Behavioral Health

Definitions

• Tardive dyskinesia: A condition that often results after long term or high dose use of antipsychotic medications. It causes disordered, involuntary, repetitive motions.

• SSRI: Refers to Selective Serotonin Re-Uptake Inhibitors. They are antidepressants.

• Somatization Disorder: A long term condition in which a person complains of pain or other undesired physical conditions but no physical explanation can be found. The symptoms experienced by people with this disorder are real and not made up.

• Bipolar Disorder: A disorder in which people experience "mood swings," switching from manic to depressive states. 

• Munchhausen Syndrome: A condition in which a person acts as though they have a disorder. It is similar to hypochondriacs however, people with Munchhausen Syndrome are aware that they are exaggerating or lying about their symptoms whereas hypochondriacs are not.

• Malingering: Lying about a condition or exaggerating in order to have some sort of gain whether it is financial, to get access to drugs, etc.

Pathophysiology

Describe the clinical symptoms which are manifested by patients with anorexia nervosa. How do these differ from the clinical symptoms of patients with bulimia? What criteria are used to diagnose anorexia nervosa, bulimia and EDNOS?

The clinical symptoms include a markedly decreased weight status, absent menses for women, and abnormal lab values may also occur including anemia, abnormally low white blood cell counts, low plasma glucose, elevated serum total cholesterol, increased BUN and serum creatinine. Bulimia nervosa clinical symptoms vary in that women still maintain their menses and maintain body weight within normal limits. People experiencing bulimia nervosa may also have lower serum potassium levels, lower serum chloride levels, and elevated serum bicarbonate. Anorexia is diagnosed by the presence of markedly decreased weight status, fear of weight gain, a distorted body image, and amenorrhea. A person with bulimia nervosa will have repeated episodes of binge eating, and repeated efforts to counteract bingeing including vomiting or excessive exercise. EDNOS is when a person has disordered eating, but does not meet the diagnostic criteria of anorexia nervosa or bulimia.  

Define depression and describe its clinical symptoms.

Depression is a mood disorder of the brain in which an individual experiences prolonged periods of sadness and depressed mood which interfere with normal life functioning. The exact cause of depression is not known. A person with depression may experience the following symptoms: feelings of hopelessness, loss of interest in daily activities, appetite or weight changes, insomnia, irritability, and loss of energy.

Describe the most common clinical symptoms of a patient with Bipolar disorder. How might these impact nutritional intake?

Periods of overactive, disinhibited behavior for periods of up to 4 days without periods of depression and three or more depressive episodes. A person experiencing mood swings such as these will most likely experience extreme shifts in hunger and eating patterns. Their eating regularity will be altered and they may intake more or less food depending upon whether they are in a manic or depressive state. 

Drug Therapy

For each of the following classifications of drugs provide: indication/contraindication for use, effect of drug on nutrient absorption and utilization, effect of nutrients on drug absorption and utilization, side effects of the drug. 

• Neuroleptic: Risperidone, olanzapine, clozapine, aripripazole (abilify).
• Indication/contraindication: Used to treat resistant depression or anxiety
• Effect of drug on nutrient absorption ad utilization: Riboflavin, Ubiquonone absorption are decreased. Sodium levels are decreased.
• Effect of nutrients on drug absorption and utilization: Caffeine and tannins inhibit drug metabolism and drug levels. Grapefruit should be avoided.
• Side effects of the drug: drowsiness, insomnia, tachycardia, diabetes, dizziness, headache, tremor, fever, visual changes, orthostatic hypertension, syncope, sweating, seizures
• TCA (tricyclic antidepressants): Elavil, pamelor.
• Indication/contraindication: Used to treat depression, anxiety, ADHD, panic disorder, migraine, insomnia, and bulimia nervosa
• Effect of drug on nutrient absorption ad utilization: May increase or decrease glucose
• Effect of nutrients on drug absorption and utilization: Fiber may decrease effectiveness, caffeine and tannins can inhibit drug metabolism, saint johns wart and grapefruit should be avoided
• Side effects of the drug: sedation, drowsiness, blurred vision, delirium, dizziness, fine tremor, headache, weakness, orthostatic hypotension
• Alcohol deterrent: Antabuse, naltrexone.
• Indication/contraindication: to help patients avoid drinking alcohol
• Effect of drug on nutrient absorption ad utilization: the drug can increase the effect of caffeine, increases cholesterol 
• Effect of nutrients on drug absorption and utilization: alcohol consumption can cause rapid release of the drug
• Side effects of the drug: drowsiness
• MAOI (monoamine oxidase inhibitors): Nardil, parnate.
• Indication/contraindication: Used to treat depression
• Effect of drug on nutrient absorption ad utilization: Vit B6 deficiencies, amplification of Tryptophan 
• Effect of nutrients on drug absorption and utilization: avoid foods containing tyramine
• Side effects of the drug: insomnia, hyper or hypotension, dizziness, drowsiness, blurred vision

Discuss the use of lithium therapy. Include indications/contraindications for use, its effect on sodium balance in relation to dietary implications, and possible complications associated with its use.

