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Psychiatry > Child psychiatry - comprehensive > Flashcards

Child psychiatry - comprehensive Flashcards

1
Q

special considerations with children ?

A
  1. who decides to bring child for any assessment/ CAMHS?
    - parent, teacher, SW, child
  2. what influences symptoms expression
    - cognitive and language development
  3. what influences behaviours are normal or abnormal
    - age and IQ
  4. confidentiality
    - prior to commencing individual assessment the child is guaranteed confidentiality, except in 2 circumstances
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2
Q

attributes of clinical assessment ?

A
  1. purpose
    - elicit information for differential diagnosis and treatment
  2. method: gather data
    - history
    - physical exam
    - investigations: medical/ psychological/ educational – cross sectional and longitudinal
  3. source
    - range of informants: self, parent, teacher, peer
  4. Criteria for diagnosis
    - reliable, valid, and standardized
    - ICD11 or DSM5
  5. Procedure
    - same each person
    - dr similarities/ difference with adults
    - some adaptations based on age/IQ/situation
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3
Q

example of where a behaviour may be ‘normal’ when young and ‘pathological’ when older?

A
  • bed wetting
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4
Q

example of a behaviour that is ‘normal’ when older but a cause for concern in children

A
  • sexual interactions
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5
Q

what are the 2 circumstances where confidentiality must be broken with child?

A
  1. where the child indicates that they may be at risk, either of harming themselves or of being harmed by others AND/OR
  2. where the child indicates that they may harm someone else
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6
Q

When taking a history in child psychiatry always think in terms of the following 4 domains?

A

1) individual
2) environment: employment or school
3) family
4) medical

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7
Q

what are the 4 domains that should form the basis for any management plan in child psychiatry ?

A
  1. individual
  2. Environmental: employment or School
  3. Family
  4. Medical

*this ensures a bio-psycho-social framework, whilst allowing a medical model, and encourages respectful engagement with all involved

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8
Q

structure of child psychiatry history in the IFME model

A
  1. individual
    - presenting complaint
    - history of complaint
    - past psychiatric history
    - “systems review” to out-rule comorbidity
  2. Family history
    - family environment
    - family history mental health
    - parenting
    - relationship
    - life events
    - adverse childhood events (ACE)
  3. Medical
    - developmental history
    - medical history
    - medications
  4. Environment
    - employment work history
    - in youth, school, or college history
    - social history, drugs, alcohol, peers, bullying
    - neighbourhood
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9
Q

clinical risk assessment: 2 concepts information gathering and therapeutic engagement

A
  1. IF-ME
  2. 4 Ps
    - predisposing
    - precipitating
    - perpetuating
    - protective factors
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10
Q

what is include in the systems review and importance

A
  1. child psychiatric illness are frequently co-morbid
    - e.g anxiety and depression
  2. ask a range of questions focusing on typical features of all potential psychiatric illness to determine if co-morbidity present
    - e.g anxiety disorder (specific phobias, GAD, social anxiety disorder, Agoraphobia, separation anxiety, OCD, Panic disorder
  3. systemis review is essential to ensure diagnoses are not missed
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11
Q

what to include in childs development history ?

A
  1. Birth history
    - term?
    - complications?
    - special care baby unit?
    - mother well being postnatally?
    - *the older the child, the less detail we take
    - * peri-natal history crucial for attachment
  2. Development Milestones
    - motor development
    - social development
    - speech and language development
    - self help: toilet training, feeding, sleeping
    - temperament
  3. Possible traumatic events
    - adverse childhood experiences or ACES
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12
Q

what to include in the family history when taking child psychiatry history?

A
  1. parents own background
  2. occupations
  3. home environment: who is living at home?
  4. medical history
  5. psychiatric history (family tree useful)
  6. Pattern of drug and alcohol use by parents
  7. Specifically ask about all psychiatric diagnoses
    - ADHD i.e what was mothers experience of schooling life
    - learning difficulties, Dyslexia
  8. Who is index child most like?
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13
Q

what to ask about in environmental domain of child psychiatric history with relation to education?

