social context.
• 75% of people previously diagnosed with hypochondriasis would now
be categorized under somatic symptom disorder
• 25% of those with hypochondriasis have high anxiety in the absence
of somatic symptoms and many wouldn’t qualify for anxiety disorder
diagnosis
 A comparison between DSM4 and DSM5
• DSM IV over emphasized the centrality of medically unexplained
symptoms.
• Somatic symptom disorders accompany other medical disorders.
• Reliability that a somatic symptom is medically unexplained is limited.
• Grounding a diagnosis on the absence of a medical explanation reinforces
mind body dualism.
• In the absence of a medical explanation, such illnesses were seen as
demeaning and pejorative
• It is accepted that symptoms are not consistent with medical
pathophysiology.
 Etiology of somatic symptom disorders
maybe due to
• Genetic and biological factors, such as an increased sensitivity to pain
• Family influence, which may be genetic or environmental, or both
• Personality trait of negativity, which can impact how you identify and
perceive illness and bodily symptoms
• Decreased awareness of or problems processing emotions, causing
physical symptoms to become the focus rather than the emotional issues
• Learned behavior — for example, the attention or other benefits gained
from having an illness; or "pain behaviors" in response to symptoms,
such as excessive avoidance of activity, which can increase your level of
disability
Risk factors for somatic symptom disorder
• Having anxiety or depression
• Having a medical condition or recovering from one
• Being at risk of developing a medical condition, such as having a
strong family history of a disease
• Experiencing stressful life events, trauma or violence
• Having experienced past trauma, such as childhood sexual abuse
• Having a lower level of education and socio-economic status
Somatic symptom disorder can be associated
with
• Poor health
• Problems functioning in daily life, including physical disability
• Problems with relationships
• Problems at work or unemployment
• Other mental health disorders, such as anxiety, depression and
personality disorders
• Increased suicide risk related to depression
• Financial problems due to excessive health care visits
• Prevalence rates for somatic symptom disorders in the general
population range from 11 to 21% in younger, 10 to 20% in the middle-
aged, and 1.5 to 13% in the older age groups in all cultures.
Differential diagnosis
• If consistent with another mental disorder and diagnostic criteria
fulfilled, then that mental disorder should be considered an additional
diagnosis.
• A separate diagnosis is not made if the thoughts, feelings or behavior
occurs only during other major episodes.
• If criteria of both are fulfilled, then both should be coded.
•
• Panic disorder – somatic disorder and anxiety occur in acute episodes while in SSD , they
are persistent throughout .
• Generalized anxiety disorder worry about multiple events only one of which is health .
• Depressive disorders –separated from SSD by low mood and anhedonia
• IAD- worry about health but no presentation ,exhibition of somatic symptom
• Conversion disorder –presenting feature is loss of function of a limb or organ while in SSD
focus is on distress caused by that symptom
• Delusional disorder –In SSD ,no symptom of delusional intensity .In delusional disorder .In
delusional disorder , somatic symptoms are stronger than in SSD
• Obsessive compulsive disorder – In OCD, repetitive behavior aimed at reducing anxiety
unlike IN SSD
 Illness anxiety disorder
• A. Pre-occupation with having a or acquiring a serious illness .
• B. Somatic conditions are not present or if present are in mild intensity
• C. High level of anxiety about health and the individual is easily alarmed
about health status.
• D. The individual performs excessive health related behaviors or exhibits
maladaptive avoidance
• E. Illness preoccupation present for atleast six months or more but the
specific illness may change over time.
• F. The preoccupation with illness is not better explained by another disorder.
• Specify whether care seeking type or care avoidant type
Case discussion of A
• The individual has preoccupation thoughts with having COVID
• Mild somatic symptoms present within him
• The individual is easily alarmed about Covid discussions around him
• The individual performs excessive health related behaviors around
COVID
• Illness pre occupation has been present for atleast six months
 Symptoms of illness anxiety disorder involve preoccupation with the idea that you're
seriously ill, based on normal body sensations (such as a noisy stomach) or minor
signs (such as a minor rash). Signs and symptoms may include:

