• 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

• 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

• 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

• 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