Chapter Fourteen
Summary
In the typical practice, patients present with a host of psychological and physical concerns. These patients
are likely to present with unexplained symptoms to their primary care physicians. Depression has been shown to be
a factor for declining health, and declining health increases or worsens one’s mental illness. In fact, having a serious
physical condition or disease like cancer, HIV or diabetes, results in a two-fold increase in the risk for developing a
depressive or anxiety disorder. Further, it has been shown that 40-65% of those who experience a heart attack also
suffer from depression. In general, 25% of cancer patients also report depression.
As we discussed in Chapter 13, substance abuse and mental illness often go hand–in-hand, but we also see
that 50-75% of those with an eating disorder may also have a history of major depression. The presence of an Axis
II condition, further complicates and hinders the treatment of an Axis I condition.
Pain management is often a tricky endeavor as there is no typical pain patient. There is often a collage of
both physiological and psychological factors that necessitate multidisciplinary cooperation and specifically tailored
services. While many pain patients resist psychotherapy, many therapy patients who present with chronic pain have
conditions like major depression, GAD, PTSD, panic disorder or a substance abuse disorder. Further, unresolved
issues such as grief, sexual abuse, physical abuse and chronic anger complicate treatment by influencing one’s
perception of pain.
While historically psychotherapy has been used in the treatment of chronic pain with emotional
components, the use of psychopharmacology may be considered. Traditionally TCAs are used due to their
noradrenergic effects, which decrease neuropathic pain. SNRIs such as Effexor, Cymbalta, Savella, Fetzima, and
Pristiq are also helpful, as they increase both norepinephrine and serotonin levels in patients with co-occurring pain
and depression/anxiety. Research has shown that increasing levels of serotonin and norepinephrine together is most
effective for pain management. Mood stabilizers such as gabapentin or topiramate are also used to calm pain
patients and increase sedation for improved sleep.
Specific Discussion Questions:
1. Explain how physical illness affects mental illness and vise versa.
2. Why would communication between various professionals be so critical when treating the mentally ill -pain
patient?
3. Explain the role of medications in the treatment of bulimia and anorexia.
Possible True/False Questions:
1. Roughly 10% of the general population has neuropathic pain.
2. It is estimated that nearly 20% of those with an eating disorder also have a history for depression.
3. Roughly 40-65 of cardiac patients also experience depression.
4. Elavil, Effexor, Cymbalta, and Neurontin are commonly used in pain management.
5. SSRIs work equally well for anorexic and bulimic patients.
6. Medications tend to play more of a significant role in the maintenance/ weight restored phase of treatment.
7. The use of medications that increase both serotonin and norepinephrine are typically more effective than the
medications that enhance serotonin alone.
8. Up to 80% of primary care patients meet criteria for a mood or anxiety spectrum disorder, which can lead to
poor medical compliance.
Multiple Choice Questions:
1. It is estimated that about ____% of eating disorder patients also have a history of depression.
a. 15-20%
b. 29-30%
c. 50-75%
d. None of these
2. All of the following have been used to treat Anorexia Nervosa except:
a. antipsychotics
b. benzodiazepines
c. lithium
d. zinc
3. While the use of medication in anorexia patients has had less than promising results, the use of ___________
has been shown some success in stimulating weight and reducing concerns about size and shape.
a. Nardil
b. Ativan
c. Wellbutrin
d. Zyprexa
4. Patients with BED or Binge-eating Disorder tend to respond well to:
a. TCAs
b. SSRIs
c. anti-obesity medications
d. All of the above
5. Research on comorbid pathology suggests that as many as ____ % of patients with bulimia also have a
personality disorder.
a. 30
b. 50–55
c. 42–75
d. None of these
6. Which type or school of psychotherapy has been found to be especially helpful for pain management patients.
a. Psychodynamic
b. Cognitive-behavioral
c. Rational Emotive
d. Person-centered
7. Chronic gambling has been shown to be successfully reduced with which of the following medications?
a. Anti-psychotics
b. Benzos
c. Neltrexone
d. None of these
8. All of the following have been used in the treatment of PIU?
a. Lexapro
b. Celexa
c. CBT
d. All of these
Case 1 and 2 Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in each case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in each case?
Answer Key to Possible True/False and Multiple Choice Questions
Chapter Fourteen
Possible True/False Questions:
Multiple Choice Questions: