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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Basicobservationsmayshow:
Bradycardia
(Postural)Hypotension
Lowtemperature Weight:
ParticularlyhighorlowBMIforage ECG:
AnECGshouldbedoneifanyofthefollowingapply:
Veryrapidweightloss Excessiveexercise Severepurgingbehaviour Currentbradycardiaorpreviousarrhythmias Hypotension Highcaffeineintakeoruseofothermedications Muscularweakness
Electrolyteimbalance Commonabnormalitiesincludebradycardia,↑QTc, andchangesrelatedtohypokalaemia (↑ amplitude and width of P waves, PR elongation, T wave flattening and inversion, ST depression,andUwaves).
Bloods
Afullelectrolytepanelincludingsodium,potassium,calcium,glucose,magnesium,andphosphate shouldbechecked.Commonabnormalitiesinclude:
Hyponatraemia Hypokalaemia Hypoglycaemia
Impairedrenalfunctionandraisedtransaminasesarealsocommon.
Management
Consider whether the patienthas capacity to make their own decisions (see Chapter
112).UseoftheMentalHealthActmayberequiredifthepatientisrefusingtreatment
andhassignificantimpairmentofdecision-makingabilities.
Considerwhetherthepatientneedsanurgentreferraltospecialistservices,oriftheyrequire acutemedicalcareduetoelectrolyteimbalancesordehydration.
Patienteducation
Explaintothepatientaboutthenatureofthedisorder,andtherisksandbenefitsoftreatments Patientsshouldbeadvisedthatlaxativesanddiureticswillnotaidweightloss.
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Lifestyleandsimpleinterventions
Ifvomiting,advise:
Regulardentalreviews Avoidimmediateteethbrushingaftervomiting Avoidacidicmouthwashes,foods,ordrinks.
Psychologicalinterventions
Considerstructuredself-help,structuredspecialisttherapyprogrammes,orCBT.
Pharmacologicalmanagement
Medicationaloneshouldnotbeusedasatreatmentforanyeatingdisorder Medicationshouldonlybeprescribedunderspecialistguidance Considerlikelycomplianceandmedicationriskswhichmaybeexacerbatedduetomalnutrition EnsureECGmonitoringiscarriedoutifamedicationcouldaffectcardiacfunctionaspatientsare pronetoarrhythmiassecondarytomalnutrition Oralsupplementationispreferableforthetreatmentofelectrolyteimbalance,unlessthereisvery severeimbalanceorthepatientisunabletoabsorbenterally.
Psychosocialconsiderations
Beawareofpotentialsocialandfamilyissuessuchasbullyingandabuse Patientsandfamilymayfeelguiltyandthisneedstobeaddressedfortreatmenttobesuccessful Eating disorders are often heavily stigmatized and this may cause patients to avoid accessing treatments Eating disorders often affect young people so psychological interventions need to be age appropriate.
Complications
Request specialist paediatric/endocrine advice if physical growth and development has been affected Considerbonemineraldensityscanningafter1yearofbeingunderweightifage<18years,orafter 2 years if age >18 years. Scan earlier if recurrent fractures or bone pain. Repeat annually if ongoingconcerns.Ifabnormal,thepatientmayrequirehormonalorbisphosphonatetreatmentfrom a(paediatric)endocrinologist.
Monitoringandfollow-up
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Ifthepatientdeclinestreatmentandtheissuesarenotcomplexorsevere:considerdischargingto primarycareandre-referringasneeded If thepatientdeclinestreatment andhasissueswhicharecomplexorsevere:continuetosupport withinputfromeatingdisorderservices Monitor weight/BMI,bloodpressure,bloods, andECGatleastannually. Theassessment should includeariskassessmentandadiscussionofongoingtreatmentoptions Monitorgrowthanddevelopmentinchildrenandyoungpeople.
