As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea. So we remove 1. One loses weight when one gets sad, worries, etc... 3 does not make sense in the MIR because of the clinic -in reality the history is different and in psychiatry everything is evolution-. 4 has to meet temporal criteria that are not met here. So we are between 2 and 5. Depression or anxiety? There is no anxiety clinic and she also meets the criteria for depression. The poor girl has been diagnosed with depression. The answer is 5 (another option is that she was studying the MIR).

As soon as we hear about weight we go to anorexia nervosa, but anorexia nervosa has three features: significant self-induced weight loss, body image distortion and amenorrhea. So we remove 1. One loses weight when one gets sad, worries, etc... [HIDDEN] -in reality the history is different and in psychiatry everything is evolution-. [HIDDEN]. So we are between 2 and 5. Depression or anxiety? There is no anxiety clinic and she also meets the criteria for depression. The poor girl has been diagnosed with depression. [HIDDEN] (another option is that she was studying the MIR).

A 19-year-old female university student comes to the clinic accompanied by her parents, reporting feeling progressively more asthenic in the last two months, with loss of appetite and weight and with greater difficulty in concentrating on her studies. The anamnesis also highlights that she has lost interest in going out with friends, has ideas of death without self-harming ideation and pessimistic cognitions of the future. Her weight is 90% of that considered ideal for age and gender. She does not present weight phobia or body image distortion. The most appropriate diagnosis is:

Growing Pains

In 1990, Tracey Gold began group therapy in an eating disorder program but only learned more ways to lose weight. That season, her weight loss problem was touched upon slightly on her television series, when Gold is seen looking at her body in a carnival mirror and describes to another character the distorted image in her head. In 1991, she started starving herself more than ever and vomiting, and lost a massive amount of weight, to the point that she was admitted to a hospital in early 1992. Her lowest weight is estimated to have been near 80 pounds. She was suspended from the show for her skeletal appearance. Photos of Gold's emaciated body were plastered all over tabloid magazines, and she was one of the first celebrities ever to be formally outed for anorexia. She last appeared in the 1991 episode, "Menage a Luke," after missing the two prior episodes where her problem is very obvious in some scenes and did not return until the last two episodes of the series in the late spring of

The Truth About Size Zero

During the course of the documentary, Redknapp visited different locations to talk to people. She visited with friend and actress Denise van Outen in Los Angeles, and they discussed van Outen's experiences with people the pressure to lose weight. She went to Rhodes Farm Clinic to meet with several young women who are recovering from anorexia or bulimia to talk about their experiences with eating disorders. She also met with Spice Girl Mel C ("Sporty Spice") to discuss her severe eating disorder during her time the Spice Girls and the media portrayal. She met with her school friend, "Sophie," who had suffered with a severe eating disorder during her teenage years, and they talked about the experience of low caloric intake. She visited her old stage school the Italia Conti Academy of Theatre Arts to talk with students and warn them about the horrors of crash dieting. She presented Clothes Show Live in Birmingham, and while she was there, she interviewed some models, and talked to a

Neurology_Adams

Reports concerning the percentage of first-degree relatives of anorectic patients with bipolar disease are also inconsistent. An increased prevalence of neurosis or alcoholism has been noted in other members of the family. However, psychiatrists seem to agree that the patient does not have symptoms that conform to any of the major neuroses or psychoses. Certainly loss of appetite, lack of self-esteem and interest in personal appearance, and self-destructive behavior—common features of anorexia nervosa—are also symptoms of depressive illness, yet most of the patients do not look or admit to being dejected. Moreover, endogenous depression affects both sexes. The pathologic fear of becoming fat and the obsession with weight might be interpreted as a phobic or obsessional neurosis.

Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl.