• Being preoccupied with having or getting a serious disease or health condition

• Worrying that minor symptoms or body sensations mean you have a serious illness
• Being easily alarmed about your health status
• Finding little or no reassurance from doctor visits or negative test results
• Worrying excessively about a specific medical condition or your risk of developing a medical condition because
it runs in your family
• Having so much distress about possible illnesses that it's hard for you to function in daily life
• Repeatedly checking your body for signs of illness or disease
• Frequently making medical appointments for reassurance — or avoiding medical care for fear of being
diagnosed with a serious illness
• Avoiding people, places or activities for fear of health risks
• Constantly talking about your health and possible illnesses
• Frequently searching the internet for causes of symptoms or possible illnesses
Etiology
• The exact cause of illness anxiety disorder isn't clear, but these factors may
play a role:

• Belief system . You may have a difficult time tolerating uncertainty over
uncomfortable or unusual body sensations. This could lead you to
misinterpret that all body sensations are serious, so you search for evidence
to confirm that you have a serious disease.
• Family. You may be more likely to have health anxiety if you had parents who
worried too much about their own health or your health.
• Past experience. You may have had experience with serious illness in
childhood, so physical sensations may be frightening to you.
Risk factors for illness anxiety disorder
• Illness anxiety disorder usually begins in early or middle adulthood and may get worse with age.
Often for older individuals, health-related anxiety may focus on the fear of losing their memory.

• Risk factors for illness anxiety disorder may include:

• A time of major life stress

• Threat of a serious illness that turns out not to be serious
• History of abuse as a child
• A serious childhood illness or a parent with a serious illness
• Personality traits, such as having a tendency toward being a worrier
• Excessive health-related internet use
Factitious disorder - artificially created
disorder
• FS imposed on self - falsification of physical or psychological signs or
symptoms or induction of injury and disease, associated with identified
deception
• Presents himself as ill impaired or injured .
• Deceptive behavior is evident in the absence of external rewards
• Not better explained by another mental disorder such as delusional
disorder or any psychotic disorder
• Single or recurrent episode.
• Imposed on another – the perpetrator, not the victim receives the
disorder
• Factitious disorder and malingering imply that the patient is purposely
deceiving the physician (i.e., faking the symptoms). The difference
between factitious disorder and malingering is that, in malingering,
the reason for the deception is tangible and rationally understandable
(albeit possibly reprehensible) such as avoiding military duty, avoiding
work, obtaining financial compensation, evading criminal prosecution,
or obtaining drugs. In factitious disorder, the motivation is a
pathologic need for the sick role.
 Pinocchio syndrome
• Pinocchio Syndrome is a syndrome that causes hiccups when lying due to problems in the
autonomic nervous system .It is an incurable syndrome, which occurs in 1 in 43 people.
People suffering from Pinocchio Syndrome will hiccup even if they lie over the phone or
text.
• When a person lies, he or she experiences a "Pinocchio effect", which is an increase in the
temperature around the nose and in the orbital muscle in the inner corner of the eye.
• "Research has linked telling lies to an increased risk of cancer, increased risk of obesity,
anxiety, depression, addiction, gambling, poor work satisfaction, and poor relationships,” -
Deirdre Lee Fitzgerald, professor of psychology at Eastern Connecticut State University )
• While lying, the body releases chemicals called catecholamines, which cause the tissues
inside the nose to swell. The increased blood pressure makes the nose to swell and causes
the nerve endings inside the nose to tingle, thus makes it itchy.
Comorbidity

• As a result of its defining characteristics and the deception of those

who suffer from the condition, factitious disorder is difficult to study.
As such, most reports are single cases or small case studies. (Steel, R.
M. 2009)

• However, there appear to be meaningful clinical links discovered

between factitious disorder and other mental illnesses, such as
borderline personality disorder. (Gordon, D. K., & Sansone, R. A. 2013)
LIVING WITH FD
• Factitious disorder affects both the individual and those around them to a significant degree. Friends, family and other
acquaintances generally experience the effects of factitious disorder more acutely than the sufferer themselves, often as a
result of the individual being unwilling to confess to their deception. Obtaining truthful accounts of life with factitious
disorder is tricky, and mainly limited to deducing from the causes. (Steel, R. M. 2009)

• The individual will have a need to receive attention and care, and will often go through many unnecessary and potentially
risky methods like surgery in order to obtain what they desire. They may induce illness in themselves in order to achieve
this goal, potentially putting their need for nurture higher than their own safety. (Jaghab, K., Skodnek, K. B., & Padder, T. A.
2006)

• Life for those around such individuals can be stressful. Doctors especially risk litigation from diagnosing factitious disorder
too hastily, or abuse if they confront the individual about their suspicions.