Lithium therapy is very effective at treating manic depression. However, it must be taken in very high doses in order to be properly taken up by the body's cells. Toxic levels of lithium can deplete sodium by altering normal functioning of the kidney and the antidiuretic hormone. A person taking lithium medication should maintain a normal/balanced sodium intake, a steady intake of caffeine,  stay hydrated, monitor glucose levels if the patient is a diabetic, and avoid alcoholic beverages. 

Nutritional Management

What are the nutritional considerations in the management of a patient with major depression?

Drug/Nutrient interactions and maintaining proper intake of food- avoiding binge eating, ensuring adequate intake. 

Discuss the effects of alcohol abuse on a patient’s nutritional status. What dietary recommendations would you give to an alcoholic patient?

Alcohol abuse can cause nutritional deficiencies of folate, vitamin B12, vitamin A, and calcium among other less common deficiencies. These occur as a result of heavy alcohol consumption replacing a normal balanced diet. As alcohol abuse continues the liver is likely to be damaged and more nutritional damage can occur. Until a person returns to normal eating patterns a vitamin and mineral supplement should be considered. Focus should be on returning to normal calorie intake. Small meals throughout the day and small snacks can be added to the diet. If the alcoholic has other medical conditions for example hypertension or cardiovascular conditions, their diet should be adjusted as appropriate. 

What are the nutritional goals for patients with anorexia nervosa? What are the nutritional goals for patients with bulimia nervosa? Describe methods for achieving successful food intake with these patients.

Goals include improving the individuals eating behaviors, restoring weight to a healthy range, eliminating electrolyte disturbances and other medical complications, returning from a catabolic state to an anabolic state, and improving psychological relations with food. The nutritional goals for a patient with bulimia nervosa are to reduce binging and purging and to normalize eating habits. Some methods to achieve successful food intake with these patients include normalizing eating patterns by developing a structured eating plan which may include three meals a day with one to three snacks. Including feared foods in the diet is another method. Anorexic patients may require more intense treatment and long term care based on their likelihood of severely low weight status. In such cases they may be required to be placed on oral feedings to eliminate medical complications. Meals should be consumed with the supervision of staff who can stress the importance of consuming adequate food while proving reassurance about recovery. 

What is re-feeding syndrome? What are the clinical and laboratory indications of re-feeding syndrome? What Behavioral Health patient population is at risk for developing re-feeding syndrome? 

Refeeding syndrome occurs in patients who are malnourished. Refeeding syndrome is a condition in which fluid and electrolyte imbalances occur after introducing food to patients who have not been consuming food and are severely malnourished. The imbalances are the result of the body conserving muscle and protein breakdown by using ketones from fat breakdown as the primary source of energy during a prolonged fasting state. With refeeding syndrome there is serious potential for cardiac, hematological, and neurological complications. Anorexia nervosa patients are at risk for developing the syndrome.

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INTERN’S NAME: Melissa Cannon

INSTITUTION: Cooler-Goldwater

ROTATION AREA: Behavioral Health

CHARTING TYPE: Not specified 

PRECEPTOR’S COMMENTS / CORRECTIONS OF CHARTING

Although the patients diet is limited and we have tried several nutritional attempts to lower his fasting blood glucose there are still a few remaining options to lower his fasting blood glucose levels within his current diet including switching to whole fruit and switching to whole wheat bread. Other than diet, suggesting the patient increase his physical activity level can be beneficial for lowering fasting blood glucose levels.

INTERN’S COMMENTS ABOUT NUTRITIONAL INTERVENTION(S):

The patient was very receptive to the idea of switching to whole wheat bread as opposed to white bread. He was attentive during the nutrition education session. The patient was on a drug therapy regimen to assist with his Psychosis. Many of these drugs have durg/nutrient interactions. 

WAS THE NUTRITION INTERVENTION SUCCESSFUL? WHY/WHY NOT?:

The patient’s diet was changed to include whole wheat bread in place of white bread. The patient does continue to have higher fasting blood glucose levels most likely due to his continual consumption of food from outside sources. The patient’s current physical activity is limited as he is in a wheel chair.