Study group discussion: Legionella confusion

A few days back, we had a discussion on legionella.

Legionella affects three systems - Lungs, GIT (diarrhoea) and CNS (Altered sensorium, confusion, etc).

Why does it cause CNS symptoms?

Study group discussion: Case control and cohort study mnemonic

Any mnemonic for case control study vs cohort study and how to identify which study to conduct or not?

Study group discussion: Transpulmonary pressure

What is transpulmonary pressure and its significance?

I remember it's something like... General lung pressure without alveolar pressure. I don't know.

It's the difference between the intrapleural pressure and the alveolar pressure. The athmosphere pressure is constant, but air still needs to flow in and out of our lungs, so we adjust the pressure inside our body.

The basic principle is that air flows from higher pressures to lower, so we constantly change the pressure in our lungs to higher or lower than the atmosphere.

Transpulmonary pressure (when everything is fine) is always positive.

I'm getting what he is saying, go on!

Transpulmonary pressure is always positive, intrapleural is always negative and alveolar fluctuates.

That's how I remember from my physiology classes, anyway.

Yeah, alveolar fluctuates so that air can flow in and out easily.

Transpulmonary pressure is basically the elasticity of the lungs. The recoil.

Since atmospheric pressure is relatively constant, pressure in the lungs must be higher or lower than atmospheric pressure for air to flow between the atmosphere and the alveoli. It is nothing but the elastic recoiling of the lungs. If 'transpulmonary pressure' = 0 (alveolar pressure = intrapleural pressure), such as when the lungs are removed from the chest cavity or air enters the intrapleural space (a pneumothorax), the lungs collapse as a result of their inherent elastic recoil. Under physiological conditions the transpulmonary pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly positive to slightly negative as a person breathes. For a given lung volume the transpulmonary pressure is equal and opposite to the elastic recoil pressure of the lung.

Study group discussion: Physiology books

Which is the best physiology book? I find Guyton to be really dull and Rhoades lacks details.

Ganong is okay, I guess.

Ganong has always been my first love.

I usually go for Ganong, but Costanza and Berne-Levy are also pretty good.

Costanza is not as detailed though, it's good for refreshing your memory the week before exams.

Yep. BRS is good for last minute revision!

Which are the simpler books for physiology? I know of Ganong.

Which was the other one?

Guyton?

Guyton is too extensive.

I read Guyton only in 1st year.
Good for clearing basics.

Yes, I find Guyton better than other physiology books.

Try BRS physiology.. It's little and has everything you need to know. Like it's smaller than Ganong.

Smaller the better!

I think it's 100 -  200 pages.

Study group discussion: Respiratory physiology

Does anyone have a mnemonic for respiratory centers?

DIVE!
The Dorsal nucleus is for Inspiration (tidal).
The Ventral nucleus for Expiration.

The ventral nucleus is especially important for forced respiration because expiration in general is passive. In tidal respiration, during the inspiration phase, the diaphragm and external intercostal muscles work. But the tidal expiration is completely passive because of elastic recoil.

Review question: Which all values of lung volumes you cant measure by spirometry? And why?

Reserve volume.

Functional residual capacity.

Vital capacity.

It's because spirometry measures through expiration. And the stuff that stays inside the lungs can't be measured!

What is the importance of residual volume? Why is it crucial for your body to retain air even after forceful expiration?

So that the lungs don't collapse on themselves. That's the most important one. There are two other uses!

Gas exchange is a continuous process, just because you expire, doesn't mean the gas exchange stops.

Third, the residual volume doesn't allow sudden changes in the outside concentration of air to affect your internal homeostasis. It takes 16 to 20 breaths for the outside air to affect your residual volume. This gives ample of time for your chemoreceptors to detect the slight changes in pH and respond.

Oh wow.. I didn't know this. Cool stuff. The breaths part though. Our body is waaay ahead of us than we think.

Totally!

Another review question! Mechanism of chemoreceptors? What passes through the BBB?

CO2 is not polar and is small, the BBB allows hydrophobic substances to pass through, so CO2 would pass the BBB.
The chemoreceptors monitor the H+ concentration of cerebrospinal fluid (CSF), including the brain interstitial fluid.
CO2 readily penetrates membranes, including the bloodbrain barrier, whereas H+ and HCO3– penetrate slowly. The CO2 that enters the brain and CSF is promptly hydrated. The H2CO3 dissociates, so that the local H+ concentration rises. The H+ concentration in brain interstitial fluid parallels the arterial PCO2.

Mechanism of peripheral receptors?

Oxygen potassium sensitizer channel. Lack of oxygen closes this channel, leading to increase in potassium in the ICF, depolarising it.

Do you know about the conditions in which you do not give 100% oxygen to the patient?

In cases where the CO2 levels are increased. Example, emphysema.. Cause the problem here is the respiratory drive is completely dependent on the blood CO2 level. So if you give 100% O2 the patient will go in apnea.

Yep. There's one more besides the CO2 indication. The neonate. Why?

Causes retinopathy of prematurity due to oxidative stress!

Study link!  http://medicowesome.blogspot.ae/2013/12/case-scenarios-when-you-dont-give.html

Study group discussion: Cause of decreased glucose levels in CSF in bacterial meningitis

I have a question, my professor told us that the cause of decreased glucose in CSF relates to permeability changes caused by the exudates. Which I find a good reason for the protein levels but glucose is not the same. In books and other references, I found the reason being bacterial and brain tissue consumption of glucose and non replenishment of it being the cause.

Can someone tell me for sure the cause for glucose depletion in csf in meningitis?

I think it's the glucose consumption. Permeability changes play a minor role.

Yes I'd also go with consumption.

Because permeability changes occur in viral meningitis as well.

That's what I also thought because permeability changes occur in all of the forms even the non infective ones.

Study group discussion: How to do percussion

I can't seem to get the hang of percussion and I have OSCE exams coming up :(
Any tips?

What exactly are you having trouble with?

I was always told to just hit once and not repeatedly like a drum, just once or twice and listen.

Ok well I know the technique it just doesn't sound as loud as the docs that are training us.

Ahh i know that you mean, happens to me too, but I don't know how to make it louder, I just try really hard to focus and block all external sounds... Plus, I lean as close as I can to the patient without it being obvious.

I think in part it just comes with practice and gaining experience.

Yeah I'll keep practicing.

When I was first learning it the sound was very dull and I had to try a few times to hit the correct spot.
But now it's just two quick taps.

Make sure that you're not resting your palm on the patient since that can dull the sound.

Ok, I see.

And when tapping make it fast and strong, as if your fingers were hot and you just wanted to get it over with.

Some people tap and let the finger rest, which can also full the sound.