A

*most likely will be focused on school as kids spend most of their time there

  1. Age school commenced
  2. mainstream school
  3. Educational support
  4. ability relative to peers

want to ask questions specifically in 3 domains;
1. behaviour
- any behavioural issues
- separation difficulty
- peer relationships (including bullying)

  1. Academic
    - are they passing
    - honours ?
  2. Social
    - do they have friends at school
    - do they come to house and hangout
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14
Q

what to ask about environmental domain in child psychiatric history in terms of social history?

A
  1. Hobbies and outside interests
  2. strengths in any area
  3. friends
  4. relationships
  5. Clubs, participation in group activities
  6. involved in any ‘subculture’
  7. Cigarettes/glue sniffing/ drugs/ alcohol
  8. use of drugs by peers groups
  9. attitude to drugs?
  10. any trouble with the law ?
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15
Q

what to ask about in medical domain of child psychiatric history?

A
  1. major illness
  2. head injury, seizures
  3. previous hospitalizations
  4. allergies
  5. on any current medication ?
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16
Q

why is attachment an important component of assessment ?

A
  • basis for future relationship styles and self esteem
  • assessed at all stages of assessment directly and indirectly
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17
Q

what is the definition of autism spectrum disorder ?

A

biologically based neurodevelopmental disorder characterized by persistent deficits in social communication and social interaction and restricted, repetitive patterns of behaviour, interests and activities

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18
Q

Epidemiology of autism spectrum disorder ?

A
  • 3-4 times more common in males than females
  • the estimated prevalence of ASD in siblings of a child with ASD who does not have an associated medical condition or syndrome is approximately 1-20%
  • approximately 33-45% of patients with ASD have Intellectual delay
  • as many as 50% have ADHD
  • as many as 30% have epilepsy
  • up to 25% of cases of ASD are associated with organici disease (e.g tuberous sclerosis)
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19
Q

aetiology of ASD

A
  1. environmental and prenatal factors
    - viral infection
    - parenteral age
    - zinc deficiency
  2. epigenetic factors
    - DNA methylation
    - Histone modification
    - micro RNA
  3. genetic factors
    - copy number variation
    - point mutation
    - translocation
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20
Q

Autism spectrum disorder - dyad of impairment

A
  1. social communication and interaction
  2. restricted and repetitive behaviours and interests
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21
Q

examples of impairment in social communication and interaction in ASD patients?

A
  1. eye contact
  2. nonverbal gestures to communicate
  3. social cues
  4. social rules
  5. echo words they hear (echolalia)
  6. communication own wants and needs
  7. shared interests with others, or unequal sharing
  8. language development
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22
Q

examples of restrictive and repetitive behaviours and interests in autism spectrum disorder?

A
  1. lines up toys or other objects and gets upset when order is changed
  2. plays with toys the same way every time
  3. is focused on parts of objects (for example, wheels)
  4. gets upset by minor changes
  5. must follow certain routines
  6. flaps hands, rocks body, or spins self in circles
  7. has unusual reactions to the way things sound, smell, taste, look or feel
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23
Q

criteria for Autism spectrum disorder in DSM5

A
  1. persistent deficits in social communication and social interaction
  2. restricted, repetitive patterns of behaviours (RBBs), interest and activities
  3. symptoms must be present in early developmental period
  4. symptoms cause clinically significant impairment in social and occupational functioning
  5. these disturbances are not better explained by intellectual disability or global developmental delay
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24
Q

assessment for autism spectrum disorder

A
  1. caregivers and patient concerns
  2. experiences in home life, social life, education
  3. developmental history
  4. medical and family history
  5. assessment (through interaction with and observation of the child or young person) of social and communication skills and behaviours, focusing on features consistent with ICD-11 or DSM-5 criteria (consider using an autism specific tool to gather this information
  6. Physical examination
  7. development of a profile of the childs or young persons strengths, skills, impairments and needs that can be used to create a needs-based management plan, taking into account family and educational context
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25
Q

