Anorexia nervosa, or major depression

1. Patient #1 comes to your office because of weight and appetite complaints. Two doctors argue. One says it’s Anorexia Nervosa. The other says it’s Major Depression.

– What are 3 questions you would ask to the patient to verify which disorder is causing the issues;

– Discuss the similarities and differences between the two disorders in terms of symptoms and causes (biological, psychological and social).

The first question I would ask is if the patient is participating in behavior that interferes with weight gain such as dieting, fasting, excessive exercise, or purging. Although, depression may cause certain behaviors that interfere with weight, Anorexia Nervosa involves a purposeful and persistent behavior with efforts to control or lose weight. Weight loss that comes with MDD is usually unintentional, while the center of anorexia is to have control over weight. The second question I would ask is if the patient is in a depressed mood most of the day, nearly everyday. A depressed mood, is of course a defining symptom of MDD. While those with Anorexia may experience a depressed mood it’s not as consistent and frequent as MDD. With AN, the heart of the disorder is the intense fear of gaining weight, not necessarily depression. The third question I would ask is if the patient is experiencing anhedonia, or the diminished pleasure or interest of things that used to bring pleasure. This is a common symptom of those suffering from MDD. Those with MDD will stop participating in usual activities because they become unable to experience pleasure anymore. On the other hand, those with anorexia nervosa will stop participating in activities due to being too preoccupied with their restrictive behaviors. A similarity between the two disorders is a symptom for both is a significant amount of weight loss. For causes, the biological approach suggests that both disorders are possibly caused by the decrease in serotonin in the individual. Both disorders are also more frequently diagnosed in women than men. Differences in symptoms include acts of restriction, binge-eating and purging in Anorexia that cause changes in weights. The duration of the symptoms in order to receive a diagnosis are different. MDD has a duration of 2 weeks, while AN has a duration is 3 months. Psychodynamic causes in MDD include a reaction to a real or imaginary loss. In AN, psychodynamic causes include 3 important factors: ego deficiencies, perceptual differences, and ineffective parents that all contribute to issues regarding how much one eats.

2. Patient #2 comes in complaining of gastrointestinal issues. These have been present for the better part of a year now. She has lost weight because of it. She insists that something is wrong with her but she doesn’t know what exactly. Two possible diagnoses for this are: Generalized Anxiety Disorder and Somatic Symptom Disorders. – What are 3 questions that would help you distinguish one disorder from the other? What important information would each question provide? – Discuss three reasons why these two diagnoses could be easily mistaken.

The first question I would ask is if the patient is experiencing an excessive amount of anxiety and worry about a number of events or activities. While someone with somatic symptom disorder may experience anxiety and worry, it is usually focused on their somatic symptoms and health. Someone suffering from GAD will experience anxiety from a range of different situations. The second question I would ask is if the patient is putting an excessive, distressing amount of time in energy into their symptoms. Those diagnosed with GAD will experience somatic symptoms such as the gastrointestinal issues but compared to somatic symptom disorder, they most likely won’t focus specifically on their symptoms. They will go to the doctors constantly, get tests done, avoid work due to the somatic symptoms, and spend money on medical bills. The third question I would ask if the patient feels the somatic symptoms are triggered by any particular event. Somatic symptoms in somatic symptom disorder are unexplained by any other reason or medical cause. On the other hand, somatic symptoms in generalized anxiety disorder are usually directly caused by the anxiety or worry the patient is experiencing. If the patient is experiencing the gastrointestinal symptoms after a period of anxiety or worry about an event/ activity it’s probably a cause and effect situation.While both disorders featuring somatic symptoms, it’s not a core feature of GAD. One reason these two disorders can be mistaken for eachother is because they both include a symptom of a significant amount of anxiety or worry that interferes with daily life. Another reason is both disorders include somatic symptoms such as muscle tension, weight loss, gastrointestinal issues, etc. Lastly, the two can be confused because they both have the same duration of six months of persistent symptoms.

3. Many media like to use the “violent psycho” stereotype. Discuss three disorders that maybe associated to increased risk of violence towards others. What would motivate aggression in each disorder? Is this aggression a core feature of the disorder or a possible consequence of the symptoms?

Three disorders that can possibly be associated with an increased risk of violence are schizophrenia, antisocial personality disorder, and bipolar disorder. Around 90% of those suffering from Schizophrenia experience delusions. These delusionals can vary among different categories but persecutory is the most common. This delusional is the belief that an individual or organizations are trying to harass or harm the person. Any delusional, but this one in particular may cause aggression because the individual feels particularly threaten. Another symptom, hallucinations may cause sensory modality that also might make the individual feel they have to be aggressive. This may be when an auditory hallucinations tells them to do something or a visual hallucination presents them with some kind of danger. Aggression isn’t a core feature of the disorder, but some of the symptoms may cause that reaction in particular individuals suffering from schizophrenia. Antisocial Personality Disorder features a disregard for and violation of other people. Due to a disregard for others and a lack of remorse, those suffering from antisocial personality are at a higher risk of displaying aggression. Aggression towards others may come easier to individuals diagnosed because they don’t care to conform to social norms or laws. Another symptom is impulsivity, which may cause those diagnosed to display aggression without thinking about the repercussions. Aggression can be a core feature because it’s quite common in the disorder but there are also those suffering from the disorder may choose to express their disregard in other ways. Lastly, those suffering from bipolar disorder may have a tendency to display aggression due to dramatic shifts in mood. A manic episode consists of a elevated or irritable mood along with high energy. This “top of the world” feeling or feelings of irritability may cause one suffering from the disorder to become easily frustrated. The shift back to a depressive episode may also cause feelings of frustration which they may project onto themselves or others. Aggression isn’t a core factor of bipolar disorder but can be a reaction to dramatic mood episodes.

4. Fear is at the heart of Panic Disorder, Specific Phobia and PTSD. Discuss how fear differs in its cause, object and symptoms between the three diagnoses. Then, discuss the similarities and differences between these diagnoses in terms of biological and psychological causes.

The cause of the fear behind panic disorder is the unexpected attacks and consistent worrying about having another panic attack. The object of the fear is the idea of losing control or the idea of dying. Some symptoms of panic disorder include recurrent unexpected panic attack with at least four elements of a panic attack, a persistent concern about additional panic attacks, and avoidance of triggers. Signs of a panic attack include swearing, accelerated heart rate, shaking, and shortness of breath. The cause of fear behind specific phobia is about the specific object or situation or having an encounter with it. The object of the fear differs from person to person and is specific to the individual. The five categories of phobias are animals, natural environment, blood-injection-injury, situational and others (objects, vomiting, clowns, etc.). Symptoms of the disorder include fear or anxiety about the object, avoidance of the object/situation, and immediate fear or anxiety when encountering the object/situation. The cause of fear behind Post Traumatic Stress Disorder is the reminders of a particular event and unwanted memories and thoughts that come along with it. The object of the fear is the event or trauma the individual experienced. Symptoms of PTSD are flashbacks, memories, behavioral or cognitive avoidance of reminders, and negative alterations in mood and cognition. A biological cause of PD is the neurotransmitter, norepinephrine which increases arousal. Another neurotransmitter, yohimbine mimics norepinephrine activity and can trigger a panic attack. The combination of norepinephrine and an overactivity in the amygdala create a panic response. Just like PD, the biological causes of Post Traumatic Stress Disorder feature the amygdala, a region of apart of the fear circuit. Differently, the behavioral cause behind specific phobia disorder is suggested to be fear through association and avoidance due to positive reinforcement of avoiding fear.