Someone told me to press the pleximeter firmly, it gives better results than trying to strike harder with the plexiform during percussion.

Our supervisor usually sits a far from the patients and asks one to tap until she can hear from a far.

But yeah..Quick double strikes and fast finger withdrawal.

Yes, you can tap as hard as you like but if you aren't pressing your finger down firmly you're not gonna get much.

Note that firmly does not mean hard.

You should not get tired from pressing down your finger.

Plus concentrate on the feel of the vibration against your fingers.

My taps are never really loud enough, but then I practised by percussing myself to know the feel. That's good enough.

Study group discussion: Schizophrenia and Schizotypal disorder

What's difference between schizophrenia and schizotypal?

Schizotypal have odd behaviour and magical thinking.

Why schizophrenia is not placed in personality disorder?

Schizophrenia is a much more serious mental disorder, while schizotypal personality disorder is a (relatively) mild condition where the patient has social anxiety, extreme need to be alone and usually believes in odd things.

For example, have you seen or read Harry Potter? Luna Lovegood could be an example for a schizotypal personality disorder.

Schizophrenia on the other hand, could be... Hmm... Couldn't think of a HP reference.
Anyway, a person who is delusional, has hallucinations, hears voices, again believes odd things but on a much more serious level and is willing to do a lot of things to support those beliefs or because of them.

"Personality" is like, the things that make you YOU... That makes you different from other people.

Our teachers says prophets were schizotypial.. No offense, Living alone in deserts and hearing voices!

Personality disorders are classified as the differences from the norm, they are not always extremely dangerous/harmful mental disorders like schizophrenia. "personality disorders" are just a certain behavioral pattern.

Hahah well that could be said actually, if a person came to my hospital claiming he was a prophet we would give him medication probably!

Can you help me differentiate thought content vs thought form and thought process?

I can try to help.
Thought content is what you are thinking about. Say, you are sitting in your house looking out the window, there are 2 people walking and they have a dog. Looking at them your thought content would be those 2 people, the dog, and that they are walking.

This is in the beginning..

Then you start to form more complex thoughts, the way those develop are your thought process.

"Those people are walking. They are walking in front of my house. They have a dog. Why do they have a dog? Why are they in front of my house? Are they watching me? Who sent them here?"

This is an example of a thought process, the way ideas are forming and developing in the person's head.

This was an example of a paranoid way of thinking by the way, which is common in schizophrenia.

Hey buddy thanks it was very helpful!

You are welcome :)

Renal tubular acidosis types mnemonic

Hi everyone!

We were discussing RTA on our study group when we decided we needed a mnemonic for it!

Study group discussion: Malignant hypertension

What the difference between essential & malignant hypertension?

Essential is of unknown cause. Also known as the primary hypertension.
Malignant hypertension is also known as hypertensive emergency.

Malignant hypertension is an acute form that effects one or more organ systems.
Cardiovascular system, central nervous system and renal systems are irreversibly damaged.

Also papilledema! Remember reading it in ophthalmology.

In malignant hypertension, BP shd be lowered asap with antihypertensive agents. Mostly, iv injection of sodium nitroprusside is given for immediate effect so that BP is lowered.

There was also something about nitroglycerin and nitroprusside.. Which should be used when in malignant hypertension.
Don't remember what it was.. Like if cerebral edema is more use this stuff and if some other symptom is more you'll use the other one of the two.

Just read it up.. They say you choose based on the end organ damage.
Nitroprusside is widely used, especially if the person has neurological symptoms, cerebral edema.
Nitroglycerine will be the drug of choice if the heart is involved (Ischemia, acute coronary syndrome)

I'll have to correct myself, nitroglycerin isn't used anymore in hypertensive emergencies because of the side effect profile. If used, it's used as an adjunct.

Read a ncbi article on the same: Nitroglycerin is a potent venodilator, and only at high doses does it affect arterial tone. It causes hypotension and reflex tachycardia, which are exacerbated by the volume depletion characteristic of hypertensive emergencies. Nitroglycerin reduces blood pressure by reducing preload and cardiac output, which are undesirable effects in patients with compromised cerebral and renal perfusion. Low dose (60 mg/min) nitroglycerin may, however, be used as an adjunct to intravenous antihypertensive therapy in patients with hypertensive emergencies associated with acute coronary syndromes or acute pulmonary edema.

*After a lot of unsure discussions on hypertensive emergency, hypertensive urgency and malignant hypertension we concluded this*

Emergency: End organ damage.
Urgency: No end organ damage.

Malignant hypertension = Hypertensive emergency.

Hypertensive crisis: Severe elevation in blood pressure, with diastolic blood pressure (DBP) > 120-130 mmHg.

Nitroprusside is given in hypertensive emergency. However, watch out for cyanide toxicity when you choose to administer it.

Got a revision question! Which drug is used in cyanide toxicity?

Nitrites.
Sodium thiosulphate.
Cyanide toxicity - GTN.

Yes!

Study group discussion: Migraine, aura and floaters

What did Leonardo have in the movie Shutter Island?

Migraine, I think.

Migraine? When was that?

Migraine was what he started having as a symptom may be.

Oh yes, the headaches and flashes of light.

Auras?

Yes, those.

What are auras?

The lights some people see before they have a migraine headache.

Auras can present in any way of sensation.

Some patients also complain that something smells before the attack.. Smell of burning rubber or something. It's also a part of the aura.

You can have flashes of light, ringing in ears, sensation on hands and even sudden salivation. 

In migraine I guess the most common type of aura is of the visual type.. Seeing flashes of light.

In reality, it moves and vibrates. then expands and fades away.

I see bits and pieces of light too against a very bright room.. I read it's the pieces of proteins in the vitreous of your eye moving around.

Oh yes, I found those proteins very fascinating as a kid.

Would rub my eyes intentionally to see them and wondered if others could see them as well.

Seemed like little bubbles floating!

Floaters!

And when it is sudden and excessive.. It is a sign of retinal detachment!

Floaters.. I once argued with an opthalmologist, I kept telling him it was normal and he kept saying they're pathological.

Did he said why?
If the person has no other symptoms.. Just floaters once in a while.

Study group discussion: Dissociative identity disorder, Post-Traumatic Stress Disorder and Shutter Island

What about split personality disorders?

What I know it's that they're quite uncommon. But they present upon a trauma.

Psychological trauma.

There was a theoretical mcq in a question bank on split personality disorder. A female who said she recieved phone calls of strange men that she didn't remember meeting. It's easy to think it's a delusion if you don't keep split personality disorders in mind.

Was that shown in the movie
Karthik calling Karthik?

Haven't seen the movie.

Do no harm shows a neurosurgeon with a split personality. I am not sure if the series was purely fictional or based on a real life incident.