model for management of autism spectrum disorder in children

A
  1. individual
  2. family
  3. environmental
  4. medical
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26
Q

management of ASD - individual

A
  1. behavioural interventions
  2. OT
  3. Psychology
  4. speech and language therapy
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27
Q

management of ASD - family

A
  1. support organizations (opportunity to meet other families)
  2. information about specific courses for parents and carers and/or young people
  3. Advice on welfare benefits
  4. information on educational support and social care
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28
Q

management of ASD - Medical

A
  1. monitor physical health
  2. treat comorbidities
  3. medication is not recommended for the core features of ASD, but can be used for short-term treatment of behaviour that challenges
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29
Q

Management of ASD - environment

A
  1. environmental adaptations - OT
  2. support groups
  3. school psycho-education and support
  4. address bullying or learning problems
  5. housing benefits
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30
Q

define ADHD

A

attention deficit hyperactivity disorder (ADHD) is a psychiatric condition that has long been recognized as affecting childrens ability to function. Individuals suffering from this disorder show patterns of developmentally inappropriate levels of inattentiveness, hyperactivity and impulsivity

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31
Q

three core features of ADHD

A
  1. inattentiveness
  2. hyperacitivity
  3. impulsivity
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32
Q

etiology of ADHD

A
  1. abnormal dopamine signalling in the prefrontal cortex
  2. deficiency of noradrenaline in the reticular activating system (RAS)
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33
Q

genetics and ADHD

A
  • the risk of ADHD in parents and siblings of children with ADHD is increased 2-8 times with heritability estimated at 76% based on pooled data from twin studies
  • sibling recurrence risk 25%
  • parental ADHD 15%
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34
Q

prevalence of ADHD

A
  • community prevalence globally approx. 5%
  • 30-50% of children referred to child psychiatry clinics have ADHD
  • most common reason for referral to CAMHS
  • diagnosed in boys 3-4x more often than in girls
  • Persists in 30-50% of patients into adolescence and adulthood (symptom profile may change)
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35
Q

with regards to inattention and ADHD, … or more symptoms of inattention for children up to age 16 years, or … or more for adolescent age 17 years and older and adults; symptoms of inattention have been present for at least … months, and they are inappropriate for developmental level

A

6
5
6

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36
Q

inattentive symptoms of ADHD

A
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37
Q

with regard to hyperactive and impulsive symptoms of ADHD, … or more symptoms of hyperactivity-impulsivity for children up to age 16 years, or … or more for adolescents age 17 years and older and adults; symptoms of hyperactivity-impulsivity have been present for at least … months to an extent that is disruptive and inappropriate for the persons developmental level

A

6
5
6

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38
Q

hyperactive and impulsive symptoms of ADHD

A
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39
Q

subtypes of ADHD

A
  1. predominantly inattentive presentation
  2. predominantly hyperactive-impulsive presentation
  3. combined presentation
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40
Q

co-morbidities of ADHD

A
  1. anxiety
  2. depression
  3. OCD
  4. tic disorders
  5. Autism
  6. substance use disorder
  7. other
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41
Q

Assessment for ADHD

A
  1. full clinical and psychosocial assessment of the person and a full developmental and psychiatric history and observer reports and assessment of the persons mental state
  2. rating scales such as the Conners rating scales and the strenghts and difficulties questionnaire
  3. must meet the diagnostic criteria in DSM-5 and cause at least moderate impairment in multiple settings and be pervasive, occuring in 2 or more important settings including, social, familial, educational, and/or occupational
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42
Q

general approach to treatment of ADHD

A
  1. individual
  2. family
  3. environment
  4. medical
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43
Q

Management of ADHD - individual

A
  1. psychoeducation
  2. individual therapy like CBT can be considered to help with social skills, self control, listening skills
  3. OT can help with structuring day
  4. support groups
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44
Q

Management of ADHD - family

A
  1. ADHD focused group parent - training
  2. advice on parenting strategies
  3. support groups
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45
Q

management of ADHD - environment

A
  1. organizational techniques and timetables
  2. establish routine
  3. informing school and identifying educational needs
  4. movement breaks in school
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46
Q

management of ADHD - Medical

A
  1. treat comorbidities
  2. consider medication options
    - stimulants/ non-stimulants
    - monitoring
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47
Q

stimulants side effects

A
  1. headache
  2. Trouble sleeping
  3. Stomach ache
  4. feeling more anxious
  5. racing or fluttering heart
  6. Dizziness
  7. loss of appetite
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48
Q

mechanism of methylphenidate ?

