Personality disorders, Eating disorders and Addictions

1. Psychiatry

2. Normal Personality OCEAN Openness to experience Conscientiousness Extroversion Agreeableness Neuroticism Personality Disorder Maladaptive patterns of behaviour, modes of thinking and relating to oneself, the environment and others which causes impairment of social functioning to the individual or others Features usually present in adolescence and persist through life Not usually thought of as an illness Largely unresponsive to Rx Diagnosis doesn’t imply change from previous level of functioning (psychosis +neurosis imply change from previous level of functioning and development of symptoms) Different categories 1)ODD 2) DRAMATIC 3) ANXIOUS

3. Personality Disorders Majority never come in contact with psych services, those who do generally do because of another psychiatric disorder Predispose to other psych disorders, and affect presentation and Rx “severe disturbance in the personality and behavioural tendencies of the individual not directly from disease, damage to the brain or other psych disorder. Usually involving several areas of the personality. Nearly always associated with considerable personal distress and social disruption. Usually manifest since childhood/adolescence 3 clusters A: paranoid, schizoid, schizotypal (ODD) B: antisocial, borderline, histrionic and narcissistic (DRAMATIC) C: avoidant, dependent, obsessive-compulsive (ANXIOUS)

4. Personality Disorders 10% population have personality disorders and up to 50% psych inpts and outpts More males, younger adults and those in urban communities Aetiology: genetic factors and early life experiences e.g. Child abuse Impulsive behaviour linked to reduced CSF serotonin, more? After a highly threatening experience personality disorders can develop though normally personality is set from late childhood

5. Paranoid Personality Disorder Pervasive distrust of others including friends and partner Person is guarded, suspicious and constantly on the lookout for clues to confirm his fears etc Strong sense of self-importance & personal rights Overly sensitive to rebuffs and setbacks Easily feels shamed and humiliated Persistently bears grudges Difficulty engaging in close relationships, tendency to withdraw from others M>F PROJECTING – their way of coping may be to blame others/society e.g. Get guilty, project it to partners and become morbidly jealous and suspicious

6. Schizoid personality disorder : Cold and aloof / cold and callous Incapable of expressing strong emotions Cold, detached and flat. Lacks emotional response Little capacity for intimate relationships . No desire for social/sexual r’ships Few friends. Indifferent to others, social norms and conventions Solitary pursuits Natural tendency to direct ones attention to ones inner self Prone to introspection and fantasy. Function well so no Rx really given . Schizotypal personality disorder : Oddities of appearance, behaviour, speech Anomalies of thinking similar to schizophrenics. E.g. Odd beliefs, magical thinking, suspiciousness and unusual perceptual experiences Fear social interaction and see other people as harmful Development of ideas of reference (not delusions) where they think everything is related to them, even though they know it is irrational. High chance of becoming schizophrenic.

7. Dissocial/antisocial personality disorder : M>W Callous unconcern for the feelings of others Dangerous anti-social behaviour. No signs of remorse. Disregards social rules and obligations, irritable and aggressive, acts impulsively and lacks guilt Lots of relationships but generally fiery, turbulent and short Most highly correlated with crime BEDWETTING, CRUELTY TO ANIMALS & PYROMANIA ( macdonalds triad) ? Underlying brain dysfunction Emotionally unstable/borderline personality disorder : Lack a sense of self, feel empty and fear abandonment Pattern of intense but unstable relationships, emotional instability, anger and violence May have transient psychotic episodes due to intensity of emotions May be involved in mutilating behaviour/ODs Poor self control Emotions experienced with unbearable intensity Threats of suicide/self harm common Often due to child sex abuse. W3:1M.

8. Histrionic personality disorder Lack a sense of self-worth, depend on attention and approval of others. Often thought to be dramatising/”playing a part” to attract and manipulate attention. SHALLOW, labile affect. Self-absorbed and cannot form lasting r’ships Great care of appearance and behave charmingly/seductively Act on impulse, crave excitement. “ACTING OUT” Superficial or insincere when dealing with people Sensitive to criticism and rejection. React badly to loss or failure. Narcissistic personality disorder: grandiose sense of self-importance Sense of entitlement and a need to be admired. Envious of others and expects people to be jealous of him Lacks empathy and readily exploits others to reach his goal. May seem controlling, self-absorbed, intolerant and selfish Provoked into fit of anger and revenge seeking if slighted or ridiculed. Ego defence: denial, distortion and projection.