Trichotillomania (TTM) is defined by the Diagnostics and Statistic Manual of Mental Disorders, 4th edition (DMS-IV) as hair loss from a patient`s repetitive self-pulling of hair. The disorder is included under anxiety disorders because it shares some obsessive-compulsive features. Patients have the tendency towards feelings of unattractiveness, body dissatisfaction, and low self-esteem (1,2). It is a major psychiatric problem, but many patients with this disorder first present to a dermatologist. An 11-year-old girl came to our department with a 2-month history of diffuse hair loss on the frontoparietal and parietotemporal area (Figure 1). She had originally been examined by a pediatrician with the diagnosis of alopecia areata. The patient`s personal history included hay fever and shortsightedness, and she suffered from varicella and mononucleosis. Nobody in the family history suffered from alopecia areata, but her father has male androgenetic alopecia (Norwood/Hamilton MAGA C3F3). The mother noticed that the child had had changeable mood for about 2 months and did not want to communicate with other persons in the family. The family did not have any pet at home. At school, her favorite subjects were Math and Computer Studies. She did not like Physical Education and did not participate in any sport activities during her free time. This was very strange because she was obese (body-mass index (BMI) 24.69). She was sometimes angry with her 13-year-old sister who had better results at school. The girl had suddenly started to wear a blue scarf. The parents did not notice that she pulled out her hair at home. Dermatological examination of the capillitium found a zone of incomplete alopecia in the frontoparietal and parietotemporal area, without inflammation, desquamation, and scaring. Hairs were of variable length (Figure 1). There was a patch of incomplete alopecia above the forehead between two stripes of hair of variable length (Figure 2). The hair pull test was negative along the edges of the alopecia. Mycological examination from the skin capillitium was negative. The trichoscopy and skin biopsy of the parietotemporal region of the capillitium (Figure 3) confirmed trichotillomania. Laboratory tests (blood count, iron, ferritin, transferrin, selenium, zinc, vitamin B12, folic acid, serology and hormones of thyroid gland) were negative. We referred the girl for ophthalmologic and psychological examination. Ophthalmologic examination proved that there was no need to add any more diopters. The psychological examination provided us with a picture in which she drew her family (Figure 4). The strongest authority in the family was the mother because she looked after the girls for most of the day. She was in the first place in the picture. The father had longer working hours and spent more time outside the home. He worked as a long vehicle driver. He was in the second place in the picture. There was sibling rivalry between the girls, but the parents did not notice this problem and preferred the older daughter. She was successful at school and was prettier (slim, higher, curly brown hair, without spectacles). Our 11-years-old patient noticed all these differences between them, but at her level of mental development was not able to cope with this problem. She wanted to be her sister's equal. The sister is drawn in the picture in the third place next to father, while the patient's own figure was drawn larger and slim even though she was obese. Notably, all three female figures had very nice long brown hair. It seemed that the mother and our patient had better quality of hair and more intense color than the sister in the drawing. The only hairless person in the picture was the father. The girl did not want to talk about her problems and feelings at home. Then it was confirmed that our patient was very sensitive, anxious, willful, and withdrawn. She was interested in her body and very perceptive of her physical appearance. From the psychological point of view, the parents started to pay more interest to their younger daughter and tried to understand and help her. After consultation with the psychiatrist, we did not start psychopharmacologic therapy for trichotillomania; instead, we started treatment with cognitive behavioral therapy, mild shampoo, mild topical steroids (e.g. hydrocortisone butyrate 0.1%) in solution and methionine in capsules. With parents' cooperation, the treatment was successful. The name trichotillomania was first employed by the French dermatologist Francois Henri Hallopeau in 1889, who described a young man pulling his hair out in tufts (3-5). The word is derived from the Greek thrix (hair), tillein (to pull), and mania (madness) (5). The prevalence of TTM in the general adult population ranges from 0.6% to 4%, and 2-4% of the general psychiatric outpatient population meet the criteria for TTM (2-5). The prevalence among children and adolescents has been estimated at less than 1% (5). The disease can occur at any age and in any sex. The age of onset of hair pulling is significantly later for men than for women (3). There are three subsets of age: preschool children, preadolescents to young adults, and adults. The mean age of onset is pre-pubertal. It ranges from 8 to 13 years (on average 11.3 years) (2-5). The occurrence of hair-pulling in the first year of life is a rare event, probably comprising <1% of cases (5). The etiology of TTM is complex and may be triggered by a psychosocial stressor within the family, such as separation from an attachment figure, hospitalization of the child or parent, birth of a younger sibling, sibling rivalry, moving to a new house, or problems with school performance. It has been hypothesized that the habit may begin with "playing" with the hair, with later chronic pulling resulting in obvious hair loss (2). Environment is a factor because children usually pull their hair when alone and in relaxed surroundings. The bedroom, bathroom, or family room are "high-risk" situations for hair-pulling (5). Men and women also differed in terms of the hair pulling site (men pull hair from the stomach/back and the moustache/beard areas, while women pull from the scalp) (3). Pulling hair from siblings, pets, dolls, and stuffed animals has also been documented, often occurring in the same pattern as in the patient (5). Genetic factors contributing to the development of TTM are mutations of the SLITRK1 gene, which plays a role in cortex development and neuronal growth. The protein SAPAP3 has been present in 4.2% of TTM cases and patients with obsessive-compulsive disorder (OCD). It may be involved in the development of the spectrum of OCD. A significantly different concordance rate for TTM was found in monozygotic (38.1%) compared with dizygotic (0%) twins in 34 pairs (3). The core diagnostic feature is the repetitive pulling of hairs from one`s own body, resulting in hair loss. The targeted hair is mostly on the scalp (75%), but may also be from the eyebrows (42%), eyelashes (53%), beard (10%), and pubic area (17%) (3,5). There are three subtypes of hair pulling - early onset, automatic, and focused. Diagnostic criteria for TTM according to DSM-IV criteria are (2,3,5): 1) recurrent pulling of one`s hair resulting in noticeable hair loss; 2) an increasing sense of tension immediately prior to pulling out the hair or when attempting to resist the behavior; 3) pleasure, gratification, or relief when pulling out the hair; 4) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatologic condition); 5) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The differential diagnosis includes alopecia areata (Table 1) (6), tinea capitis, telogen effluvium, secondary syphilis, traction alopecia, loose anagen syndrome, lichen planopilaris, alopecia mucinosa, and scleroderma (2-5). Biopsy of an involved area (ideally from a recent site of hair loss) can help to confirm the diagnosis (5). On histologic examination, there are typically increased numbers of catagen and telogen hairs without evidence of inflammation. Chronic hair pulling induces a catagen phase, and more hairs will be telogen hairs. Pigment casts and empty anagen follicles are often seen. Perifollicular hemorrhage near the hair bulb is an indicator of TTM (2). Complications of TTM are rare, but they comprise secondary bacterial infections with regional lymphadenopathy as a result of picking and scratching at the scalp. Many patients play with and ingest the pulled hairs (e.g. touching the hair to lips, biting, and chewing). Trichophagia (ingestion of the hair) can lead to a rare complication named trichobezoar (a "hair ball" in stomach). This habit is present in approximately 5% to 30% of adult patients, but it is less frequent in children. Patient with trichophagia present with pallor, nausea, vomiting, anorexia, and weight loss. Radiologic examination and gastroscopy should not be delayed (2,4,5). The management of the disease is difficult and requires strong cooperation between the physician, patient, and parents. The dermatologist cannot take part in the therapy, strictly speaking, but without the psychological, psychopharmacologic, and topic dermatologic treatment a vicious circle will be perpetuated.

[Treatment Outcome in Female In-Patients with Anorexia nervosa and Comorbid Personality Disorders Prevalence - Therapy Drop out and Weight Gain].

<bIntroduction</b Personality disorders (PD) are among the most common comorbid disorders in female patients with Anorexia Nervosa (AN). Recent research findings suggest that comorbid PD are associated with a higher treatment drop-out rate and a worse therapeutic outcome. However, no study to date has distinguished between certain age groups concerning these issues. <bResearch questions</b Therefore, the present study focuses on the prevalence of PD (1), treatment drop-out rates (2) and weight gain (3) in female in-patients with AN. Thereby, we differentiate among three age groups (17-24 years; 25-34 years; 35-65 years). <bMaterial & Methods</b We assessed female in-patients (N=331) with AN at the Helios Clinic in Bad Grönenbach in Germany using the Eating Disorders Inventory-2 and the psychotherapeutic-medical basic documentation at the beginning and at the end of their treatment. Furthermore, we investigated the drop-out rate and weight gain by comparing anorexic patients with and without comorbid PD that were diagnosed by clinicians using ICD-10 criteria. <bResults</b In sum, our patients with AN demonstrated a prevalence rate of 34% for one or more comorbid PD. Interestingly, patients between 17-24 years showed a lower prevalence rate of 22% compared to those between 25-34 years (42%) and 35-65 years (41%). Furthermore, younger age and comorbid PD seemed to be significant predictors for treatment dropout. One of the most striking results was that younger patients (17-24) without a comorbid PD had the highest weight gain during treatment. This could not be observed in patients with a comorbid PD, who demonstrated the highest weight gain between 25 and 34 years of age. <bConclusion</b Our findings support the hypothesis that comorbid PD are related to a worse outcome in patients with eating disorders. Future studies might do well in assessing dimensional scores of personality disorders and other relevant aspects like for example the amount of social support to draw further conclusions on these associations. Our results emphasize the need for more disorder-specific interventions tailoring at patients with AN and comorbid PD to improve treatment outcome.