I guess it was fiction.

It was a very bad show.
Because it's super difficult to find a straight split personality.

Yes, it was based on DID.. Was a fiction.

It was a very bad show.
Because it's super difficult to find a straight split personality.

What's DID?
Dissociative identity disorder.

I don't know what the term is on the DSM V.

DSM V calls it dissociative identity disorder.

Multiple personality disorder is the same as split personality, right?

More than two personlities are called multiple personality disorder.

I have seen so many fictional works on it.. Makes you think it's common when it's not.

I know people who live with mental illness(es), and so I know what worked for them as well as what didn't.  And because so many people have approached me to talk to me about their mental health issues, I have very strong feelings about mental healthcare, so I do my own research, too.

Dissociative identity disorder is often treated by psychological therapy trying to merge the personalities into the core personality.  I don't know exactly how it's done.  I don't think there's medication for it.  It's pretty rare.  I don't know anyone with DID.

I wonder if perhaps dissociation as part of PTSD etc. instead of as part of DID would also be a good explanation for why someone might get phone calls from someone they don't remember meeting.

What's PTSD ?

Post-traumatic stress disorder.

It's a type of anxiety disorder that people sometimes develop after a traumatic experience.

Sometimes people with PTSD dissociate (they might 'lose' bits of time, for example).

Not remembering phone calls of strange men could be dissociation as part of a post traumatic stress disorder. But in that case, would the inciting trauma be of rape?

Potentially.  Not necessarily.  And rape isn't the only form of sexual assault.  [I'm not sure whether rape causes more *psychological* damage than other forms of sexual assault or not... if someone knows, I'd appreciate an answer.  I seem to recall someone saying that all forms of sexual violence are approximately equal in terms of suffering and trauma, because ultimately the important part is the existence of that violation, not the type of violation.]

Which are the other forms of sexual violence? Groping?

Yes.
Rubbing up against a person in a sexual way.
Taking photographs up someone's skirt would be a sexual crime, although I don't know how that would fit within definitions of sexual assault and violence.  It's still a violation of someone's body, though.

If someone kills a person, will he forget that, in case, he has PTSD ?

Not everyone with PTSD forgets the incident.  A lot of people with PTSD actually remember the incident very, very vividly.

If the person remembers the incident, then will he be in a state of shock? Or will he act normally?

It depends on the person.  If it was a sudden crime of passion there's a good chance the person will be shocked once they realise what they've done.
But some people are entirely capable of killing people without real remorse or shock.
And those people act normally.

What did Leonardo have in the movie Shutter Island?

I read a post online which says that the character Teddy Daniels or Andrew Laeddis played by Leonardo DiCaprio in the movie Shutter Island had Delusional Disorder, Post-Traumatic Stress Disorder, Schizophrenia and Dissociative identity disorder.

I didn't think someone could have delusional disorder and schizophrenia at the same time.

There are a lot of inaccuracies in the movie.

Migraine, I think.

Migraine? When was that?

Migraine was what he started having as a symptom may be.

We started taking about migraines after that which will be continued in the next post!

The Bicarbonate buffer system

some real cool facts i learned today--

1.       Buffers don’t eliminate acid, they simply neutralize acid at the tissue level..and transport it to areas from where it can be eliminated.

2.       The body has a three level of defense system, the first line are the buffers which are available for immediate action.. and the second (lungs) and third line (kidneys) through which these acids are permanently eliminated

3.       Why is it necessary to maintain the pH at a narrow range of 7.35-7.45? The structure and function of enzymes and proteins are dependent on pH..cause the containing amino acids have a charge which is highly dependent on the pH value. The body just can’t afford for the blood pH to rise or fall without deleterious consequences.

4.       Bicarbonates are the most important buffers in extracellular fluid. Why? Cause it is present in very high amount. 

Plus to top it all the HCO3- base component is in excess by 20 times! over its counterpart acid H2CO3. A very huge ratio of 20 to 1, means that the HCO3- component will always be available plenty whenever there is excess of metabolic acids to be eliminated. This is called the alkali reserve.

 Also the acid H2CO3 when formed can be very easily eliminated from the body via the lungs through the release of CO2.

 So overall bicarbonate is the only buffer which is excessive, fast acting and can be easily replenished.

5.       How does this buffer system work? The base HCO3- combines with H+ to form H2CO3. This is a weak acid, meaning once it is formed..it won’t let the H+ roam around free in the blood that easily. There will be only a mediocre rise in pH in comparison to a tremendous rise if bicarbonate wouldn't have been there. This pH stimulates the respiratory centre, which causes hyperventilation and release of CO2. 

-M-

Study group discussion: Histrionic personality disorder, Munchausen syndrome and MSBP

What's histrionic personality disorder?

I looked it up and found this on wiki:
A mnemonic that can be used to remember the characteristics of histrionic personality disorder is shortened as "PRAISE ME":
Provocative (or seductive) behavior
Relationships are considered more intimate than they actually are
Attention-seeking
Influenced easily
Speech (style) wants to impress; lacks detail
Emotional lability; shallowness
Make-up; physical appearance is used to draw attention to self
Exaggerated emotions; theatrical

Attention seeking in general.

Oh so how does this relate to mothers bringing their children in often for medical attention. Same thing?

Umm isn't that Munchausen syndrome by proxy? Different things.

Munchausen is more of medical attention seeking and histrionic looks like attention seeking in general.

If you're seeking medical attention for yourself, it's Manchausen syndrome and if you're trying to get attention to yourself by showing others are sick (mostly a child) it's Munchausen syndrome by proxy.

Oh ok. Thanks!

MSBP cases tend to involve faking medical symptoms, though. So mothers bringing in their children frequently for medical attention for real symptoms are probably helicopter parents (overly anxious and involved) but not necessarily MSBP.   Although if they exaggerate real symptoms that could be MSBP as well.

As for histrionic, it's not impossible that it would manifest as a parent bringing their child in for medical attention far more than is necessary, but as with all personality disorders, it's much more pervasive and would affect all other areas of their life and how they interact with the world, not just how often they bring their child in for medical attention.

Ah ok. Is Munchausen only specific to using another as a portal to attention. Or can this be self afflicted in order for the same degree of attention?

Munchausen by proxy is using other people's medical issues for attention. Usually children or the elderly or other dependents. Sometimes pets.

I had a patient who went to repeated doctors complaining that her child has joint pain, stiffness. Diagnostic procedures were done and all of them came out to be normal. They were suspecting MSBP in that case.

Munchausen syndrome (not by proxy) is when the person uses their own medical symptoms (often fake).

Ah ok. Now I see. So how does one start treatment for something like this?

