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12.09.10 Child psychiatry notes

Mentalisation
  • Process of learning to understand emotions
    • Children initially have the feelings, but don't know what they are
  • Key part of parenting
    • Esp. if first few years of life
  • May be missing if e.g. parents have mental health problems
  • One manifestation is parents who, with the best intentions, try to pretend everything is fine despite emerging problems
    • Fails to acknowledge anger/pain/distress
  • Failure of mentalisation can be extremely confusing for children
    • "Internalisation"
    • Leads to behaviours such as self-harm / aberrant coping strategies


Anorexia signs

  • Russel's sign
    • Scars on knuckles from self-induced vomiting
  • Lanugo
    • Adaptive attempt by the body to trap and retain heat when the insulating effect of body fat is missing
  • Oedema
  • Squat test
    • Arms out in front - can they squat and stand up again without help
  • SUSS test
    • Sit-up
    • Squat
    • Stand
    • Scoring
      • 0: Unable
      • 1: Able only using hands to help
      • 2: Able with noticeable difficulty
      • 3: Able with no difficulty
  • Orthostatic hypotension


Transference
  • Phenomena where the listener (doctor) starts viscerally to feel the emotions felt by the patient
  • Occurs frequently in other walks of life
    • e.g. Shop assistants get angry when dealing with an angry customer
  • Also counter-transference
    • Putting your emotions back into the patient


BPD Symptoms

  • Impulsive / Unstable / Turbulent
  • Often uncertain about their identity
    • As a result, their interests and values may change rapidly
  • Tend to see things in terms of extremes, such as either all good or all bad
    • Views of other people may change quickly
    • A person who is looked up to one day may be looked down on the next day
    • These suddenly shifting feelings often lead to intense and unstable relationships
  • Fear of being abandoned
  • Feelings of emptiness and boredom
  • Frequent displays of inappropriate anger
  • Impulsiveness with money, substance abuse, sexual relationships, binge eating, or shoplifting
  • Intolerance of being alone
  • Repeated crises and acts of self-injury, such as wrist cutting or overdosing


DKA in T2DM
  • Due to "ketosis-prone type 2 diabetes"
  • The exact mechanism for this phenomenon is unclear
  • There is evidence both of impaired insulin secretion and insulin action
  • Once the condition has been treated, insulin production resumes and often the patient may be able to resume diet or tablet treatment as normally recommended in type 2 diabetes


Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) Guidelines for Hospital Staff
  • Physical assessment
    • patients near to death often look well
    • BMI range: <13 high risk
    • physical examination, including muscle power (Sit up–Squat–Stand test)
    • blood tests: especially electrolytes, glucose, phosphate, Mg, liver function tests, full blood count
    • electrocardiogram, especially QT interval.
  • Nutritional issues
    • consult a medical expert in nutrition
    • replace thiamine early and prescribe a vitamin and mineral supplement
    • avoid re-feeding syndrome by slow re-feeding and close monitoring in vulnerable patients
    • avoid underfeeding syndrome by frequent (12-hourly) reassessment and increasing calories as soon as safe
  • Psychiatric issues
    • transfer to a specialist eating disorders unit (SEDU) if possible
    • regular liaison with a psychiatrist
    • be aware of sabotaging behaviour such as falsifying weight, water drinking, exercising
    • use only experienced and trained nurses to observe
    • ask psychiatrist to consider Mental Health Act section if patient fails to improve.


Notes

  • It's just "self-harm"
    • The "deliberate" is a misnomer
    • They can't help it
  • Brushing your teeth after vomiting is really bad
    • Rubs the acid into enamel
    • Wash with water and brush later
  • <85% weight-for-height usually stops periods
  • Predisposing / Precipitating / Protective factors
  • Intelligence + money as protective factors
  • Olanzapine: Atypical antipsychotic
  • Use of family therapy
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