Letter to the Editor: Depression As The First Symptom Of Frontal Lobe Grade 2 Malignant Glioma.

Dear Editor, Next to focal neurological symptoms, epileptic seizures and head aches, brain tumors can less frequently bring about cognitive changes, slowed speech, difficulty sustaining mental functioning and psychiatric symptoms of personality changes and. loss of interest in daily activities, these symptoms may be evaluated as anxiety or depression. Depression is known to be a complication of brain tumours and may sometimes be seen after the presentation of neurological symptoms linked to brain tumours, and sometimes after tumor treatment (Oğuz et al. 2005, Litofsky et al. 2004, Moise and Madhusoodanan 2006, Oreskovic M et al. 2007, Rooney A et al. 2010). The dorsolateral prefrontal, orbitofrontal and medial frontal circuits constitute the three subcortical neuronal circuits in the frontal cortex. The dorsolateral prefrontal circuit is associated with planning and operational functions and lesions on it may give rise to apathy, abulia, perseveration, personality changes and planning disorder. Lesions involving the orbitofrontal circuit, which is associated with response suppression and disinhibition, may involve emotional lability and memory problems. Whereas lesions affecting the right orbitofrontal circuit give rise to elevated mood, lesions on the left orbitofrontal circuit lead to depressed mood. In cases with medial frontal circuit involvement, akinetic mutism may result from lesions in the superior medial region and anteroretrograde amnesia and confabulation are observed with lesions in the inferior medial region (Tosun et al. 2016, Chirchiglia 2018). A diagnosis of psychiatric disorder may be given during the first examination of patieants with primary brain tumours, especially if localized in the frontal lobe. Thorough history taking and physical examination are necessary for early diagnosis. The case reported here concerns a 29-year-old university graduate female patient, living with her partner and children, who consulted the clinic with complaints of tendency to frequent crying, anhedonia, having difficulty with speech fluency, forgetfulness and distractedness that had presented suddenly, 2 months previously, without any causative stressor. In her mental status examination, she appeared having normal self-care with appearance at her actual age. She was fully conscious and oriented, not willing to cooperate with the interview, had distinct difficulty in maintaining attention and with fluency of speech. Her mood was depressive. She described loss of appetite, fatigue and energy loss. Her difficulty in paying attention was pronounced. She did not have a history of psychotropic medication use or family history of psychiatric disease. She did not smoke or use alcohol or substance. After evaluating the clinical interview, a preliminary diagnosis of major depressive disorder was considered on the basis of the DSM-5 criteria. Routine blood tests were requested. Given the continuation of her complaints, the difficulty with fluent speech and the increase in tendency to sleep at the first week follow up, cranial MRI was planned. The MRI results showed on the right, in the frontal lobe a multilocular mass with precallosal extension, undiscernable margins with the right lateral aspect of the corpus callosum genu and dispersed cystic-necrotic areas with T2 signal series. The dimensions of the mass were nearly 5 x 3 cm causing a 1-cm right-to-left shift of the midline (Figure 1) DEPRESSION AS THE FIRST SYMPTOM OF FRONTAL LOBE GRADE 2 MALIGNANT GLIOMA 2 Türk Psikiyatri Dergisi 2 Turkish Journal of Psychiatry Letter to the Editor 143 144 The patient was referred for surgery with the preliminary diagnosis of high-grade glial tumour. Pathology results identified a grade 2 glioma. It was learned that radiotherapy sessions were begun after surgery. The patient did not have any symptoms of psychopathology during the 2 monthly psychiatric interviews made after surgery. Brain tumours generally indicate their presence with headache, seizures and other neurological symptoms and very rarely with depression as seen in the case of our patient. It should be kept in mind that atypical psychiatric symptoms may have an underlying organic lesion and subtle neurological symptoms should be investigated in detail. A recent meta-analysis on 37 observational studies determined a 21.7% prevalence of depression in a total of 4518 patients with intracranial tumours. Comorbidity of depression with brain tumor was demonstrated to worsen the quality of life, increase suicidal risk and lower the chance of survival (Huang et al. 2017). The possibility of psychiatric symptoms being the clinical clues for brain cancer was noted and the necessity of neuroimaging tests in cases of recent-onset psychosis or mood disorder symptoms, atypical personality changes and anorexia without body dysmorphic disorder was emphasized (Madhusoodanan et al. 2015). Loss of interest, tendency to frequent weeping, introversion and anhedonia were the sole complaints in the case discussed here. The increase in psychomotor retardation and slowing down of movements at the very first weekly control follow up necessitated neuroimaging. Despite the reports in the literature on the frequent association of unpreventable excessive behavior, disinhibition and irritability with right frontal injury and lesions (Okumuş and Hocaoğlu 2018), depression was the dominant symptom in the case presented here. There are differences between primary major depression and depression presenting with underlying somatic diseases which is known to occur at later ages (Rouchell et al. 2002). However, our patient was aged 29 years. Also, cases of depression due to somatic disease are less associated with family history of depression and suicidal ideation and attempts, while cognitive symptoms come to the foreground during mental status examination. (Sertöz and Mete 2004, Rouchell et al. 2002). Our patient did not have suicidal ideation or attempts, or a family history of depression. In apathy, which may be explained as emotional blunting, indifference or detachment from the external world, targeted behavior is also reduced next to the lack of emotional expression. The individual discussed here was learned not to sit at the table or change the television channel unless reminded to do so. When the reason was asked, she could not think of one. The reduction in emotional expression accompanies reduced insight, abulia and lack of empathy (Sözeri Varma et al. 2019). In depression, apathy is defined as 'sorrowless depression'. Our patient cried but had very blunted mimics and gestures. She explained that she could not help weeping even at times when she did not feel internally distressed. The seriousness of apathy, as a symptom difficult to differentiate from depression, is still not understood. Neuroimaging Figure 1- Cranial MRI of the patient 145 Received: 16.08.2020, Accepted: 04.12.2020, Available Online Date: 05.10.2021 1MD., Antalya Kepez State Hospital, Department of Psychiatry, Antalya, 2MD., Ordu University Training and Research Hospital, Department of Psychiatry, Ordu, Turkey e-mail: bosbora@yahoo.com https://doi.org/10.5080/u25957 studies indicate apathy to be a reflect of impaired frontal-subcortical circuits and the functional disorder of the connections between the ventromedial prefrontal cortex and the basal ganglia (Chase 2011). Comparison of 45 individuals with depression due to aging and 43 healthy individuals showed apathy to be associated with fronto-limbic gray and white matter abnormalities which continued after antidepressant treatment. The structural anomalies of the posterior subgenual cingulate gyrus and the uncinate fasciculus were discussed (Yuen 2014). The case discussed here is presented to emphasize the importance of brain imaging methods and detailed investigation of atypical symptoms for diagnostic approaches to psychiatric disorders. Especially, complaints at young age of depression with psychomotor retardation, reduced fluency of speech and sudden onset withdrawal without stressors should be a warning of secondary depression. Yours sincerely... Şerif Bora Nazlı1 , Muhammet Sevindik2 REFERENCES Chase TN (2011) Apathy in Neuropsychiatric Disease: Diagnosis, Pathophysiology, and Treatment. Neurotox Res 19:266-78. Chirchiglia D (2018) Pseudodepression as an Anticipatory Symptom of Frontal Lobe Brain Tumors. Int J Depress Anxiety 1:007. Huang J, Zeng C, Xiao J et al (2017) Association between depression and brain tumor: a systematic review and meta-analysis. Oncotarget 8:94932-43. Litofsky NS, Farace E, Anderson F et al (2004) Depression in patients with high-grade glioma: Results of the glioma outcomes project. Neurosurgery 54:358-67. Madhusoodanan S, Ting MB, Farah T et al (2015) Pyschiatric aspects of brain tumors: A review. World J Psychiatry 5:273-85. Moise D, Madhusoodanan S (2006) Psychiatric symptoms associated with brain tumors: a clinical enigma. CNS Spectr 2006;11:28-31. Oğuz N, Ilnem C, Yener F (2005) Psychiatric symptoms in brain tumors: Case reports. Bulletin of Clinical Psychopharmacology 15:18-21. Hocaoğlu Ç, Okumuş B (2018) Psychiatric manifestations and brain tumor: A case report and brief review. The Medical Journal of Mustafa Kemal University 9:42-9. Oreskovic NM, Strother CG, Zibners LM (2007) An unusual case of a central nervous system tumor presenting as a chief complaint of depression. Pediatric Emergency Care 23:486-8. Rooney A, Carson A, Grant R (2011) Depression in cerebral glioma patients: a systematic review of observational studies. J Natl Cancer Inst103:61-76. Rouchell AM, Pounds R, Tierney JG (2002) Depression Textbook of Consultation-Liaison Psychiatry, 2nd Edition, Volume 1. MG Wise, JR Rundell (Ed), Washington DC American Psychiatric Publishing, Inc, p.307-38. Özen SÖ, Hayriye ME (2004) Bedensel Hastalıklarda Depresyon. Klinik Psikiyatri Ek 2:63-9. Sözeri Varma G , Bingöl C , Topak O et al (2019) Relationship of apathy with depressive symptom severity and cognitive functions in geriatric depression. Arch Neuropsychiatry 56:133-8. Yuen GS, Gunning FM, Woods E et al (2014) Neuroanatomical correlates of apathy in late-life depression and antidepressant treatment response. J Affect Disord 166:179-86.