Histrionic is in my opinion the most self defeating of the personality disorders with the exception of self defeating personality disorder, which isn't actually a recognized personality disorder anymore. Because people with histrionic need attention so much that they'll take on whatever role will get them the most attention  instead of being true to themselves.

Treatment for munchausen by proxy or not: Psychological treatment.  Helping them figure out how to get attention in healthier ways.  Interpersonal skills training.  Self esteem help so they don't need attention so much. Not giving them as much attention or sympathy might help, but it's mean and you need to be absolutely certain their faking it.

There was an episode in House MD on a patient with Munchausen syndrome. She induced hypoglycemia, seizures and took colchicine to mess up her blood profile.
She however had a medical condition that needed attention which made me realize that you can not dismiss every symptom in a patient with Munchausen without diagnostic procedures. It could be something serious. Interesting episode.

That's a huge issue with dealing with people with mental illnesses.   Doctors so often dismiss them because the mental illnesses can distort how they see things, but dismissing them means that you could miss out on something real and serious.

Would be truly unfortunately for a misdiagnosis that could potentially lead to death because the patient took antibiotics or of that nature.

Thanks for the information. Came accross the disorder while strolling the hospital. Answered so well.

Which did you come across?  Histrionic or MSBP?

Histrionic. While I walking through mental health. A group of docs were discussing personality disorders from the sound of it. That was one of which I over heard.

Ah. Personality disorders are tricky.  People aren't very likely to seek treatment, and they're not particularly easy to treat even when people seek help.  And they're complicated to diagnose because people often have symptoms from more than one, so trying to figure out which fits best is complicated.

Yeah that makes sense. I work in a military hospital so we alot of patients that will come back with not only physical but mental damage as well. The last patient I over saw had cellilitus, 2nd degree burns of the feet and would only speak to the females of the ward.
Mutisim something?

Selective mutism?

Yes!

Study group experience #3

Here's what we discussed so far:

Reason behind names of oral contraceptive pills and retroalimentation

Osler Weber Rendau syndrome

Eating disorders (A must read)

When dealing with a lesbian, gay, bisexual and transgender patient  

Ascites (USMLE oriented question) 

Diuretics (Very interesting stuff)

Difference between acute myelogenous leukemia and chronic myeloid leukemia 

Hepatitis B serum markers mnemonic  

Succinylcholine 

Anatomy study tip 

Myopia and power mnemonic  

Hybridoma technology 

Oculogyric crisis  

Extrapyramidal effects of antipsychotics and treatment

A lot of mini discussions happen here and there and I can't keep up. So everything is not published (Sorry!) but I have posted most of the important discussions (Yaay?)

Since there is a time zone difference, we have a lot of messages every morning. Some members (Including me) read like over 200 messages at once and reply to them together which is adorable!

We changed our original plan of making a separate group for every 50 members and added new people to the same group. The new comers fit in well, were excited and didn't feel like aliens to a new world (Sweet!)

People who found the main group giving too many notifications because of discussions were added to the mini group for strict study discussions. However, the mini group is very inactive (Probably because the participants are focused on the upcoming exam they have to study for!) I post stuff from the mini group to the main group so that no one misses out on anything!

A few people left without even having the courtesy of informing or letting me know why. It took a lot of work for me to organize this - Reply emails, verify identity, save numbers and then add on the group. I felt they should've at least left a message.

People at times ask me how many spots are left, I can't really answer that because some people leave and new people are always coming in. Send us your number though, we'll squeeze you in like we did for the extra 30 people! :)

-IkaN

Study group discussion: Extrapyramidal effects of antipsychotics and treatment

Guys do you know the side effect/time line of antipsychotics?

I mix up akathisa  akinesia etc. Then there's tardive dyskinesia and dystonia!
So confusing.

4 hours dystonia
4 days akinesia
4 weeks akathesia
4 months tardive dyskinesia

Thank you!

I was discussing timeline of extra pyramidal side effects of antipsychotics earlier and got a doubt - Some books say akinesia comes before akathesia while others say akathesia comes before akinesia.
Like my book says opposite of the image of a book posted by someone on the group and I couldn't find a good resource online.
Anyone has an insight on what we actually see clinically?

Well after asking around it seems the general consensus is that akathisia precedes akinesia. At since it has logic to it that's what I'm sticking with.

Thanks! Why is it logical though? Because Parkinsonian symptoms take longer to appear?

Well akathisia is restlessness and agitation, and akinesia is when you start losing voluntary movements, and it seems logical that it would precede dyskinesia.

Makes sense to me now, thanks!

Hey concerning the extrapiramidal effects of antipsychotics, I consulted my Goodman and Gilman and found this:
Akathesia: 5-60 days.
Parkinsonian symptoms: 5-30 days.
There we go. Basically the argument could be made for either order since their appearance overlaps.

Oh. So you can't have a clear cut line. Thanks for this!

You use anticholinergics for akinesia, right?

Yes, right. And for akathisia beta blockers like propanolol is drug of choice.

Ohh and what's the treatment for dystonia?

Probably Anticholinergics or muscle relaxant like baclofen. Not confirmed.

Dopaminergic drugs
Anticholinergic drugs
GABA Agonists
Carbamazepine
They all can be used in dystonia!

Woah. I didn't know this.

Dopaminergic drugs like?

Levodopa

Here's a post I wrote after this discussion - Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic  http://medicowesome.blogspot.com/2015/01/antipsychotics-timing-of-evolution-of.html

Antipsychotics: Timing of evolution of extra pyramidal symptoms mnemonic

Greetings people!

The timing of evolution of extra pyramidal symptoms of antipsychotics is something you should be thorough with:

4 hours dystonia
4 days akathesia
4 weeks akinesia
4 months tardive dyskinesia

I made a mnemonic for it because I have been struggling with it since forever!

The mnemonic is, "Distant people are Restless. Parking cars is Stereotyped and Retarded."

"Distant" is for Dystonia which comes first!

"Restless" is for akathesia (Compelling desire to move restlessly!)

"Parking" is for the Parkinsonian like symptoms seen in akinesia.

Sterotypical ("Sterotyped") movements are seen in tardive ("Retarded") dyskinesia.

Lastly, a mnemonic to remember the treatment of Neuroleptic Malignant Syndrome!

The mnemonic is, "BAD NMS"
Bromocriptine
Amantidine
Dantrolene

That's all!

-IkaN
Related post:
Extrapyramidal effects of antipsychotics and treatment (Link: http://medicowesome.blogspot.com/2015/01/study-group-discussion-extrapyramidal.html)

Study group discussion: Oculogyric crisis

What's oculogyric crisis?

I have read it a couple of times as a side effect of a couple of drugs, I don't remember the drugs though.