Furtherreading
1.RoyalCollegeofPsychiatrists(2014).MARSIPAN:managementofreallysickpatientswithanorexia nervosa, 2nd ed (CR189). Available at: https://www.rcpsych.ac.uk/docs/default-source/improving-
care/better-mh-policy/college-reports/college-report-cr189.pdf?sfvrsn=6c2e7ada_2
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Chapter40
Generalizedanxietydisorder
Guideline:NICECG113(Generalisedanxietydisorderandpanicdisorderin
adults:management):https://www.nice.org.uk/guidance/cg113
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
The main feature of generalized anxiety disorder (GAD) is excessive worry regarding multiplethings,associatedwith↑tension.
Diagnosis
History/diagnosticcriteria
Consider GAD if recurrent primary care attendances, with significant worry or anxiety over a range of issues. It tends to present in those who have chronic physical health problemsand/orregularlyneedreassuranceonvarioussymptoms.
Askabout:
Currentandpastphysicalandpsychiatrichistory Previoustreatmentstrialled Comorbidsubstanceabuse.
DSM-5criteria
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Extreme/disproportionateanxietyorworry,occurringonmostdays,regardingmultipleevents Occursfor>6months Difficultycontrollingworry Additionalsymptoms—threeormoreof:
Feelingrestlessor‘onedge’ Becomingfatiguedeasily Difficultyinconcentrating Irritability Musculartension
Sleepdisruption Clinicallysignificantdistressorfunctionalimpairment Symptomscannotbeattributedtoanothercauseordisease.
Examination
Nospecificexaminationrequired.
Investigations
Nospecificinvestigationrequired.
Management
Managementstages
Stage1:anypresentationofGAD:
Identification,assessment,education,activemonitoring Stage2:GADnotimprovedwithstage1management:
Lowintensitypsychologicalinterventions Stage 3: GAD with poor response to stage 2 management OR GAD with marked functional impairment:
High-intensitypsychologicalinterventionsORpharmacologicaltreatment Stage 4: treatment refractory GAD OR high risk of self-harm or self-neglect OR complex comorbidities:
Specialisttreatment.
Patienteducation
Informthepatientregardingthediagnosisandtreatmentoptions Patientsshouldbemadeawareofthelackofevidenceforover-the-countermedications,andalso theriskofdruginteractionswhenusingthem.
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Lifestyleandsimpleinterventions
Avoidcaffeine,excessalcohol,andillicitdrugs.
Psychologicalinterventions
Ifnoimprovementwithstage1,offeroneormoreofthefollowing(stage2treatments):
Individualnon-facilitatedself-help Individualguidedself-help Psychoeducationalgroups.
If poorresponse to stage2, ormarked functional impairment (i.e. stage3disease),and thepatientwishestouseapsychologicalintervention,offereither:
CBTOR Appliedrelaxation.
Ifthepatientdoesnotrespondtothisordoesnotwishtousepsychologicalinterventions, progresstopharmacologicalmanagement.
Pharmacologicalmanagement
Ifapatientatstage3choosespharmacologicalmanagement:
SSRIs are first line e.g. escitalopram 10mg OD. Note that they may take a week to reach full anxiolyticeffect Secondline:serotonin–noradrenalinereuptakeinhibitor(SNRI),oralternativeSSRI Avoidbenzodiazepines,asidefrominanacutecrisis.
Whenprescribing,consider:
Riskofwithdrawalsyndrome Sideeffectprofile(Table40.1) Potentialdruginteractions Risk of suicide and toxicity in overdose. Inform patients aged <30 years of the small risk of suicidalideation/self-harmwhenusingSSRIs/SNRIs.
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Table40.1SideeffectsofmedicationsusedinGAD
Commonsideeffect/risk Exampleofcausativemedication
Riskofwithdrawalsyndrome Paroxetine,venlafaxine
Riskofsuicideandtoxicityinoverdose AllSSRIsandSNRIs,especiallyvenlafaxine
↑anxiety/agitation/insomnia AllSSRIsandSNRIs
↑riskofbleeding SSRIs
↑riskofsuicidalthinkingandself-harminthoseaged<30years AllSSRIsandSNRIs
Psychosocialconsiderations
Supportcarerswhereappropriate.