Stacy London

In the early 1990s, London struggled with anorexia, binge eating, and other weight issues. Standing , she was at her lightest weight and at her heaviest. In a 2007 interview with Sirens magazine, she said of the experience, "I have been every size in my life. I've been smaller than a zero, up through a size 16. I've had lots of issues with body image and weight my whole life and it really took a great deal of work to recognize that at all those weights, no matter how I felt, I could still find a dress that made me feel sexy and powerful."

A 9-year-old girl with persistent obsessive and compulsive behaviors in a primary care pediatric practice.

Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores.

Debbie Martin

Reece-Wilmore revealed she came up with the idea for the bulimia storyline, saying "When I came back from my Christmas holiday, I'd lost tons of weight. Everyone commented on my new figure and I thought to myself 'If there was anything wrong with me, those sorts of comments would have made me really paranoid about my weight.'" The actress then suggested the storyline, believing it was a subject familiar with a lot of teenage girls. The Neighbours bosses were initially "wary" of tackling such a difficult and sensitive storyline and a spokesperson said "We try to tackle serious issues such as bulimia as much as possible. We may not be able to wave a magic wand and make the problems go away, but by dealing with current situations they become topics for wider discussion." Reece-Wilmore added that she could see how eating disorders were connected to teenagers' anxieties about approaching adulthood as she used to make herself sick to avoid going to school.

A 9-Year-Old Girl With Persistent Obsessive and Compulsive Behaviors in a Primary Care Pediatric Practice.

Bulimia sufferer Joanna Goodfellow is staging an exhibition of photographs portraying the distorted perceptions she has of her body and the self-hatred she sometimes feels. Joanna has suffered from an eating disorder for the past five years and wants people to understand the 'frustration and anger' she feels when she looks at her bod)'. The exhibition, at the Barbican Theatre in Plymouth, runs until February 12.

Inattentive Attention-Deficit/Hyperactivity Disorder, Stimulant Medication, and Weight Loss in a 15-Year-Old Girl: Are We Enabling the Development of an Eating Disorder?