Neuroleptic drugs.

It's antipsychotic induced.

But what happens in it.. How does the patient present?

Sounds like deviation of the eye.

These are the ones I came accross:
Mutism, palilalia, eye blinking, lacrimation, pupil dialation, drooling, increased BP and HR, flushed face, headache, vertigo, anxiety, fixed stare or maximal deviation in all direction (usually at one a time), malaise.

Seems like it messes up your autonomic nervous system along with the eyes.

Yeah :-/

General question, what does gyric mean? Like is it a Spanish or Latin word?

Latin. It's like twisting.

Study group discussion: Hybridoma technology

Something about immunology?

What about immunology?

I love immunology. Have a separate immunology comics blog, as you probably know :D

Can you provide the link for the immunology comics blog?

immense-immunology-insight.blogspot.com

I thought you guys knew.

Thanks!

Hybridoma technology. I wanna know about that!

I'll have to read those up. Anyone in the group has an idea on those?

Hybridoma technology. Never knew of this. I'm reading into now. Cool stuff.

Let us know a short summary once you're done!

Yeah sure. I'll try.

If anyone can better explain please feel free.

This is regards to the question of Hybridomas.

Hybridomas are cells that have been specialized to produce a specific antibody in large amounts. Made by exposing the test subject (animal) to an antigen to which your insterested in isolating a antibody against.

Once the animals splenocytes are isolated, the B cells and immortalized myeloma cells are fused.

The new product is incubated in HAT (Hypoxanthine, Aminopetrin, Thymidine) medium. The medium is specialized to allow only the hybrids to survive.

The dilution process and the disired antibody production is then checked.

What ever cells are not producing the antibody they're removed and over a course of weeks the status of the subject is checked.

Oh I remember! We were taught this is first year!

Theres alot more. As far as I got :-/

Ohh thank you.

Glad I could help. Interesting read.

Yo it's really nice of you!

My pleasure.

Study group discussion: Myopia and power mnemonic

Myopia (short sightedness) mnemonic, "Cave May Be Long"

CAVE - We use conCAVE lens
MaY - in MYopia
BE - BEfore image is formed before retina
LONG - eyeball eLONGate

When eye become Myopic it is acting as converging lens (+) convex lens (bend the rays coming from object the rays towards centre) more power more convergence more bending so we use diverging lens which is a concave lens to correct or to neutralise the bending or converging.

Concave lens negative (-ve) power.

Another study link! http://medicowesome.blogspot.ae/2013/10/myopia-and-hypermetropia-mnemonic.html

Study group discussion: Remembering Anatomy

Is there any easy way to remember the relations of the viscera?

Diagrams will help you remember the relations! There are a few mnemonics for arteries and stuff but in general, painting a picture in your head is the best way to remember!

Use Atlas for visualisation, see  videos of anatomy (Acland, Dalhousie) for awesome live experience... Highly recommended.

Seeing the viscera during cadaver dissection also helps in anatomy.

For anatomy, I find it helpful to draw the pictures out and label them. This allows you to appreciate the boundaries. 

I always drew diagrams in anatomy..Netter's helped a lot. 

Dissections are equally important...I  always read anatomy and revised it in my dissection class

Paroxysmal nocturnal hemoglobinuria mnemonic

Here's a mini post on PNH!

P: PIG A gene affected (On X chromosome that makes a glycosyl phosphatidyl inositol anchor)
N: Night. Hemolysis occurs at night.
H: Ham test confirms the diagnosis.

Patient presents with a history of dark coloured urine in the morning.

That's all!

-IkaN

Study group discussion: Succinylcholine

Can someone explain succinylcholine?

Succinylcholine is different than other neuromuscular blockers because it has two phases.

It is broken down in our body by pseudocholinesterase. And this enzyme differs in different people based on genetics. Hence, while using as a muscle relaxant it can prove quite deleterious to some people who have a weaker type of the enzyme.

Deficiency of pseudocholinesterase in some people causes succinyl choline apnoea.

Also, pseudocholinesterase is different than the more common acetyl cholinesterase enzyme.

Hepatitis B serum markers mnemonic

HBsAg: Surface protein of hepatitis B which means the person has infection presently. It's a marker for current infection.

Mnemonic: S antigen Stays in Sick patients (Active or chronic infection, negative in resolved infection).

Study group discussion: Difference between acute myelogenous leukemia and chronic myeloid leukemia

Good morning everyone! Just about to start studying some haematology. I can't seem to differentiate between acute and chronic myeloid leukemias.

The number of blast cells help you differentiate on blood smear! Blasts cells are present in acute myelogenous leukemia and are absent in chronic myelogenous leukemia.

Philadelphia chromosome too.

Ph +ve or -ve

The philadelphia chromosome in chronic, right?

Yep.

But there are some CML's without the chromosome.

The major difference in AML and CML is the mortality.
Death in AML occurs in 2 months is not treated, whereas in CML, it prolongs to 4-5 years.

CML has three phases..Chronic, accelerated and blast transformation.
In blast transformation, the patient's profile converts to AML and the prognosis is grave.

Basophilia in CML, classically.

Auer rods are characteristic of AML.

Most prominent cells in CML are myelocytes and metamyelocytes.

Thanks for the help everyone :)

AML is of seven types.

Study links!

http://medicowesome.blogspot.ae/2014/02/french-american-british-classification.html

http://medicowesome.blogspot.ae/2014/12/cml-treatment-mnemonic.html

Thanks!

Study group discussion: When dealing with a lesbian, gay, bisexual and transgender patient

Although talking about it, makes me wonder how all of you would handle an LGBT person if you saw one in the course of practicing medicine (And you probably will... whether you notice or not).

LGBT?

Why would it be different if you are handling an LGBT patient?

Lesbian, gay, bi- and trans*

Their sexuality may be a thing to consider but I doubt it should alter your duty to care.

Mostly if you're handling a trans* patient, actually.  Things like referring to them by correct pronouns (which sometimes won't match the gender listed on their medical records), or using a name they're more comfortable with, even if it's not their legal name.

I know a gynaecologist who refused to treat a gay, referred him to another doctor.

Right.  And intersex people.  That's kind of controversial as far as medical things go.  What would you advise the parents of an intersex baby?
Intersex as in a baby that isn't biologically male or female.
A lot of the time doctors will perform surgery on them to make their genitals more male or female.  But a lot of intersex people think that's a bad thing to do.

We had a girl come to our clinic for primary amenorrhoea.
She was later diagnosed as genetically male.
Intersex girl with amenorrhoea. She was 15.

Oh, that's kind of interesting.
Did she want male genitals?

I don't think she was given much of a choice. And as far as I know..People out here prefer a male child better.