9. Anankastic personality disorder Excessive preoccupation with details , rules, lists, order, schedules. Cautious and anxious. Perfectionism so extreme it prevents the task being completed Expense of leisure and relationships: pedantic and stubborn Doubting and cautious, rigid and controlling. View their obsessions as rational. Anxious-avoidant personality disorder Constant feeling of apprehension and low self esteem Fear of social inadequacy and inferior- ness Fear of being embarrassed, criticised or rejected May be linked to rejection in childhood, strong link with anxiety disorders. Excessive monitoring of reactions to everything. HYPERSENSITIVE

10. Dependent personality disorder : lack of self-confidence and excessive need to be taken care of. Need lots of help to make decisions. Greatly fears abandonment, go through extreme measures to secure and maintain relationships. Naive and child like attitude. Helplessness. DDx – affective disorders, substance misuse, psychotic disorders, anxiety disorders, OCD, learning disability, dementia and autism. Mx : lifelong but tend to mitigate in middle/old age as people grow and gain wisdom. Emotional and practical support, psychological therapies, monitoring and crisis intercention . Complications: depressive disorder, substance misuse, accidents, DSH and suicide. Socially unemployment, homelessness and criminal activity. Up to 75% prison inmates have personality disorders! Antisocial the most common one by far.

11. Eating Disorders Markedly disordered eating due to profound emotional disturbance in specifically predisposed people Core features: Psychological: low self-esteem, over evaluation of weight/shape/eating control, drive for thinness, fear of weight gain/fatness, body image distortion, total preoccupation with food/weight/eating Behavioural: dietary restriction, overeating/binge eating, compensatory behaviours (purging/non-purging) Physical: weight loss, amenorrhoea, decreased libido, delayed growth Anorexia Nervosa Bulimia Nervosa Eating disorder not otherwise specified e.g. : binge eating disorder (associated with obesity. Binge but no compensatory behaviours). Disorders of eating that resemble AN/BN but do not meet specific diagnostic criteria

12. Aetiological Factors Lack of control in other aspects of their lives, want something they can take full control over Any age, Boys or Girls (more commonly girls but rising in males) Low self-esteem : child abuse, bullying, lack of attention Can be attention seeking Not being able to cope with the pressures of life (control) Emotional struggle: problems with family, relationships, finance, job, unemployment ProAna websites: give eachother inspiration and tips etc Predisposing factors: genetics, FHx , early trauma, weight/dieting Hx , personality/self-esteem Precipitating: difficult transitions, adverse life events, extreme dieting Prepetuating : starvation syndrome, vicous behavioural cycles, stressors

13. Anorexia Nervosa Deliberate dietary restriction leading to marked weight loss or growth failure BMI >17.5 Intense fear of gaining weight or becoming fat Body image disturbance; overevaluation of weight/shape; denial of seriousness of low weight Amenorrhoea (absence of >3 menstrual periods) Bulimia Nervosa Recurrent binge eating (large amounts, 2hour period, lack of control) Compensatory behaviours: self-induced vomiting, laxatives, diuretics, exercise Binge eating and compensatory behaviours occur at least 2x/week for 3months Overevaluation of body weight/shape

14. “Multi-impulsive” ED Significant trauma histories and associated psycopathy Selfharm /suicidality, substanse misuse, sexual promiscuity, increased spending, stealing... Symptoms more related to mood than dietary restriction Link with borderline personality disorder etc Common major co-morbidities of eating disorders Depressive disorder Anxiety disorder OCD PTSD PD Substance misuse BDD

15. Consequences Individual Physical: Starvation: hypothermia, lanugo hair, bradycardia, hypotension, GI disturbance, myopathy , anaemia, hypoglycaemia, infertility, OP Binge-eating: Russell’s sign ( calluses on the knuckles or back of the hand due to repeated self-induced vomiting over long periods of time.), electrolyte disturbance (hypokalaemia), arrythmia , parotitis , oesophageal tears, acute gastric dilatation, pancreatitis, rectal prolapse , perimyolysis Refeeding : electrolyte disturbance ( hypophosphataemia ), cardiac failure, acute pancreatitis, convulsions, coma Others: fluid overload/ hyponatraemia (weight falsification), musculoskeletal injury/increased CK ( overexercising ) Family Society Services