• An individual with factitious disorder may find doctors distance themselves, or cease all treatment except that required to
prevent death, rather than risk the individual sabotaging continued treatment and procedures. (Steel, R. M. 2009) It is not
unknown for untreated factitious disorder to result in serious and ultimately fatal illness or suicide. (Jaghab, K., Skodnek,
K. B., & Padder, T. A. 2006)
Symptoms of FS
• By its nature, factitious disorder can seem asymptomatic. In order to make a diagnosis of factitious disorder, it may
be necessary for a health professional to look for clues and patterns in behavior that suggest an individual is being
misleading. Some behaviors, however, do make factitious disorder easier to spot, including:

• Inconsistencies between patient history and medical observations.

• Vague details that seem plausible on the surface but that don’t hold up to scrutiny.
• Lengthy medical records with multiple admissions at different hospitals.
• Willingness to accept any discomfort and risk from many medical procedures, even surgery.
• Overdramatic or outlandish presentation of a factitious illness, or hostility when challenged.
• (Jaghab, K., Skodnek, K. B., & Padder, T. A. 2006)

• Once the initial indicators have been identified, other avenues of investigation open up. An individual presenting
with any of the above symptoms may have a history in the medical profession, or an otherwise textbook knowledge
of their factitious illness and overall medical practice, which can make the deception more difficult to uncover.
• The individual may have unexplained injuries that present as being potentially self-
inflicted, ranging from minor cuts to abscesses or sepsis induced by injecting
themselves with fecal matter. Other signs can include significant surgical scarring from
repeated unnecessary operations - a so-called ‘gridiron abdomen’, for example - and
affected individuals may even resort to tampering with hospital charts or
contaminating test samples. Symptoms of the factitious illness may only appear when
the individual believes they have attention, or in the case of negative test results.
(Elwyn, T. S. 2018)

• Whatever the symptoms, it is important that as many as possible are evidenced and
preferably reviewed by a peer to rule out the possibility of a genuine rare or obscure
illness, as many of these symptoms on their own can be purely circumstantial. (Steel,
R. M. 2009)
• Factitious disorder is still not very well understood - a low number of individuals from a wide range of backgrounds are
successfully diagnosed with the condition. As such, it’s difficult to identify causes of factitious disorder with any certainty.

• Risk factors are believed to include childhood trauma, working in the healthcare profession and suffering from depression
or a personality disorder. (Psychology Today 2019)

• Other factors that may relate to the onset of factitious disorder include a desire to be nurtured or to be distracted from
life stressors, and enjoyment of having relationships with doctors or others of high perceived status.

• Dynamics of a parent and child relationship may be a contributing element if these relationships result in:
• - a need to be loved or cared for
• - a need to deceive
• - a need for control
• - a need to master abusive parents
• - a need to be hurt or punished
• Exaggeration of symptoms
• Fabrication of symptoms
• Simulation of symptoms
• Induction of symptoms
• May report depression and suicidality following death of someone when
there is no relationship .
• Deceptive report of neurological symptoms – seizures, dizziness, blacking
out
• Manipulates a laboratory test
• Falsely indicate an abnormality
• Falsify medical records to indicate an illness
• Ingest a substance to falsify (insulin)- to indicate abnormal test results
• Physically injure themselves (by injecting fecal material to induce sepsis )
• An example of a psychological factitious disorder is mimicking
behavior that is typical of a mental illness, such as schizophrenia. The
person may appear confused, make absurd statements, and report
hallucinations (the experience of sensing things that are not there; for
example, hearing voices.
• The difference between a factitious disorder and malingering is that
malingering is when they fake an illness to get an external gain like
attention from parents or financial compensation. While patients that
have a factitious disorder producing symptoms simply because they
wish to be a patient.
• Factitious disorder is often defined as the intentional production (or
feigning) of disease in oneself to relieve emotional distress by
assuming the role of a sick person. Although the self-induction of
disease is a conscious act, the underlying motivation is usually
unconscious.
Signs of faking an illness can include
• Reporting symptoms that aren't witnessed by others.
• Receiving healthcare from multiple providers and often leaving
healthcare facilities against medical advice.
• Undergoing numerous extensive procedures and treatment.
• Erratic medical history with a strange set of symptoms.
Difference between factitious disorder and
somatic symptom disorder.