That's a great share.

Hmm.  I'm sorry to hear she wasn't given much of a choice.  I hope she identified as male.

My bff is an LGBT.
We've been best friends for 10 years now, so I know how to treat an LGBT person: just like another human being.
They're actually very sensitive on how you call them.
I used to have a male patient that was in transition and she told me to call her: female transgender. She used to show me pics of herself modeling at the patients room and they were actually awesome.
I don't think people should treat other people differently because of their sex preferences.

I had seen a neurofibromatosis patient in the bus once. They were no place to even stand there..But even then nobody sat besides him..It was heartbreaking.

I think on one hand, treating an LGBT person is the same way you should treat any other person, but there are also some things that are different, like having to be careful about pronouns and gendered terms (for trans* people), or being careful about how you refer to their potential partners (i.e. not referring to future boyfriends when talking to a lesbian).

Also nonbinary people have a hard time, because they can't always access transition (because a lot of resources for gender dysphoria are for people who identify as male or female), and because their gender can't go on their medical records since very few countries recognise nonbinary genders (i.e. people who don't identify as male or female, but kind of somewhere in the middle, or they don't identify with gender at all etc.)

I don't think patients should be treated differently regardless of anything.  I think everyone should be offered the same standard of care, regardless of race, sexuality, gender or even things like mental health status (I strongly disagree with people not being given the same quality of health care for self-inflicted injuries).

Human beings are different from each other, yet so similar.... That is what makes humans so beautiful in their own kind of ways.

Intersex babies are often taken into surgery here (They mostly make them "more male", bc it's a patriarchal society and having a son is important). There was a major case in Cyprus a few years back, a surgeon operated on an intersex baby without fully informing the parents about the condition and/or their options. The whole deal was very ugly.

I've been actively working to improve the conditions of LGBTI patients here for years. I work with local and national Queer associations, and Turkish Medical Students' International Committee to teach medical students about the LGBT community, so that we can be more sensitive and we can help them out more. The society here is quite homophobic, so trans people can't access healthcare at all in some places. Only 2 weeks ago a trans acquaintance of mine passed away due to an infection after her gender-reassignment surgery because some of the hospital staff didn't take care of her. Very sad situation.

I'm a queer person myself (most people can't decide if I'm a man or a woman when they first see me) and that also brings about some funny conversations. Patients tend to not care though, as long as I have the white coat on, I could be a 6 foot lizard and they wouldn't mind.

Haha the 6 foot lizard bit!
I like how people are able to get through any situation with a good sense of humor :)

That's amazing..Hopefully one day the world will stop labelling people.. And consider everyone a human.

That's a feeling I get everytime someone is chastised for their choices..I just say out loud..Have you looked inside a human body? I have! And I know for sure we all are the same on the inside.

Well put!

Study group discussion: Diuretics

Which diuretic would you use in a person who has a previous history of skin rashes by the use of sulphonamides?

The only loop diuretic you can use in a patient with sulfa drug allergy is ethacrynic acid.

Also, you have to monitor the levels... Because ethacrynic acid is the most ototoxic.

There is an antibiotic that causes ototoxicity too. Which one?

Aminoglycosides!

Study group discussion: A question on ascites

Here's a exam oriented question I made up:

28 year old male presents with abdominal distension. Temp 37, pulse 92, BP 110/70, RR 18. On examination you find that he has hepatomegaly, ascites and his jvp is 8 cm above the sternal angle. Urinalysis is normal. He has history of alcohol abuse, had a viral infection few weeks back.

What is the cause of his ascites?
Urinary protein loss
Malnutrition
Liver disease
Portal vein compression
Thrombosis of hepatic vein
Pericarditis
Nephrotic syndrome

Discussion:

Liver disease?

Umm it's not liver disease. He would have symptoms of jaundice if he had liver disease.

Ohh, I thought hepatitis virus.

Pericarditis! The jvp and viral infection is the catch here.

Yes!

Nice question.. Hungry for more!

I almost thought it was viral hepatitis then I remembered that viral hepatitis shrinks the liver...Good question ..moore.

But what's the connection between pericarditis and the ascites!? Someone explain please!

Blood can't fill in the heart adequately during diastole, which causes an elevated venous pressure. It results in JVP, ascites etc

What's the answer to the case IkaN?

It's pericarditis.

Anyone wants to guess the etiology? Like what caused the pericarditis?

Alcohol abuse? Immunosuppression?

The alcohol abuse was intended to be a huge distractor. The guy simply had viral pericarditis due to Coxsackie B virus.

You have to assume Coxsackie because it's the most common cause of viral pericarditis.

I read somewhere that people who binge drink a lot are at risk of getting bacterial pericarditis..Streptococcus or Staphylococcus type..I didnt know about viral...It makes a lot sense though..Epidemiology rarely lies.

Oh I didn't know this. I know that alcoholics are predisposed to spontaneous bacterial peritonitis.

Yah its due to low immunity..another risk is in patients who have undergone pericardiocentesis.

Yes.

What is the mechanism of pericarditis?

Pericarditis is when there is inflammation of the pericardial sac. One of the many uses of pericardial sac is to reduce the friction over the heart with every heartbeat. There also can be collection of fluid in the pericardial sac.

It can be acute or chronic, and is usually classified by what the pericardiac fluid contains.

Extra hepatic complications of hepatitis C mnemonic

Hey!

A short post for today! :)

The mnemonic for extra hepatic complications of hepatitis C is, "ABC LMNOP"

Study group discussion: Eating disorders

Binge eating disorder is when the person stuffs himself in one day and then doesn't eat for a couple of days. In bulimia, patient eats normally / in excess but then voluntarily vomits out the food to avoid gaining from it.

Binging and then not eating  for a couple of days sounds like bulimia nervosa more than binge eating disorder.

People with BED don't compensate for their binges.  People with bulimia do (by restricting, exercise, purging etc).

Restricting is reducing caloric intake.   Purging can be making themselves throw up or by using laxatives.

Anorexics can also restrict and purge. But anorexics don't binge, definitionally.

So bulimics can be over weight, right? Because they binge? And anorexics are typically under weight? I always get the two mixed up!

Bulimics can be overweight or underweight, depending on how successful their compensatory strategies are after they binge (if they manage to throw up most of the food, and also exercise enough to compensate for the calories their body did manage to absorb, they can actually lose weight extremely quickly, like anorexics).

Anorexics are always underweight, definitionally.  If someone has symptoms of anorexia but they aren't underweight (or if they're female and they still have their period), then they'll probably be diagnosed with ED-NOS instead (specifically 'atypical anorexia').

ED NOS?

ED-NOS is eating disorder not otherwise specified.