16. AN associations Premorbid personality Anxious/avoidant Anankastic/obsessional Achievement-oriented/ perfectionistic Alexithymic (difficulty experiencing/expressing emotion) or inhibited Autistic etc IT SERVES A PURPOSE!!! Avoided: negative emotion, frightening change, family disruption Gained: control, safety, attention, regard, self-esteem, value, achievement, specialness, anxiety relief, mood lift Expressed: anger, frustration, guilt, self-hatred (self-punishment) Outcome: AN: Mortality 5%, full recovery 47%, partial recovery 34%, chronic illness 20% BN: recovery 50%, partial recovery 30%, chronic 20%

17. SCOFF questionnaire Do you make yourself S ICK because you feel uncomfortably full? Do you worry you have lost C ONTROL over how much you eat? Have you recently lost more than O NE stone in a 3 month period Do you believe yourself to be F AT when others say you are too thin Would you say F OOD dominates your life 2+: further questioning

18. Assessment Establish rapport History-taking: c hronology, c ore features: eating pattern, compensatory behaviours, weight history, endocrine Hx . , c omplications, c omorbidity , c ontact with services. Mental state examination Physical Examination Further investigations Collateral Hx Repeated interviews Risk Assessment Physical: BMI (trend), medical complications Psychiatric: suicidality, major comorbidity Social: home situation, child protection issues Services: appropriate care environment?

19. Anorexia And Bulimia BMI: 19-25 Normal range <17.5 Part criteria for AN <15 Worrying (physical safety) <13.5 Very worrying (?admission) <12 extremely worrying (“critical”) NICE AN: competent outpt psychotherapy, skilled inpt refeeding , specific family interventions BN: CBT, SSRI ENDOS: treat similarly, CBT/SSRI for BED Management Practical, General, Physical: (medical, nutritional, pharmacological), Psychological, Social and Others

20. Starvation Syndrome Starvation effects can resemble/intensify primary features of anorexia nervosa and make it harder to recover Obsessionality , cognitive rigidity, preoccupation with food/eating, cravings, constriction of interests, social isolation, increased drive for thinness, body image distortion ***Hence priority of weight restoration

21. Anorexia Nervosa Bulimia Nervosa Risk Management: history, examination, investigations Risk Management: history, examination, investigations Engagement: being non-judgemental, willing to listen, appreciate the complexity/severity, try instil some hope Engagement: being non-judgemental, willing to listen, appreciate the complexity/severity, try instil some hope Nutritional restoration: restore weight, watch electrlytes , normalise eating patter, practicalities of managing food, principles of healthy eating CBT: specifically adapted for BN Competent Psychotherapy: work through internal conflicts SSRI: 60mg fluoxetine daily. Competent psychotherapy Support for families/carers Support for families/carers

22. Substance Misuse Substance = alcohol, illegal drugs, prescribed drugs, OTC drugs and chemicals such as solvents Misuse = use that creates problems/harm to the individual or others SM = Taking drugs/alcohol in a way that adversely affects health: physical and psychological The use of prescribed drugs in a way other than intended by the prescriber Neurophysiology of addiction: psychoactive substance misuse characterised by reward, tolerance and neuroadaption, withdrawal and dependence Codeine misuse is a HUGE problem, opiates too

23. Clinical Assessment Drug type, route and duration of use: symptoms with cessation and last use (misuse diary for those in long term care) Start using- when, what, why. Escalating – what else, more often, when, withdrawal when stopped?? Social: relationships, forensic Hx Risk factors, symptoms and previous testing for BBVs PMHx and review of symptoms of chronic misuse: malnutrition, TB, trauma, endocarditis and STDs Mental Health Hx Physical Exam: vital signs and cardiac status for signs of fever, murmur, haemodynamic instability. SKIN for areas of scarring, atrophy and infection (SITE of injection: neck/groin- infection risk) Lab Evaluation: FBC, comprehensive chemistry panel, HIV, ECG, CXR, STD screening Urine drug screens and breath analysis of alcohol Alcohol: AUDIT or SADQ questionnaires

