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