If you recall, anorexia as a symptom and not a disorder just means loss of appetite (I really don't like that it's the same word).  So anorexia nervosa is a disorder largely characterised by not eating (although it's more complex than that, and a lot of anorexics do binge, just not frequently enough to be diagnosed with bulimia nervosa).

A person might also be diagnosed with ED-NOS if they have symptoms of bulimia, but don't binge often enough to be diagnosed with bulimia nervosa.

Up to 60% of people in eating disorder programs have ED-NOS.

It's also sometimes called OSFED (especially if you're not American).  OSFED is 'other specified feeding or eating disorder'.

I didn't know this about this. I thought Anorexia and Bulimia were the only ones!

So does the management of atypical Anorexia differ?

In the new DSM, the amenorrhea criteria of anorexia will be removed. 
So you still have a significantly lower weight than you should with anorexia, but you don't necessarily need to stop having your period anymore to meet the diagnosis.
Because many women even severly underweight can still have their period.
Also "binge eating disorder" is added, which is eating too much but without compensating behaviors.

But previously you had to miss your period 3 months in a row to have anorexia. They removed this criterium

Oh that's why I heard the no period criteria for the first time!

Yep it's new in DSM-V.

And as for the different treatment.. Since you are underweight in anorexia and not usually in ED-NOS, you will find more people with anorexia being treated by refeeding/feeding tube.

I didn't know that, but that's awesome.  It would be better if they removed the criteria for low weight, too, though. I know a lot of people in the pro-anorexia communities tended to want to wait until they met the weight and amennorhea criteria before getting help so that they could be diagnosed with anorexia nervosa instead of EDNOS.

Yep. It's an "honor" to have anorexia, "shame" to have EDNOS because you're not good enough at having an eating disorder and worse when you have bulimia.

It's strange they make a ranking system for eating disorders, while many people will fluctuate between all three disorders in their lifetime

Which is incredibly unhealthy, because:
1. EDNOS can be as physically damaging to your body as anorexia nervosa (bulimia nervosa is less likely to be physically damaging, although Boerhaave's syndrome, enamel erosion etc mostly only happen for bulimia).
2. Eating disorders, like anything else, are far more treatable if caught early.  Discouraging people from seeking help because the diagnosis they'll get is a less desirable one isn't helpful.

That's sad. The criteria shouldn't get in the way of someone who wants help.

I think the ranking system makes sense, though.  A really high percentage of people in the pro-anorexia community are perfectionists.  If the goal is to be skinny, having an eating disorder where the diagnostic criteria include being extremely skinny would be seen as relative success.  I don't think the ranking system is healthy in any way, but it makes sense.

As for bulimia being the worst... there's a pro-bulimia community, too... there isn't a pro-EDNOS community (although they tend to be absorbed by the pro-anorexia one).  So I don't think it's necessarily accurate to put bulimia at the bottom of the hierarchy (although I do realise that a lot of bulimics wish they were anorexic instead because they think they'd lose weight faster that way).

Hmm. So what do you guys think would be a sensitive way to approach eating disorders, in terms of clinical encounters or diagnosis? How might we be more body positive in the clinical setting?

Well it's hard to approach people with eating disorders properly... Because if they are still in denial (much like in addiction), they will see a comment about looking sick as a compliment

Someone asked whether the management of atypical anorexia is different.  In general, all restrictive eating disorders can be seen as fairly equal, and the recovery process is largely similar for anorexia nervosa and atypical anorexia.  The only significant difference I know of is that people with anorexia nervosa are more likely to be put in inpatient, and achieving a healthy weight tends to be more of a focus for anorexia nervosa than for EDNOS.

And yes, being told that they look sick would almost definitely be taken as a compliment.

I see. It's like they are different colors of the same spectrum.

I think what you can do is just ask the patient if they are okay, mentally. If they want to talk about anything, because you are worried.

I had a colleague this past week and she ate next to nothing, so I asked her. And told her if she needs to talk, she can e-mail or call me

Pretty much... I strongly disagree with the way they separate atypical anorexia from anorexia nervosa based on weight.  The psychological symptoms are the same, the mental distress tends to be the same, the treatment is the same, the potential physical harm that the eating disorders cause are the same.

Just never minimize the problem if your patient has an eating disorder, because they will try very hard to prove you wrong

A friend of mine has had people say to her that her eating disorder wasn't "that bad" because she wasn't severely underweight, which stimulated her to not eat. She ended up in the hospital. It's a sensitive subject, so try to get an expert to talk to them instead of potentially saying the wrong things.

I figured it was something like that. But expert aside, seems like it's still important to leave them to open the conversation, similar to any other mental illness and let them talk it out than seek immediate referral.

Definitely :) if you are willing to help and listen, just tell them that you don't know much about it/don't have experience treating people with eating disorders, but you would like to try and help.

As far as being sensitive goes:
1. If a blood test and/or an ECG is part of the diagnostic process (I know it's a requirement for the eating disorder treatment program here, I don't know if it is elsewhere), assuring someone (especially if they aren't thin enough to be diagnosed with anorexia nervosa) that even if the blood test results look 'normal', it doesn't mean that they haven't done damage to their body, and it doesn't mean that they aren't sick enough to deserve help (this is especially true for people who are voluntarily seeking help for an eating disorder).
2. Not telling people to just eat... I don't know why on earth people, including medical professionals, insist on doing this.  It's awful.  Don't.  If it was that simple they wouldn't need medical treatment.
3. Acknowledging that the eating disorder serves as a useful and valuable coping mechanism.  Even though eating disorders are their own special kind of hell to have, the feeling of control they give to people who suffer from them can still feel good and make it hard to recover.  It's possible to be sensitive and acknowledge the things that make it hard to *want* to recover, while still pointing out that on the whole, it's harmful, and recovery would make the patient's life better.
4. If someone has atypical anorexia, don't constantly remind them of it.  They probably think about it a lot.  Saying "eating disorder" validates the severity of what they're going through, and emphasises that all eating disorders are serious and should be treated as equally serious.
5. Unless their life is in immediate danger, don't try to force recovery-oriented behaviours on them.  Let them recover on their own time: it'll make it so that the recovery process is less scary/unpleasant, and will also make it so that their recovery lasts longer.  Eating because you've been forced to isn't the same as eating because you want to recover.  Encourage them to choose recovery on their own.
6. Following on from that... don't just focus on the physical symptoms.  Yes, it's important that people figure out how to eat properly, because not eating properly can result in very serious physical consequences, but it's also very important to acknowledge the mental symptoms, because those can cause very serious effects on the person's quality of life, too.  A friend of mine saw a psychiatrist for anorexia nervosa, and the psychiatrist kept focusing on her weight, and as she reached her healthy weight, the psychiatrist acted as though that meant she was nearly recovered.  Never forget that eating disorders are mental illnesses, and just because someone's at their healthy weight doesn't mean they're recovered, or that they don't still need help.

