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Query: UMLS:C0042963 (vomiting)
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A patient is described who developed the classical syndrome of anorexia nervosa at the age of 52. Her illness occurred in relation to the marriages of her daughters and showed an extreme preoccupation with her body shape and a determination to slim by diet, purging and vomiting, and the hiding of food to the extent of rendering herself too weak to cope with the demands of her life. It is suggested that anorexia nervosa, though predominantly a disease of onset in adolescence, may present at any age and should be considered in the differential diagnosis of anorexia in patients over the age of 50.
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PMID:Anorexia nervosa after the menopause. 127 64

A prevalence study of attitudes and behaviours associated with anorexia nervosa and bulimia was carried out among female undergraduate students at the University of Cape Town. Findings were similar to those found in surveys overseas. More than one-tenth of respondents (11.8%) scored in the 'anorexic range' on the Eating Attitudes Test (EAT); more than one-fifth (21.9%) are at present binge-eating, and 6.3% using self-induced vomiting as a means of weight control. Use of laxatives, diet pills, fasting, strict diets and exercise was common. The findings are discussed within the context of sociocultural pressures on women to conform to a slim ideal shape and size. Sensitive management of the problem is needed.
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PMID:'Abnormal' eating attitudes and behaviours among women students. 366 Jan 33

Anorexia nervosa (AN) can be considered a result of complex instrumental conditioning. It is postulated that in healthy nonsatiated individuals, the sight and smell of the preferred food, acting as a conditioned stimulus (food CS), activates a memory pattern of associations "eating--desirable sensory input" (approach pattern). This leads to the instrumental reaction of eating which is reinforced by sensory satisfaction. In victims of AN, in addition to the approach pattern the food CS activates another pattern of associations consisting of such components as "eating--obesity--failure" and " noneating --thinness--success" (avoidance pattern). The establishment of the avoidance pattern depends on such factors as social preferences and pressures to be slim, inborn dispositions, and personal psychological problems. If the activation of the avoidance pattern prevails over the activation of the approach pattern, the individual refrains from eating. The refusal to eat is here an instrumental avoidance reaction; its performance is reinforced by satisfaction derived from successful self-control and losing weight. A prolonged activation of the avoidance pattern leads to malnutrition and ultimately to death. In cases in which the approach pattern and the avoidance pattern are frequently activated simultaneously to the same degree, a neural conflict may develop. In a variation called "bulimia nervosa," an activation of the approach pattern alternates with the activation of the avoidance pattern. First, overeating takes place; it is reinforced by oral-gastric satisfaction. Then, the avoidance reaction of self-induced vomiting or purging follows; it is reinforced by satisfaction derived from preventing weight gain.
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PMID:Anorexia nervosa as a case of complex instrumental conditioning. 672 79

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.
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PMID:Trichotillomania: Bizzare Patern of Hair Loss at 11-Year-old Girl. 2747 78

In our society a huge tension is caused by three types of contradictory messages in relation to our body structure: medical message, aesthetic message and gastronomic message. The abundance of food, some very attractive, together with the social "order" of having to be slim to be accepted, originates very complicated internal situations that lead predisposed people to develop an eating disorder. In concrete, bulimia nervosa is a disorder nobody spoke about three decades ago, and there are only some detailed references about it in the last 80 years. In 1979, Rusell coined the name of bulimia nervosa and considered it as a variation of the anorexia. From the 80s on, it has been noticed how the incidence of the bulimia nervosa has increased, with an important quantitative variability, being a reason for concern among health professionals and our society in general, and for the families who suffer its consequences in particular. Not likely to be a new disorder, since the references to excesses with food and to vomiting are so old that they cannot be traced in time. The origin of this disorder is multifactorial and although personality factors and environmental elements are implied, it is also true that there is a genetic predisposition that is not still well known. The individuals with bulimia nervosa show a wide range of functional limitations that are linked to the disorder, being the social field the one which can probably be affected more negatively. For all this, nowadays the deployment of resources and efforts has been increased by the health authorities, in order to implement therapeutic procedures, to boost ways of prevention and to reinforce the rehabilitation of all the aspects implied in the disorder.
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PMID:[Bulimia Nervosa]. 3027 30