Nicole is a 15-year-old girl presenting to the Developmental Behavioral Pediatrics Clinic with symptoms of the inattentive type of Attention-Deficit/Hyperactivity Disorder (ADHD) and declining school performance over the last year. She expressed frustration over her inability to concentrate on schoolwork. Assuming that her poor grades were secondary to lack of effort, her parents withdrew privileges. Nicole became increasingly depressed. She stopped participating in activities, she previously enjoyed, and her parents reported that she stopped singing in the shower. After talking to a cousin with ADHD, Nicole concluded that she had ADHD as well. She asked her parents to arrange for an evaluation.Nicole met DSM-5 criteria for the diagnosis of inattentive ADHD and was started on a stimulant medication (mixed amphetamine salts). She had symptoms of a coexisting depression, although she did not meet criteria for diagnosis of a depressive disorder. At a 3-week follow-up visit, she showed improvement in targeted ADHD symptoms; homework was now easier and her grades improved. At a 2-month follow-up, Nicole's weight dropped from 53 kg (47th percentile) prestimulant treatment to 49 kg (31st percentile). She reported appetite suppression after taking the stimulant but did not feel that her eating habits had changed significantly. Her father reported that she had a preference for junk food and snacks. Nicole did not enjoy exercising and did not participate in extracurricular sports.She weighed herself several times a day, as she was worried about losing too much weight. Nicole's mood continued to be low, despite the fact that her grades improved, and her parents were more understanding of her challenges. She was otherwise healthy and reported regular menstrual cycles. Nicole requested an increase in the dose of stimulant medication for greater improvement in concentration during homework and in school.Her pediatric clinician was concerned about the possibility of an eating disorder in addition to depression. She asked herself, "Are we treating inattentive ADHD effectively or are we enabling an eating disorder?"

Paul Cosford

Initially, Cosford had planned a career in general practice, but following the loss of a child to a genetic disorder, he moved to north west London to take up psychiatry and worked with people with learning difficulties and severe mental illness. In 1990, he became lecturer in psychiatry at St Mary’s. In 1992, he co-authored a paper titled "Eating disorders in later life: A review", which was published in the International Journal of Geriatric Psychiatry. It reported that not all anorexics were young, that the desire to be thin and happy with one's body did not lessen as women aged, and that eating disorders in older women could appear as a new problem, or recurrence or persistence of an earlier problem. It often occurred in association with severe depression or obsessive compulsive disorder, and the most common trigger for developing an eating disorder later in life, he noted, was the death of a spouse or a loved-one. He is noted to have membership of the Royal College of

Anorexia nervosa manifesting as massive ascites, hypercholesterolemia, and sequential binge eating in an 11-year-old girl: A case report.

Anorexia nervosa (AN) is a serious eating disorder associated with a distorted body image. Hypercholesterolemia has been found in patients with AN but the mechanism of hyperlipidemia in AN remains little known. Ascites in patients with AN has been attributed to hypoalbuminemia and liver diseases, but massive ascites without the aforementioned etiologies has never been reported in AN. An 11-year-old girl was admitted for exclusion of organic underlying diseases due to severe body weight loss (18% within 3 weeks), poor appetite, and hypercholesterolemia (274 mg/dL). She complained of heartburn sensation, nausea, vomiting, constipation, and postprandial dull abdominal pain with fullness. The patient's condition met with all 3 of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosing AN. On admission, her total cholesterol level was 337 mg/dL and hypocomplementemia (C3 55.5 mg/dL) was also found. Abdominal sonography and computed tomography scans showed massive ascites. However, neither proteinuria nor hypoalbuminemia was found. Upper gastroduodenal endoscopy showed chronic superficial gastritis and colonoscopy revealed negative findings. Ascites obtained by paracentesis demonstrated a transudate without bacterial infection, tuberculosis, or pancreatitis. Exploratory laparoscopy showed nonpurulent ascites. However, biopsies from the small intestine, mesentery, and liver showed chronic inflammation and fibrosis. The intensive nutritional therapy by increasing total energy intake stepwise with a combination of high-energy formula and her favorite foods. Her hypercholesterolemia, hypocomplementemia, and massive ascites resolved after her weight was restored. She developed binge eating with continuous weight gain after discharge. Her weight significantly increased to an obese level (body mass index [BMI] 25.9 kg/m) after loss to follow-up for 4 years until she returned to our emergency room due to suicide attempt. Diagnostic crossover between subtypes in anorexia nervosa might be a potential risk factor for illness severity and poor prognosis. AN can manifest as massive ascites with normal albumin concentrations that could possibly be due to chronic inflammation of the intestinal serosa, mesentery, and peritoneal surface of the liver.

List of Family Guy characters

Jillian Russell-Wilcox (voiced by Drew Barrymore) – Brian's cute, bulimic, and dimwitted ex-girlfriend who is portrayed as a stereotypical blonde. She is quite ignorant; for example, she does not understand that Adolf Hitler died decades ago. She has a close friendship with Peter, who treats her more like a daughter than he does Meg, due to their similar levels of intelligence. The remainder of the Griffin family look on her as a figure of mockery and symbol of Brian's shallowness, although she has affection for them, involving them all in her wedding. She first appeared in "Whistle While Your Wife Works". She is the only girlfriend that Brian has dated for more than one episode, and was a recurring character in season 5. He stays with her purely for sex, though after they split, he felt strong feelings of love for her. In "Prick Up Your Ears", when Brian talks about Jillian's bulimia, he goes on to compare her to Karen from The Carpenters, who succumbed to anorexia in 1983, claiming

Eating disorders and development

Diagnostic criteria Anorexia is characterized by a significant reduction in energy intake which leads to a low body weight given age, sex, development, and physical health considerations. Individuals with anorexia also experience a significant fear of weight gain or engage in behaviors that interfere with weight gain. The illness is also characterized by a disturbance in body image, a significant focus and evaluation of self based on body weight, and/or lack of recognition of the consequences and seriousness of the current low body weight. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight. Anorexia has two subtypes: the restricting type and the purging type. This is based on whether an individual engages in or does not engage in bingeing and purging behaviors. Anorexia is characterized as mild, moderate, severe, or extreme based on the extent of weight loss.

"Is It Her Hormones?": Psychiatric Diagnoses and Polycystic Ovarian Syndrome.