I have mixed feelings about handling co-morbidities, because I don't know a lot about them.  I know that there are segments of the medical profession who believe that if someone presents with a comorbid eating disorder and anxiety/depression, that they'll try to treat the eating disorder first before doing anything about the anxiety/depression.  Which to some extent makes sense, because not eating can do weird things to mood, but I personally don't really like that approach (especially in cases where the anxiety/depression clearly was present before the onset of the eating disorder).  I do know, however, that if a medical professional takes the view that the eating disorder should be addressed first, it can definitely come across as them dismissing the mood and anxiety disorders as being just a by-product of the eating disorder, which can be incredibly invalidating.

I feel anxiety & depression should be addressed along with the more obvious eating disorder. But I don't know if it's feasible in clinical practice.

You can ask the patient to talk about it, sure. But if that doesn't work pharmacological treatment takes weeks. And you never know if the eating disorder caused the depression or vice versa, the depression caused the eating disorder. I really don't get how a psychiatrist would actually approach and manage such a patient.

Comorbidities are messy.  Eating disorders tend to make anxiety/depression worse, but anxiety/depression (especially anxiety) can make eating disorders worse, too.  In light of that, I feel as though treating them both at the same time makes sense because reducing the symptoms of the depression/anxiety might make the eating disorder better, even if the eating disorder is the cause of the depression/anxiety.

I know there are psychiatrists who will prescribe antidepressants and/or anxiolytics for people who have eating disorders.  But also doctors who insist on treating the eating disorder by itself first. I don't think there's a general consensus on what's the best way to handle that.

As for feasibility in clinical practice, I personally think it makes more sense to address depression/anxiety at the same time as the eating disorder, especially where it isn't certain whether any given symptom is caused by an eating disorder or anxiety (if someone's afraid to eat in public, is it general social anxiety or the eating disorder?... there's no real way to tell... but it's not important, because either way the symptom needs to be addressed)

Agreed.

Would it help treating an anorexic patient indirectly?  Say, you need to gain a little weight back even though you might not like it because.. Idk.. You have amenorrhea? And that's bad etc etc
Or is that even allowed?

Anorexic patient: I doubt it would help.  At a fairly early point in eating disorders, the desire to be thin begins to take on an irrational level of importance.  It's not uncommon for anorexic patients to express the idea that they don't care if they die, so long as they can die skinny.  Although in the early stages of illness, a lot of anorexics desire to be skinny so that they can be beautiful, or popular etc, at some point it often takes on an importance of its own, and they'll be willing to risk everything (health, beauty, popularity etc.) to be skinny.  When it gets to that point, curing amennorrhea isn't really going to be enough of an incentive to overcome the obsessive desire to be thin.

Even if they gain back the weight, you might end up in a yo-yo weight situation where any underlying disorders keep cropping up, particularly in times of stress. Eating disorders tend to be chronic and long-lasting.

Telling someone that something they do is "bad" also probably isn't really compelling, even though lots of people try that tactic :p

That is also true.  And as I said before, although gaining back the weight can be important, it's even more important to deal with the underlying mental illness.

So, it would still be difficult to show them that hey! You are back to normal weight and still looking good? As in their perception just won't change?

Once people get close to being at a normal weight, they often feel that they look incredibly fat (and in comparison to their emaciated bodies they had while severely underweight, they probably do).

I guess it makes if I think according to their thoughts.

There was an experiment where people were starved and they started engaging in disordered eating behaviour, but once they reached their healthy weight again the disordered behaviour went away.  The problem is, that only seems to be true for people who developed disordered eating behaviour after losing weight.  For people who lost a lot of weight as a result of disordered eating, regaining the weight doesn't seem to usually fix the problem.

Which is why I so strongly disagree with any treatment approach that focuses on regaining a healthy weight, and using weight as a marker for how healthy a person is.  Because if someone recovers enough to be at a healthy weight but doesn't recover fully mentally, chances are they're going to revert back to old behaviours again.  Relapse and recovery cycle and all that.

Full recovery is generally possible for restrictive eating disorders, in that a lot of people never do go back.  But that only happens if the underlying eating disorder is adequately dealt with, and not when the only recovery that has happened is weight restoration.

It falls to dealing with the cause versus dealing with the symptoms.

Precisely.

So if we don't talk about weight, how do we bring them back to a normal mental state?

Well the mental state is the problem the weight is just a visible symptom of that.

Eating disorders are often very helpful to people who have them, even if they cause a lot of suffering.  They're a way of being able to exert control in a chaotic world.  It's why eating disorders are so common among young people with controlling parents.  Eating can often be the only thing that people can control if they live in highly restrictive environments.

So changing how you think about the illness is an important first step?

To that end, making sure that people with eating disorders find things in their life that they can have control over in healthy ways can be really valuable.

Many associate these with vanity which undermines the sickness.

It has a stigma sort of like depression, where it used to be considered that the person was just sad or moody but now we know it is an imbalance of neurotransmitters that is the cause.

It's important to take. the patient seriously and treat it as a real illness so that the patient can feel that they can be cured and recover, like most illnesses.

Definitely acknowledging that it's a real medical illness and not just something someone is doing to themselves is important.  Validating someone's experiences is one of the most important things about dealing with patients, and especially important in cases of mental illness.

Validating that's the word.
Couldn't for the life of me recall it.

One more question, mentioned that one way would be to make sure they have control over other things in life in healthy ways. What exactly do we mean- lifestyle?

If they're a child, ask their parents to give them more freedom to make choices in their life.

If they're an adult, talking to them about the areas in their life where they feel they have no control, and helping them see that they do actually have quite a lot of control can be helpful.

Although that can be tricky, a lot of people with eating disorders have been victims of trauma, and that's very much a situation where they did not have control.

I see. This was incredibly insightful. Thank you guys!

You should also try to focus on giving them better coping mechanisms and expressing their feelings. A big part of eating disorders is also about not feeling, not dealing with emotions. They need to know it is okay to cry, that they can deal with whatever caused the disorder in a healthy way. And especially let them know that yes, even though this coping mechanism was helpful in the past (for example in cases of abuse), it is no longer necessary to survive.

It makes me really happy that people in this group were so willing to listen when we were talking about what to do with patients who have eating disorders.  And your desire to make a difference when you're in clinical practice.  I like how everyone in this group seems to genuinely care about being a good doctor and to care about patient welfare.  I think that's really important, and it makes me hopeful about the future generation of doctors to see how much you care.