A
  1. blocks dopamine re-uptake via the DOPA transporter
    - also reduces DOPA transporter density
    - *leads to increased dopamine at nerve endings
  2. prevents norepinephrine reuptake
    - increase levels of NA in the reticular activating system
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49
Q

behavioural effect of stimulants in ADHD?

A
  1. 75% will show normalizing levels of inattention, hyperactivity and impulsivity
  2. improvement in academic output (70%) and accuracy (50%)
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50
Q

response rate of stimulants ?

A
  1. 70% will respond to first stimulant
  2. 85-90% to one of the stimulants
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51
Q

choice of medications for ADHD ?

A
  1. stimulants
    - methylphenidate (first choice): trial of at least 2 formulations of the drug formulations: Concerta, Medikinet, Equasym, Ritalin LA
    - Lisdexamphetamine
  2. Non-stimulant
    - atomoxetine
    - guanfacine
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52
Q

Monitoring after prescribing stimulants for ADHD ?

A
  1. Height
  2. Weight
  3. Blood pressure
  4. Heart rate
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53
Q

Complications of untreated ADHD

A
  1. Features can persist into adolescence (80%) and adulthood (65%)
  2. Medical complications
  3. ADHD is a specific risk factor for conduct disorder (overall 58% chance) and high rate of drug/ alcohol misuse
  4. More likely to;
    - drop out of school
    - rarely complete college
    - under-perform at work
    - have few or no friends
    - engage in antisocial activities
    - experience teen pregnancy
    - sexually transmitted disease
    - speed or have car accidents
    - suffer from depression
    - have a personality disorder
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54
Q

what are attachment behaviours ?

A
  • attachment behaviours refer to the actions and reactions individuals exhibit to seek proximity, comfort, and security from their primary caregivers or attachment figures
  • the goal of an attachment system is protection at times of danger or when infant experiences anxiety/fear/confusion
  • these behaviours are crucial in forming emotional bonds and relationships, particularly in early childhood
  • positive actions like smiling, reaching out, and seeking comfort, as well as protest behaviours such as crying and fretting when separated from the caregiver
  • these behaviours serve as signals to caregivers, prompting them to respond to the needs of the individual, leading to the formation of selective attachments from birth and early infancy
  • infants in emotionally dysregulated states need help to regulate and manage arousal and distress
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55
Q

development of attachment - 4 phases

A
  1. pre-attachment
    - birth to 6 weeks
    - infants not yet attached to the caregiver, dont mind being alone with unfamiliar adults and dont fear strangers
    - infants recognize the caregivers scent voice, and face
  2. Attachment in the making
    - 6 weeks to 6 months
    - infants still do not mind being separated from caregiver
    - calm more quickly when picked-up with familiar caregivers than with strangers
    - learn their actions affect the behaviour of those around them
    - infants begin to develop a sense of trust - expecting a predictable response from the caregiver
  3. clear cut attachment
    - 8 months to 18 months
    - become upset and experience separation anxiety when separated from a relied upon caregiver
    - the occurence of separation anxiety depends on the infants temperament, adult behaviour and the specific situation
    - the baby may show distress when the primary caregiver leaves, but the anxiety can be short lived if the replacement caregiver is empathetic and supportive
  4. Reciprocal relationship
    - approximately 18 months and on
    - separation anxiety decreases as language and cognitive skills grow
    - toddlers can understand some of the circumstances influencing the caregivers comings and goings and can predict their return
    - as they get older, toddlers grow less dependent on caregivers and more confident that they will be accessible and responsive at times of need
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56
Q

Three attachment styles in infants?

