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