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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