A
  1. Type B - Secure
    - infants are keen to explore, display high stranger anxiety, are easy to calm and are enthusiastic on return to the caregiver. Caregiver is sensitive to the needs of the infants
  2. Type A - Insecure-avoidant
    - Infants are willing to explore, have low stranger anxiety, are unconcerned by separation and avoid contact at the return of the caregiver. Caregiver is indifferent to the needs of the infant
  3. Type C - insecure-resistant
    - Infants are unwilling to explore, have high stranger anxiety, are upset by separation and seek and reject contact on return of the caregiver
    - caregiver is ambivalent to the needs of the infant, displaying simultaneous opposite feelings and behaviours
    **it is characteristic of resistant infants to seek contact, but to then push away efforts to comfort
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57
Q

what is the 4th attachment style ?

A

disorganized/ disorientated attachment
- fear
- contradictory behaviours
- jerky movements
- freezing
- apparent dissociation
**caregiver experienced as simultaneously ‘the source of alarm and its only solution’
*Can lead to: lower academic grades, impaired self-regulation, low self-esteem, internalising/externalising problems, peer rejection, and poor social adjustemnt

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58
Q

reactive attachment disorder

A
  1. emotionally withdraw and inhibited
  2. Rarely seeks or responds to comfort when distressed
  3. social withdrawl
  4. minimal responsiveness to others
  5. negative affect
  6. history of extremely insufficient care
  7. Cannot also meet the diagnostic criteria of ASD
  8. the behaviour should manifest prior to the age of 5 years of age
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59
Q

to diagnose a child with reactive attachment disorder what diagnose can they not also meet the criteria for?

A

autism spectrum disorder (ASD)

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60
Q

treatment of reactive attachment disorder?

A
  1. parent education and trauma-focused therapy
    **developing a nurturing parent-child relationship is the cornerstone to overcoming the damage caused by severe neglect and abuse
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61
Q

discuss disinhibited Social engagement disorder - attachment disorder

A
  1. disorganized attachment
  2. Wandering away from a care-giver
  3. willigness to depart with a stranger
  4. Engagement in overly familiar physical behaviours with unfamiliar adults
  5. Early caregiving environment is insufficient
  6. Child asks overly intrusive and overly familiar questions of unfamiliar adults
  7. Impair young childrens abilities to relate with adults and peers
  8. Risk of dangerous and potentially harmful situations
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62
Q

discuss oppositional defiant disorder

A
  1. ODD is a type of childhood disruptive behaviour disorder that primarily involves problems with the self-control of emotions and behaviours
  2. Angry/ irritable mood, argumentative/defiant behaviour; or vindictiveness toward others
  3. prevalence: 2-11%
  4. More common in preadolescent males, then equal sex ratio in adolescence
  5. > 90% of those who met ODD criteria also met criteria for at least one other mental disorder, including mood disorders (45.8%), anxiety disorder (62.3%), impulse control disorder (68.2%) and substance use disorder (47.2%)
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63
Q

DSM-5 criteria for oppositional defiant disorder?

A
  • 4 of the following for >6 months;
    1. often loses temper
    2. often touchy or easily annoyed
    3. often angry and resentful
    4. often argue with authority figures or, for children and adolescents, with adults
    5. often actively refuse or defy to comply with requests from authority figures or with rules
    6. often deliberately annoys others
    7. often blames others for his or her mistakes
    8. the child has been spiteful or vindictive (having or showing a strong or unreasoning desire for revenge) at least twice within the past 6 months
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64
Q

aetiology of oppositional defiant disorder

A
  1. Genetics
    - it is estimated that heritability of ODD is around 50%
  2. Environmental factors
    - childhood maltreatment and harsh, inconsistent parenting
  3. Psychosocial factors
    - Peer rejection
    - deviant peer groups
    - poverty
    - neighbourhood violence
    - other unstable social or economic factors
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65
Q

discuss Conduct disorder

A
  • more severe than oppositional defiant disorder (ODD); think of farther on the spectrum of oppositional defiant disorder
  • more common in boys than girls (4:1 - 12:1)
  • lifetime prevalence: 2-10%
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66
Q

subtypes of conduct disorder

A
  1. Conduct disorder, childhood-onset type
    - the onset of problems before the age of 10
    - more common in males
    - more physical aggression, worse prognosis
  2. Conduct Disorder, Adolescent-Onset Type
    - lack of problems before age of 10 years old
    - less physical aggression, better prognosis
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67
Q