• Somatic symptom disorder and factitious disorders both occur in

cases where psychological disorders are related to the experience or
expression of physical symptoms. The important difference between
them is that in somatic symptom disorders the physical symptoms
are real, whereas in factitious disorders they are not.
Prevalence of factitious disorder and
malingering in general population
• Although factitious disorder is recognized as an uncommon condition
(prevalence 5% or less),in a study , Mittenberg and colleagues17
estimate that 29% of personal injury cases, 30% of disability cases,
19% of criminal cases, and 8% of medical cases probably involve
faking of symptoms and malingering .
Case study
• Anil Sharma reported that feelings of endogenous depression after
the death of his wife. He said he loved her very much and not able to
live without her. He is having blackouts, dizziness, he said his life has
become meaningless since her death and he sees no purpose in living.
He reported having tried to commit suicide by taking 20 sleeping pills
and being rushed to the hospital ICU for a stomach wash. He
requested the doctors not to make a case out of it by bribing them.
• A cross check showed that he had mixed blood with his urine to fake
results.
• He had paid money to the laboratory technician to fake results.
• He had no wife. He had married long ago and his wife had left him
long ago for his behavior . He lived alone.
• He had a history of buying after faking laboratory results when
confronted .
Feeding and Eating disorders
A persistent disturbance of eating or eating related behavior that
results in altered consumption or absorption of food that significantly
alters physical and mental health and psychosocial functioning
Some of the major disorders
• Pica
• Rumination disorder
• Avoidant restrictive food intake disorder
• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder
Diagnostic criteria for PICA
• Persistent eating of non nutritive, non food substances over a period
of one month
• The eating of non nutritive, non food substances is inappropriate to
the developmental age
• The eating behavior is not part of a culturally supported or socially
normative practice
• If it continues in the context of another mental disorder like ASD,
Schizophrenia, medical condition like pregnancy it is sufficiently
severe to warrant clinical attention
People with pica crave and eat non-food items such
as:

• dirt.
• clay.
• rocks.
• paper.
• ice.
• crayons.
• hair.
• paint chips.
• Pica is a compulsive eating disorder in which people eat nonfood items. Dirt, clay, and
flaking paint are the most common items eaten. Less common items include glue, hair,
cigarette ashes, and feces. The disorder is more common in children, affecting 10% to
30% of young children ages 1 to 6.

• Pica is related to gastrointestinal distress, micronutrient deficiency, neurological

conditions, and obsessive compulsive disorder. Currently there are no clinical guidelines
for situations regarding pica and cases in clinical institutions often go unreported.
• Often, people with pica also have other mental health disorders, including
schizophrenia and obsessive-compulsive disorder. In addition, pica symptoms
sometimes increase when an individual is experiencing extreme stress and anxiety.
Many pica eating disorders begin in childhood and relate to childhood experiences
The most common causes of pica include
• pregnancy.
• developmental conditions, such as autism or intellectual disabilities.
• Conditions such as schizophrenia.
• cultural norms that view certain nonfood substances as sacred or as
having healing properties.
• malnourishment, especially iron-deficiency anemia.
 Why is my child eating feces or other non
nutritive substance?
• Through food children explore the world. Why do they mess at the
table?
• For many babies, eating feces or other non-food items is part of
natural and developmentally appropriate exploration.
• The lips, tongue, and face have the most nerve receptors in the body.
• With social conditioning including punishment these habits drop of
most children.
• Pica often occurs with other mental health disorders associated with
impaired functioning (e.g., intellectual disability, autism spectrum
disorder, schizophrenia).
• Iron-deficiency anemia and malnutrition are two of the most common
causes of pica, followed by pregnancy.
• Doctors use the term "pica" to describe craving and chewing substances
that have no nutritional value — such as ice, clay, soil or paper. Craving
and chewing ice (pagophagia) is often associated with iron deficiency,
with or without anemia, although the reason is unclear.
• Researchers theorize that chewing ice sends more blood to the brain,
temporarily improving alertness and clarity of thought. This feels good,
and so they keep doing it even when it causes dental problems.
• Geophagia, the practice of eating dirt, has existed all over the world
throughout history. People who have pica, an eating disorder in which
they crave and eat nonfood items, often consume dirt. Some people
who are anemic also eat dirt, as do some pregnant women
worldwide.
Differential diagnosis
• Different from anorexia nervosa – by the eating of non nutritive and
non food substances
• Factitious disorder – there is a element of deception involved
• Non suicidal self injury – as a maladaptive personality behavior
• In individuals with autism, schizophrenia, and certain physical
disorders (such as Kleine-Levin syndrome), non-nutritive substances
may be eaten. In such instances, pica should not be noted as an
additional diagnosis.
Pica is the consumption of substances with no significant
nutritional value such as soap, drywall, or paint. Subtypes are characterized by the substance eaten