Beth, whom you have cared for in your primary care practice since she was born, is a 15-year-old adolescent girl with no prior psychiatric history who developed significant symptoms of clinical depression, associated with self-injurious behavior (cutting on wrists, arms, and thighs). She denied any known precipitant for her depression.She is a ninth grade honors student in the gifted program at a local high school and is described as a talented musician, playing multiple musical instruments as well as soccer and basketball. She has good family support, was sociable, and had several close friends. She denied any history of trauma and denied ever using recreational drugs or other mood-altering substances.At this visit, she reported feeling "sad and anxious." Family history was significant for maternal depression, which persisted through her teens and twenties. Her older sister had been diagnosed with Social Anxiety Disorder. Beth reported anhedonia, fatigue and irritable mood, lack of motivation, impaired concentration, and anxiety related to failing grades.You decide to begin medication because of the severity of her symptoms, and 1 week after starting fluoxetine 10 mg, she reportedly overdosed on an unknown quantity of acetaminophen. Within a few days of switching to escitalopram (due to persistent gastrointestinal complaints while taking fluoxetine), she developed homicidal ideation. She reported feeling grandiose, empowered, invincible, elated, and "crazy," although she never demonstrated or endorsed psychotic symptoms. She became fixated upon the idea that she could kill someone and "get away with it." At the time she tried to suffocate a peer with her hands, she was described as having "a glazed over look in her eyes." Moods were now described as alternating between depressed and elated, with mood shifts occurring every few days. These symptoms did not improve after the antidepressant medication was discontinued.Subsequently, patient was admitted for acute psychiatric care, at which time she was described as depressed, but with an "expansive and irritable" mood, and with obsessive suicidal ideation. She had developed a plan to hang herself in the home. She started to believe that her mother was trying to give her "poison." She reported panic attacks and said that she wanted to be in the hospital where she could feel "safe." She claimed to have an "entity inside of her body who was a bully" and who was "taking over her body" and stated that he put her hand over her peer's mouth, as she watched.Psychological testing included the Minnesota Multiphasic Personality Inventory-Adolescent, showed significant paranoia, bizarre mentation, and poor reality testing. Along with interview and observation, it was determined that patient met criteria for the DSM-IV-TR clinical diagnosis of Other Specified Bipolar Disorder, with psychotic features.Aripiprazole was initiated at a dosage of 2 mg; however, moods were still described as fluctuating between extremes every few hours. It was discontinued after reaching 5 mg due to affective blunting. Risperidone 0.5 mg twice daily helped patient to feel and act "more like herself"; however, she continued to report significant depression. The addition of lamotrigine 25 mg daily, in addition to individual Dialectical Behavior Therapy, finally led to improvement of mood and a gradual return of her normal baseline, with reportedly stable emotional, social, and academic functioning.The patient's mother remained convinced that this adolescent's mood instability was caused by underlying hormonal problems so you refer her to endocrinology. Beth developed puberty at age 8, with menses occurring on average of twice yearly. She was found to have elevated free testosterone level of 8.6 (reference range, 1.2-7.5). She was of normal weight (body mass index = 21.85 kg/m) and did not manifest acne, male pattern hair thinning, or hirsutism. Thyroid functions, 17-OH progesterone, follicle-stimulating hormone/luteinizing hormone, and estradiol were within normal limits. Prolactin elevation (46.3) was assumed to be due to Risperidone. Patient refused ovarian ultrasound.After starting oral contraceptives to establish monthly menses, patient's emotional and behavioral symptoms continue to remain stable. After Beth decided on her own to discontinue psychotropic medications, she continued for 17 months following her initial visit to remain free of neuropsychiatric symptoms.Now that her symptoms seem resolved; you wonder what the medical diagnosis for Beth was? You wonder if "hormones" may have caused or contributed to her psychiatric presentation.

Imogen Bailey

In September 2008 Bailey revealed she had had anorexia nervosa, in an interview with UK magazine, NOW: "I went through a minor, but still not very good, anorexic stage and actually got down to less than 40 kg". Her weight loss occurred over about a year from 2000 to 2001 and was influenced by "being surrounded by other anorexics and the stress of a break-up from an unfaithful boyfriend". Family and friends intervened and she sought assistance for her condition. On the 3rd of June 2020, KISS FM Host Kyle Sandilands revealed on his show that he has a sexual relationship with Bailey for about 6 months after he was evicted from the Celebrity Big brother house. In 2016 Bailey met and became engaged to Robb Beckmann and they married in January 2018. In May 2020 they had a baby girl Odette after suffering three miscarriages prior. Imogen now works as a birth and end of life doula and runs workshops focussed on empowering women. Filmography References

When to Raise Our White Flag-A Discussion of Scope of Practice in a Resource Scarce World.

Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation.Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression.Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because "suicide is against our religion."Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as "the devil with fire coming out of her eyes" when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS.Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

Ellen West

Ellen West's life was marred by thoughts related to death anxiety. Towards the end of her life, it could be said that she had a death obsession. West was given a great variety of diagnoses including melancholia, severe obsessive neurosis, and schizophrenia. While her major problem dealt with food, as what started out as a diagnosis of anorexia nervosa morphed into bulimia nervosa with the fear of becoming fat through eating. This fixation caused her great depression, as her focus day in and out was on eating or not eating. This "obsession with death" became "life's only goal" and that the "symbolization of life and death took place around the act of eating." West's fear of becoming fat caused her to welcome death as an acceptable outcome, as then she wouldn't have to worry anymore. She was often quoted by her psychiatrist, Ludwig Binswanger, explaining how her life felt like a prison that could be only made better by dying. To West, her life felt empty and dull, and filling her body

Anorexia nervosa, conduct disorder, and the juvenile justice system: a case of applying traditional treatment modalities in a non-traditional setting.

