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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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