• Acuphagia (sharp objects)

• Amylophagia (purified starch, as from corn)
• Cautopyreiophagia (burnt matches)
• Coniophagia (dust)
• Coprophagia (feces)
• Emetophagia (vomit)
• Geomelophagia (raw potatoes)
• Geophagia (earth, soil, clay, chalk)
• Hyalophagia (glass)
• Lithophagia (stones)
• Metallophagia (metal)
• Mucophagia (mucus)
• Pagophagia (ice)
• Plumbophagia (lead)
• Trichophagia (hair, wool, and other fibers)
• Urophagia (urine)
• Hematophagia (vampirism) (blood)
• Xylophagia (wood, or derivates such as paper)[17]
• This pattern of eating should last at least one month to meet the time diagnostic criterion of pica.
Rumination disorder –Diagnostic criteria
• Repeated regurgitation of food over a period of 1 month. The
regurgitated food may be re chewed, re swallowed, or spit out.
• The repeated regurgitation is not attributable to an associated gastro
intestinal disorder or medical condition
• The eating disturbance doesn’t occur during the course of anorexia
nervosa, bulimia, binge eating disorder .
• If the symptoms occur during the course of another mental disorder
or neuro developmental disorder, they are sufficiently severe to
warrant another diagnosis.
• Vomiting is the ejection of contents of the stomach and upper intestine;
regurgitation is the ejection of contents of the esophagus. Regurgitation
often, but not always, happens right after eating and the pet will try to eat
the regurgitated food.
• In humans it can be voluntary or involuntary, the latter being due to a
small number of disorders. Regurgitation of a person's meals following
ingestion is known as rumination syndrome, an uncommon and often
misdiagnosed motility disorder that affects eating.
• Regurgitation occurs with varying degrees of severity in approximately
80% of GERD patients. This symptom is usually described as a sour taste in
the mouth or a sense of fluid moving up and down in the chest
• Regurgitation happens when a mixture of gastric juices, and
sometimes undigested food, rises back up the esophagus and into the
mouth.
• In adults, involuntary regurgitation is a common symptom of acid
reflux and GERD (gastroesphegal reflex disease). It may also be a
symptom of a rare condition called rumination disorder.
• A problem that can be confused with vomiting is regurgitation.
Vomiting is the ejection of contents of the stomach and upper
intestine
• Regurgitation is the ejection of contents of the esophagus. The
esophagus is a narrow, muscular tube that food passes through on its
way to the stomach.
• Biological factors such as GERD should be ruled out for its diagnosis.
1
Associated features supporting diagnosis
• Infants with this disorder have devtl. history of strain and arch their
backs with the head held back making sucking movements with
tongue
• They show gaining satisfaction from it
• Weight loss and weight gain are common features during this activity
• Malnutrition is common in this behavior
• Social avoidance common
• insights present in this condition
• Present in individuals with higher intellectual disability
• Occurs in infancy, childhood, adolescence or even adulthood
• In infants between 3 -12 months
• Remits spontaneously 7
• can lead to malnutrition
• Can be fatal at times during infancy
• Serves a self soothing and self stimulating function, similar to that of
head banging
Risk and predisposing factors
• Lack of stimulation
• Neglect
• Stressful life situations – gender related
• Problems in parent child relationship –
Anorexia nervosa – diagnostic criteria
• Restriction of energy intake relative to requirements, leading to a
significantly low body weight in context of age, sex, developmental
trajectory and physical health. Weight that is less than minimally
normal less than minimally expected
• Intense fear of gaining weight or becoming fat, or persistent behavior
that interferes with weight gain
• Disturbances in which body weight or shape is experienced, undue
influence of body weight or shape on shape evaluation or persistent
lack of recognition of seriousness of low body weight.
• Restricting type - last 3 months not engaged in binge eating or purging
behavior (self induced vomiting or misuse of laxatives, diuretics or
enemas) weight loss is achieved through fasting, dieting or exercise
• Binge eating type – in last three months repeated and recurrent
episodes of binge eating or purging behavior. Self induced vomiting