Anorexia Nervosa is highly comorbid with depressive, anxiety, and obsessive-compulsive spectrum disorders. However, it has not previously been reported as comorbid with antisocial personality traits, except when substance use disorder is also identified. We present an unusual case of a patient with resistant anorexia nervosa and comorbid conduct disorder. This case was also unique in that the juvenile justice system was involved during treatment. A 13-year-old female was admitted to our pediatric hospital for the treatment of anorexia nervosa. She had a history of violent behaviors toward family members, often jeopardizing her care. During hospitalization, she physically attacked a physician on her care team shortly before she transitioned to an eating disorders treatment program. She was diagnosed with conduct disorder, and following discharge, she attacked her father in a premeditated act. This led to her entry into the juvenile justice system. While under the custody of the juvenile justice system, she was readmitted to our hospital for further treatment of anorexia nervosa. Our treatment strategy included psychotropics, positive reinforcement, close interdisciplinary coordination among the various hospital teams, and the juvenile justice system. Following discharge from her second hospitalization back to the juvenile detention system, our patient maintained a healthy weight and appeared to show improvements in the cognitive distortions related to her eating disorder. To our knowledge, this is the first reported successful treatment of an individual with resistant anorexia nervosa and conduct disorder. It was likely a combination of weight gain, psychotropic medications, and the structured milieu provided by the juvenile justice system that led to the effective treatment of our patient. This case illustrates that a non-traditional healthcare setting can be an asset to treatment through persistence and close collaboration across institutions.

Avoidant/restrictive food intake disorder

Anxiety disorder Specific food avoidances could be caused by food phobias that cause great anxiety when a person is presented with new or feared foods. Most eating disorders are related to a fear of gaining weight. Those who have ARFID do not have this fear, but the psychological symptoms and anxiety created are similar. Some people with ARFID have fears such as emetophobia (fear of vomiting) or a fear of choking. Anorexia nervosa Though the physical symptoms may be similar, anorexia nervosa differs from ARFID because in ARFID the lack of food intake is not related to body image or weight concerns. Additionally, in a study analyzing the similarities between patients with AN and patients with ARFID, those with ARFID were significantly younger (10.8 vs 14.1 yrs old) with an earlier onset of illness (6.2 vs 13.7 yrs old) and a longer evolution time (61.2 vs 8.4 months). Also, a greater proportion of the ARFID patients were male rather than female (60.6% vs 6.1%).

Wannarexia

Many people who actually suffer from the eating disorder anorexia are angry, offended, or frustrated about wannarexia. Eating disorders are about using food to cope with life distress and poor body image, and they have very complex underlying causes. People with eating disorders might use weight as a measure of self-worth, and they often derive pleasure from losing weight while it doesn't feel enough. The notion of "wannarexic" is a very dangerous invalidation of eating disorders that are not specified based on the BMI criteria of the DSM. It can feed the eating disorder mindset of not sick enough and lead people to get too sick to validate their struggle with an eating disorder however even the most severely ill people suffering from eating disorders still struggle to feel "sick enough" .

Sounds unrealistic: an adolescent girl with anorexia nervosa consumes 19 L of fluid in a few hours: what happens to the physiology?

Adolescents with eating disorders (EDs) may present not only with abnormal eating behaviors but also with abnormal drinking behaviors varying widely. These behaviors include water loading to cheat on weight measurements, to feel full and suppress appetite and/or to induce vomiting; as well as restricting fluid intake in addition to food. We present a 16-year-old female adolescent with anorexia nervosa restrictive type and major depressive disorder who was hospitalized due to acute food refusal and developed generalized seizures due to dilutional hyponatremia in consequence of consuming excessive amount of water. Psychiatric diagnoses were made according to 'The Diagnostic and Statistical Manual of Mental Disorders' (5th ed.; DSM-5) criteria. After starting nutritional rehabilitation with a low calorie meal plan to avoid refeeding syndrome, a weight gain of 2 kg was noted in the second day of hospitalization. At the bedside visit, she was observed in a disoriented manner and consecutively in seconds, lost consciousness with a generalized tonic-clonic seizure lasting 2 min. Her serum sodium level was measured as 116 mEq/L, which was normal at the time of admission. It was later learned that she secretly ingested 19 L of water in a short amount of time. She regained consciousness and no further seizures were observed after intravenous sodium deficit correction and fluid restriction therapy. Her serum sodium level was normalized (137 mEq/L) within 12 h. A thorough clinical assessment of hydration and drinking behaviors as well as eating behaviors is essential for patients with EDs to avoid serious medical complications with high mortality and morbidity during follow-up. It is interesting that this amount of fluid consumption in such a short period of time did not present to the clinic with vomiting, gastric dilatation or bowel irrigation symptoms in a case with acute food refusal and restriction for a year, instead absorbed very quickly causing acute and severe symptomatic hyponatremia with generalized seizures.

Wintergirls

Wintergirls (2009) is a realistic fiction novel by the American author Laurie Halse Anderson. The novel was published in 2009 by Viking. The story focuses on a girl, Lia Overbrook, who suffers from anorexia and self harm. Lia struggles to cope with her mental illness while balancing everything else going on in her life. Some months after a fall out with her best friend Cassie, Lia receives the news that she has died from bulimia. This complicates Lia's life even more and forces her to confront her own illness. Plot Lia Overbrook, an 18-year-old girl, just found out that her ex-best friend Cassie has died. Cassie had called Lia 33 times the night of her death. However, Lia never answered the phone. Cassie was found in a hotel room, killed by her illness, bulimia. Lia, who has a history of anorexia, falls into a downward spiral of self-harm and calorie counting. To hide her illness from her family, Lia's obsessive and destructive behavior worsens and recovery seems impossible.

Facing an eating disorder: A case of body dysmorphic disorder and avoidant/restrictive food intake disorder.

Eating disorders can be notoriously difficult to diagnose and treat. This patient is an 18-year-old female who presents to care severely underweight and notably cachexic. For a number of years, she had experienced depressive symptoms, anxiety, and continued loss of appetite. She denied purposefully restricting foods, recognized that she was thin, and denied a fear of gaining weight. She was admitted to a disordered eating unit for refeeding and during her inpatient stay disclosed that she had a long-standing "hatred of face." Ultimately, she received the diagnoses of avoidant/restrictive food intake disorder and body dysmorphic disorder. This case highlights the importance of differentiating body dysmorphia, seen in body dysmorphic disorder, and distorted body image, as seen in anorexia nervosa. This differentiation is significant as the treatment approaches to these distinct diagnoses are not the same.