24. Dependence Craving Increased tolerance Salience of drug-seeking behaviour (getting drug most important thing in daily life) Narrowing of repertoire of drug taking behaviour (routine) Repeated withdrawal symptoms Relief or avoidance of withdrawal symptoms Reinstatement of drug taking after a period of abstinence Loss of control: difficulty with onset, termination or level of use and continued use despite knowledge of harm Class A: Heroin, methadone, cocaine, ecstasy, LSD. Possession 7yrs, supply LIFE Class B: cannabis, amphetamines. Possession 5years, supply 14yrs Class C: diazepam, lorazepam, temazepam. Possession 2yrs, Supply 5yrs

25. Cannabis: smoked/oral Onset within minutes – last hours Detected in urine up to 3 weeks after use. Stored in FAT CELLS Intoxication: dry mouth, red eyes, tachycardia, distorted passage of time, perceptual abnormalities, paranoia, panic, dependence, respiratory disease Psychosis: x2 risk schizophrenia, more violent LSD Act via serotonin systems in brain Taken orally, last up to 12 hours Intoxication: dilated pupils, tachy , HBP, distorted reality, visual hallucinations, thoughts/memories can re-emerge vividly, panic and fear can develop (bad trip) Withdrawal: no physical dependence, no substitutes, JUST STOP, flash backs can occur for years of trips Psychosis: in a minority of users

26. Ecstasy Party drug, big in 80-90s Oral, brings euphoria and empathy Neurotoxic to serotonin neurones A/Es: hyperthermia, polydipsia (why people die: overhydration), hyponatraemia (cerebral oedema) , seizures and arrhythmias, jaw grinding (CHARACTERISTIC) Low mood, anxiety, poor concentration Amphetamines “speed” Taken to get a “high” Sudden withdrawal: crash, dysphoria and craving Used as diet pills and for depression in the past. Now just narcolepsy A/Es: agitation, insomnia, HBP, arrythmias , seizures, circulatory collapse, positive on drug screen for 2-3days. Can induce paranoid psychosis , similar to schizophrenia. Tends to resolve after 3days

27. Benzodiazepines Diazepam (classical BDZ), lorazepam and temazepam Varying half lives, taken orally Taken for anxiolytic effect Acute intoxication: forgetful, drowsy, decreased concentration and coordination Chronic use: low mood, problems with concentration and memory Rapid development of tolerance in matter of weeks Withdrawal can be complicated by seizures and delirium Withdrawal: Psychological Symptoms Excitability Restlessness Insomnia, nightmares Increased anxiety, panic attacks Depersonalisation/derealisation Hallucinations Depression SERIOUS AND VERY UNPLEASANT Withdrawal: Physical Symptoms Tingling, numbness, altered sensation Weakness and pain Fatigue Flu like symptoms Muscle twitches, jerks, tics Tremor Dizziness, light headedness Blurres /double vision Tinnitus Hypersensitivity: light, sound, touch, taste, smell

28. Cocaine Euphoria, increased activity Hallucinosis: auditory and visual Frank psychosis Formication: feeling of insects crawling under skin After high: crash dysphoria, depression/anxiety, anorexia, exhaustion, HBP, tachy , arrythmias Cardiac A/Es: vasoconstriction of coronary system: chest pain long term use fibrosis and hypertrophy Crack cocaine Powerfully addictive form of cocaine Mixture of cocaine and bicarbonate of soda: base so absorbed much more readily Stronger, more addictive, typically smoked, rapidly absorbed Faster but shorter high A/E same as cocaine Stimulant Withdrawal: Easier to stop abruptly Rebound effects: Tiredness Depression Hunger Social withdrawal PSYCHOSIS

29. Heroin: Natural opiate (poppy) Intoxication: pupil constriction, constipation, N&V, drowsy, RESPIRATORY DEPRESSION In urine for 1-2 days Not associated with frank psychosis NB other opiates e.g. Codeine Physical issues: Purity is variable so can lead to accidental OD Method of use: oral, snorting, smoking, injecting (late on will inject anywhere: bad!) Neglect of functions: social, occupational, hygiene etc Putting other people at risk Dangers of injecting: can hit an artery and cause ischaemic damage Can introduce infection: septicaemia, endocarditis, BBV Can cause embolus Vein becomes hardened Abscess OD (often accidental)