or misuse of laxatives ,diuretics or enemas .
• Specify if in partial remission or full remission
Diagnostic features
• Persistent energy intake restrictions
• Intense fear of gaining weight or becoming fat
• Disturbance in self perceived weight or shape
• Begins in adolescence or late adulthood
• Begins with a stressful life event
• Most experience remission within five years of illness
• Can result in a potentially life threatening medical condition
• Amenorrhea and vital sign abnormalities are common
• Loss of bone mineral density is not reversible.
• Self induced vomiting, misuse of laxatives, diuretics and enemas may
cause several disturbances
• Depressed mood, social withdrawl, irritability and insomnia and
diminished interest in sex
• OCD is common preoccupation with thoughts of food dominating it.
 risk factors
• Temperamental - Obsessional traits in childhood
• Environmental traits - occupation
• Genetic factors
• Cultural factors - higher in post industrialized high income countries
• Higher suicidal risk
 associated features of anorexia nervosa
• Depressed mood
• Social withdrawl
• Irritability
• Insomnia
• Diminished desire in sex
• Preoccupation with thoughts of food . Hoarding or string food
• Eating in public
• Feelings of inadequacy
• Desire to control environment
• Inflexible thinking , rigidity
• Limited social spontaneity
• Excessive activity to lose weight
• Misuse of medication
differential diagnosis -
• Major depressive disorder
• Substance use disorders
• Schizophrenia
• Major depressive disorders
• Bulimia nervosa
• Avoidant food intake disorder
Bulimia nervosa
• A - Recurrent episodes of binge eating –
• in a discrete period of time say 2 hour eat an amount that is larger than
what most individuals would eat.
• A sense of lack of control over eating.
• B - recurrent self induced compensatory behaviors to prevent weight gain –
by vomiting, laxatives, diuretics, fasting, excessive exercise
• C - Binge eating and compensator behavior occur together. Once a week for
3 months
• D – Self evaluation is influenced by body weight shape
• E - the disturbance doesn’t occur during anorexia nervosa
Associate features supporting diagnosis
• Are within normal weight range or overweight – BMI > 18.5 and <30
in adults
• Amenorrhea is common
• Cardiac arrthymia, esophageal tears gastric rupture may result in rare
cases
• Peaks in older adolescents and young adulthood
• 10-1 female to male ratio
Risk factors
• Weight concerns, low self esteem, depression and social anxiety
• Environmental – individuals who experienced sexual or physical abuse
• Genetic and physiological – childhood obesity and early pubertal
maturation. Familial and genetic
• Suicide risk is elevated and should be assessed immediately without
delay
Principles for selecting
diagnostic information
clinicians use a wide variety of principles to arrive
at diagnosis.

• History is better than cross sectional information –patients with widely

differing diagnosis could have similar symptoms .
• Recent history is better than ancient history – illnesses develop
sequentially .patients change and often the evolving symptoms help to
evaluate it better
• collateral information augments history from the patient
• Signs are better than symptoms
• Objective assessments are better than subjective judgments- limit the use of
intuition - discourage diagnosis that predicts the future course of illness
• Crisis generated data are suspect – look for day to day behavior ,not
unusual behavior
Differential diagnosis – the list of all
diagnosis possible for a given patient
• Possibilities arranged in order of likelihood- most probable listed first
• Include all - For diagnosis and prognosis purposes , use the topmost ones
• Disorder due to medical conditions ,or cognitive disorders preempt all other that produce the
same condition
• Rule of parsimony –look for a single illness that explains all different symptoms. thinking small –
standard rule for a hundred years
• Consider disorders that have been present longer .if A is followed by B ,it is likely that A
caused B .
• Use family history as a guide – if people in the family have a particular disease , then the
patient is likely to have that too .
• Chose the safest diagnosis - the one that has a better outcome(remits spontaneously or
responds well to treatment ).
•