A Counterfeit Presentment

Anorexia Constance is referred to as a “ghost” or an “apparition” multiple times throughout the course of the play. Howells has most likely employed this characterization to indicate that Constance is anorexic. Anorexia is a disease that Howells held very dear to his heart. In 1889, his beloved daughter, Winifred, succumbed to the disease when she was only 26 years old and weighed a mere 79 pounds. Although this unfortunate event happened over a decade after the publication of this play, it could be speculated that Winnie was already showing symptoms, since anorexia was becoming increasingly prevalent amongst young women her age.

Anorexia, Maudsley and an impressive recovery: one family's story.

Ann was first diagnosed with anorexia nervosa at the age of 14 years. For two years she maintained unshakeable delusions that her body was grossly obese and that she did not require food to live. Her rational thought processes were swamped by overwhelming emotions of fear, self-loathing, rage and despair. She developed obsessive and compulsive behaviours, her reactions to food were phobic, she withdrew from social contact, was flooded by suicidal thoughts and had periods of self-harming. For 16 months after diagnosis Ann was seen by a variety of medical professionals who prescribed a range of treatments, some of which were life saving but none of which, crucially, had any appreciable impact on the long-term course of her illness. She then began treatment following the family-based Maudsley Approach which encourages parents to develop and maintain a programme of weight gain for their child. Six months after starting Maudsley Ann achieved a healthy body weight and all of her psychiatric symptoms began to disappear spontaneously. Over the next five months Ann's physical and mental health continued to improve dramatically. She has made a full recovery and has shown no sign of relapse for over 12 months.

[Anorexia with sinus bradycardia: a case report].

As anorexia patients always go to the psychiatric clinic, little is concerned about the occurrence of sinus bradycardia in these patients for cardiologists and psychiatrists. The aim of this paper is to discuss the relationship between anorexia and sinus bradycardia, and the feature analysis, differential diagnosis and therapeutic principles of this type of sinus bradycardia. We report a case of sinus bradycardia in an anorexia patient with the clinical manifestations, laboratory exams, auxiliary exams, therapeutic methods, and her prognosis, who was admitted to Peking University Third Hospital recently. The patient was a 19-year-old female, who had the manifestation of anorexia. She lost obvious weight in a short time (about 15 kg in 6 months), and her body mass index was 14.8 kg/m(2). The patient felt apparent palpitation, chest depression and short breath, without dizziness, amaurosis or unconsciousness. Vitals on presentation were notable for hypotension, and bradycardia. The initial exam was significant for emaciation, but without lethargy or lower extremity edema. The electrocardiogram showed sinus bradycardia with her heart rate being 32 beats per minute. The laboratory work -up revealed her normal blood routine, electrolytes and liver function. But in her thyroid function test, the free thyroid (FT) hormones 3 was 0.91 ng/L (2.3-4.2 ng/L),and FT4 was 8.2 ng/L (8.9-18.0 ng/L), which were all lower; yet the thyroid stimulating hormone (TSH) was normal 1.48 IU/mL (0.55-4.78 IU/mL). Ultrasound revealed her normal thyroid. Anorexia is an eating disorder characterized by extremely low body weight, fear of gaining weight or distorted perception of body image, and amenorrhea. Anorexia patients who lose weight apparently in short time enhance the excitability of the parasympathetic nerve, and inhibit the sympathetic nerve which lead to the appearance of sinus bradycardia, and functional abnormalities of multiple systems such as hypothyroidism. But this kind of sinus bradycardia and hypothyroidism have good prognosis. And asymptomatic sinus bradycardia with reversible causes, because of the great prognosis, they do not need special treatment. Multiple medical and psychiatric disciplines were consulted, and then, family care, nutritional support and psychiatric therapy were given, and she did not need thyroid hormone replacement therapy. The patient's overall clinical status improved gradually during her hospital stay and her heart rate was recovered to 55 beats per minute.

Psichiatry_DSM-5

V62.82 (263.4) Uncomplicated Bereavement This category can be used when the focus of clinical attention is a normal reaction to the death of a loved one. As part of their reaction to such a loss, some grieving individuals present with symptoms characteristic of a major depressive episodchfor example, feel- Other Conditions That May Be a Focus of Clinical Attention 717 ings of sadness and associated symptoms such as insonmia, poor appetite, and weight loss. The bereaxed individual typically regards the depressed mood as ”normal,” al- though the individual may seek professional help for relief of associated symptoms such as insomnia or anorexia. The duration and expression of "normal” bereavement vary con- siderably among different cultural groups. Further guidance in distinguishing grief from a major depressive episode is provided in the criteria for major depressive episode.

[Mental disorders associated with multiple sclerosis].

Findings are reported in 4 patients with multiple sclerosis (MS) and various mental disorders which were directly associated with the underlying disease, with disease-related increased vulnerability, were a reactive response or had occurred independently of the MS. CASE 1: A 53-year-old woman with MS for 24 years developed cognitive disorders with markedly impaired quality of life. CASE 2: A 44-year-old man with MS for 8 years had depression and felt suicidal. CASE 3: A 58-year-old woman with MS for 35 years suffered from both depression and symptoms of a compulsive-obsessive disorder. CASE 4: A 19-year-old woman with MS for 2 years was treated by a psychiatrist for the first time when she developed acoustic hallucinations and suicidal ideation during cortisone treatment. CASE 1: The progressive mental disorder was classified as manifestation of the chronic progressive MS: it was treatment-refractory. CASE 2: The patient underwent psychotherapy as both an in- and out-patient. His depression was thought to be reactive and improved well under this treatment, despite the deterioration of the MS, requiring him to use a wheel-chair. CASE 3: The compulsive-obsessive symptoms persisted during medication for depression, for which she then received behavioral treatment. CASE 4: The initial symptoms of hallucination and suicidal ideation ceased when cortisone was stopped. A diagnosis of borderline personality was made, based on her continuing symptoms of impaired impulse control, abnormal affect, distorted self-image, a feeling of inner emptiness, agitation with suicidal tendency and factitious injuries. The renewed occurrence of acoustic hallucinations and suicidal tendency occurred independently of cortisone treatment and was interpreted as expression of inflammatory disease activity, but differential diagnosis had to consider the patient s personality disorder, too. Mental disorders in patients with MS are manifold and their causes are complex. It is important to recognize these associated diseases and initiate individualized treatment, because they considerably impair the patients quality of life.