Monitoringandfollow-up
Reviewmedicationsevery2–4weeksforthefirst3months,andthen3-monthly Ifthemedicationisineffectiveornottolerated,consideranalternativedrugandofferthepatienta high-intensitypsychologicalintervention.Ifthepatientpartiallyrespondstomedication,consider addingahigh-intensitypsychologicaltreatment Medicationsshould betaken foratleast1year beforeattempting towean,to reducetheriskof relapse.
Specialconsiderations
Patients with stage 4 GAD (treatment refractory/high risk of self-harm or self­neglect/complexcomorbidities)shouldbeofferedaspecialistassessment.
1AmericanPsychiatric Association.(2013).Diagnosticandstatistical manual ofmentaldisorders(5th
ed.).https://doi.org/10.1176/appi.books.9780890425596
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Chapter41
Panicdisorder
Guideline:NICECG113(Generalisedanxietydisorderandpanicdisorderin
adults:management):https://www.nice.org.uk/guidance/cg113
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Themainfeatureofpanicdisorderisrepeated,unpredictableepisodesofpanic,followed bypersistentconcernregardingfuturepanicattacksandtheconsequencesofthis.
Diagnosis
History/diagnosticcriteria
DSM-5criteria
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Panicattack
Asuddensurgeofintensefearordiscomfortwhichreachesapeakwithinafewminutes, including≥4ofthefollowing:
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Chestpainordiscomfort Derealizationordepersonalization Dizzinessorfaintness Fearofdying Fearoflossofcontrol,orfearofgoingcrazy Feelinghotorcold Nauseaorabdominaldistress Numbnessortingling Sensationofchoking Sensationofshortnessofbreathorfeelingsmothered Shakingortrembling Sweatiness Tachycardiaorpalpitations.
Panicdisorder
Recurrentpanicattacks ≥1panicattackfollowedby≥1monthofpersistentconcernaboutfutureattacks,orconcernabout theimplicationsofattacksorasignificantchangeinbehaviourrelatedtoattacks.
Rememberpanicattack≠panicdisorder.
In the past medical history, ask about depression and substance abuse as these are commoncomorbidities.
Examination
Amentalstatusexaminationmayrevealthesymptomspreviouslylisted.
A general physical examination should also be performed to consider alternative
explanationsforthesymptomsofpanicdisorder.
Investigations
No specific investigations are required, although they may be useful to eliminate other possibledifferentialdiagnoses, e.g.ECG,urinetoxicology, cardiacenzymes,FBC,U&E, glucose,TFT,andD-dimer.
Management
Atpresentation:
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Checkifthepatientisalreadyreceivingtreatmentforpanicdisorder Onlyperforminvestigationswhicharerequiredtoexcludeacutephysicalpathology Avoid admitting the patient if possible, as many patients are better managed in primary or communitycare.
Patienteducation
Inform (including written information) about panic disorder and treatment options, includingsupportgroupsifavailable.
Lifestyleandsimpleinterventions
Exerciseaspartofahealthylifestyle.
Psychologicalinterventions
Individualnon-facilitatedorfacilitatedself-help(ifmildtomoderate) CBT(ifmoderatetosevere).
Pharmacologicalmanagement
Formoderatetoseverepatients,ifCBTisnotsuitableordesired:
First line: any SSRIlicensedfor panic disorder, e.g. sertraline25mgODfor 1 week, then↑to 50mg,then↑furtherifrequiredtomaximum200mg/day Secondline:tricyclicantidepressants,e.g.imipramineorclomipramine
Avoidbenzodiazepines,sedatingantihistamines,andantipsychotics.
Prescribingtips
Warnpatientsthattheiranxietylevelmayincreasebrieflywhentheystarttreatment Patientsshouldalsobeawareofothersideeffectsandwithdrawalsymptomsandshouldknow nottostopmedicationssuddenly Take intoaccountthelikelihoodof accidental overdose or deliberateself-harm (overdose or otherwise) when prescribing (consider weekly dispensing); the risk is highest with tricyclic antidepressants Ifthereisnoimprovementafter12weeks,tryanalternativemedicationortherapy Ifatreatmentiseffective,itcanbeusedlong-term.
Monitoringandfollow-up
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