30. Heroin Withdrawal “cold turkey” Withdrawal symptoms peak at 72hours but last 5-7days Craving can persist for weeks Very unpleasant but not life threatening (unlike using heroin!!!) Restless, anxious, lacrimination, rhinorrhoea, sweaty, piloerection (hairs stand up), N&V, diarrhoea, muscle cramps, insomnia Lofexidine ( britlofex ) Used in opiate detoxification 0.2mg Alpha noradrenergic agonist (like clonidine ) Alleviates withdrawal symptoms Not a substitute drug A/Es: low BP, bradycardia (Needs daily monitoring) Symptomatic relief: Buscopan 10mg 4-6hourly PRN for GI spasm Lomotil 2tabs/6hours for diarrhoea Chlorpromazine 25mg nocte for anxiety/insomnia

31. Patients who have injected: Counselling and testing for HIV, Hep B&C Vaccination HepB if seronegative Referral to liver specialist for HepC + pts Education about risks of injecting and sharing Harm minimisation Clean needles and works – pharmacy exchange programme Education on dangers, safe practice and safe sex Motivational counselling Consider substitution Nalorex : opiate antagonist Naltrexone hydrochloride, blocks opiate receptors so low effect of opiate drugs Pt must have withdrawn for 7-10days Non addictive, no high Long term, need LFT monitoring Reduces relapse risk by blocking “good” effect of opiates

32. Abstinent Pts Referral to specialist drug services for counselling and rehab Support counselling to maintain abstinence Relapse prevention techniques Rehab issues: housing, jobs, different group of friends Triggers for relapse Negative emotional states: anger, sadness, trauma, stress Physical discomfort: pain or withdrawal symptoms Positive emotional states: wanting to feel even better Testing personal control: I CAN have only one drink... Strong temptations or urges (cravings of use) Conflict with others: argument with partner Social pressures

33. Alcohol Abuse 1 unit = 8g ethanol/ 10mls absolute alcohol Men: 21units/week, 4 (6) in a day Women: 14units/week, 2 (4) in a day Alcohol related illness: GP visit x2 other pts 1/3 men and 1/10 women drink above the maximum recommended levels for a prolonged period of time Men drink 3x that of females ¼ men will be problem drinkers at some point of their lives MALE: onset alcoholism late teens/20s. Often insidious course. Recognition of alcohol dependence often not til 30s FEMALE: onset later, more likely to drink alone and delay in seeking help, higher rates of depression Common in those whose jobs have unsociable hours, shift work and easy access to workers

34. Aetiology Genetics: x7 risk in alcoholism in firs degree relatives Biochemical: changes in serotonin Psychological: death wish, self-destructive behaviour Sociocultural: peer group 1 unit: ½ pint ordinary strength beer/lager 1 glass wine 1 glass sherry 1 single measure spirits Alcopops : 1 bottle = 1.5 units 1 can extra strong beer = 4units Hazardous Drinking: Male 22-50 units/week Female 15-35 units/week Harmful Drinking: Male >50 units/week Female >35 units/week

35. History Pattern: Binge pattern compared to daily consumption Type of alcohol Time of day Drinking alone/in company Frequency of drinking Intensity of drinking CAGE questionnaire Have you ever thought you should C UT DOWN on your drinking? Has anybody ever A NNOYED you by criticising your drinking? Have you ever felt G UILTY about your drinking? Do you take a drink in the morning to steady yourself: E YE OPENER? AUDIT Investigations Physical examination Lab Investigation AST ALT GGT MCV FBC Blood tox screen Treatments Acute detoxification Long term maintenance Relapse prevention

36. History Dependence: A strong desire/sense of compulsion to take the substance Narrowing of drinking repertoire Withdrawal symptoms with relief drinking (in the morning) Evidence of tolerance Progressive neglect of other interests Difficulty controlling alcohol use despite evidence/awareness of harm Reinstatement after abstinence -3 features over last 6 months = Alcohol Dependence Syndrome Past treatment AA Detox programmes: self/GP, home/hospital Community addictions teams referral Residential programmes

37. Consequences HEALTH : oesophagitis, mallory weiss tears, aspiration pneumonia, pancreatitis, cardiac arrhythmias, liver damage/cirrhosis, peripheral neuropathy, hypoglycaemia, gastritis, CVA, HTN, infertility SOCIAL : relationships (divorce), family, children, violence and accidents, debts EMPLOYMENT: Monday absences, lunch time drinking, poor performance, dismissals FORENSIC : drunk driving, violence Co-morbidity 47% alcoholics have another psychiatric disorder: Depression Anxiety Anti-social personality Drug dependence Suicide is more common: x50 risk!!!!! DSH more common

38. Alcohol Withdrawal Syndrome In 95% symptoms occur within hours of last drink and peak within 24-48hrs Restlessness, tremor, sweating, anxiety, N&V, anorexia, insomnia, tachycardia and HTN Withdrawal seizures may occur within 24-36 hours Detoxification Alcohol withdrawal associated with significant morbidity and mortality CHLORDIAZEPOXIDE ( librium ) 10-20mg QID (BDZ, similar family to alcohol, addictive so careful) Reduce slowly over 1 weel B1 thiamine replacement Anti-epileptics may be required CHLORDIAZEPOXIDE/LIBRIUM

39. Wernickes Encephalopathy Acute syndrome Caused by THIAMINE deficieny Medical emergency, treated with IV thiamine (PABERNAX) which reverses the encephalopathy Disorientation, confusion, ataxia, ophthalmoplegia , neuropathy Precedes Korsakov's Korsakov’s Syndrome Chronic syndrome, following WE Confabulation : make things up to fill gaps in memory Normal digit span memory but impairment of short term memory No new learning Wernicke -Korsakov Outcome High acute mortality: 17% Amnesic syndrome: ¼ recover ¼ partial recovery ½ no recovery Important to have early diagnosis Important to give THIAMINE

40. Delirium Tremens 1-4 days after selective/absolute withdrawal of alcohol 1-5% mortality Trauma/infection present from outset in 50% cases Biochemical evidence of liver damage in 90% Some present insidiously with night time confusion TREMOR AND CONFUSION Vivid hallucinations, delusions, confusion, inattention, agitation and autonomic changes ( tachy , HTN) Rx: Early diagnosis IV diazepam Fluid & electrolyte replacement IV thiamine Risk Factors for DTs and Seizures: Severe alcohol dependence PHx DTs Long Hx alcohol abuse Old age Concomitant acute illness Severe withdrawal symptoms at presentation

41. Alcoholic Hallucinosis In clear consciousness (compared to DTs) Long standind drinkers Derogatory auditory hallucinations (like schiz ) Seen as substance-induces psychosis Prognosis GOOD Responds to anti-psychotic medications and abstinence Small %, symptoms last 6m Treatment of Alcohol Abuse Disulfiram ( antabuse ) Inhibits aldehyde dehydrogenase that normally metabolises acetaldehyde If + alcohol: flushing, headache, N&V If ++ alcohol: hypotension and collapse Acamprosate ( campral ) Decreases craving Naloxone Opiate antagonist, stops higher effects of alcohol CBT Motivational interviewing AA

42. Addictions Addiction is an attachment to, or dependence on, any substance/thing/person/idea so single minded and intense that virtually all other realities are ignored or given second place – and consequences (even lethal ones) are disregarded Phases of drug addiction: Initiation and development phase Continuation phase Relapse phase Routes of drug use: oral (sublingual), smoked, inhaled, sniffed/snorted, subcutaneous, IV, IM Dependence: Compulsion Impaired control Withdrawal Tolerance Salience Persistent use despite harm 3+ in last 12 months

43. Reward Pathways Drugs of dependence release dopamine causing a reward effect, linked to D2 receptor pathway. Drugs hijack normal reward pathways so things that used to make you happy no longer do All drugs of misuse except LSD and BDZs act on dopamine reward pathway Tolerance/adaptation: Receptor levels increase or decrease Transmitter production increases or decreases Metabolism (enzyme inhibition/induction) Body tried to adapt while drinking etc so once you stop “withdrawal” symptoms are experienced