DSM-5 Criteria for Conduct disorder

A

A. a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least 3 of the following criteria in the past 12 months, with at least one criterion present in the past 6 months

  1. Aggression to people and Animals
    - often bullies, threatens, or intimidates others
    - often initiates fights
    - has used a weapon that can cause serious physical harm others
    - has been physically cruel to people
    - has been physically to animals
    - has stolen while confronting a victim
    - has forced someone into sexual activity
  2. Destruction of Property
    - has deliberately engaged in fire setting with the intention of causing serious damage
    - has deliberately destroyed others’ property
  3. Deceitfullness or Theft
    - has broken into someone else’s house, building, or car
    - often lies to obtain goods or favors or to avoid obligations
    - has stolen items of nontrivial value without confronting victim
  4. Serious Violations of Rules
    - Often stays out at night despite parenteral prohibitions, beginning before age 13 years
    - has run away from home overnight at least twice while living in the parenteral or parenteral surrogate home
    - is often truant from school, beginning before age 13 years

B. The disturbance in behaviour causes clinically significant impairment in social, academic or occupational functioning

C. if the individual is age 18 years or older, criteria are not met for antisocial personality disorder

68
Q

Aetiology of Conduct disorder

A
  1. Biological
    - genetics
    - high testosterone levels
  2. Parenteral and Family
    - Marital conflict
    - lack of structure
    - Harsh parenting with verbal and physical aggression towards children
    - exposure to domestic violence
    - the family history of criminality
    - substance abuse, particularly alcohol dependence in parents
    - low SES
    - overcrowding
    - parenteral unemployement
    - neuropsychological insults to the brain in early life
    - developmental delays
    - any traumatic brain injury, seizures and neurological damage can contribute to aggression
  3. School and environment
    - large class sizes
    - fewer teachers
    - lack of supportive staff
    - exposure to increased gang violence
69
Q

Protective factors - Conduct disorder

A
  1. A positive role model in life
  2. Affectionate parenting
  3. ability to regulate emotions with self-soothing
  4. early intervention and adequate parenting
70
Q

Treatment - Conduct disorder

A
  1. evidence-based psychosocial treatments
    - parent management training
    - multisystemic therapy
    - anger management training
    - individual psychotherapy
    - community-based treatment
  2. Pharmacotherapy
    - stimulants and non-stimulants for the treatment of ADHD
    - antidepressants for the treatment of depression
    - antipsychotics for aggression if required
71
Q

role of the limbic system and neuroanatomy involved in it

A
  • the limbic system integrates emotions, memories and survival instincts
  1. Hypothalamus
    - modulates hormones associated with mood and survival
  2. Hippocampus
    - reminds us which courses of action lead to outcomes that match with our mood
    - it has been shown to be shrunken in people prone to depression
  3. Amygdala
    - attaches emotional significance to everts and memories
72
Q

presentation of anxiety disorders in young people

A
  1. difficulties with peer relationships
  2. frequent somatic complaints
  3. Low self esteem
  4. school refusal
73
Q

what organic pathologies need to be outruled in suspected anxiety disorder in a young person

A
  1. arrhythmia
  2. hyperthyroidism
  3. Neurological disease
  4. substance-induced anxiety (alcohol, caffeine, or illicit drugs)
74
Q

Anxiety disorders in children and adolescents - developmental trajectory (early childhood, all ages, late childhood/ early adolescence)

A
  1. Early childhood
    - separation anxiety
    - selective mutism
    - specific phobias
  2. all ages
    - generalized anxiety disorder
  3. Late childhood/early adolescence
    - OCD
    - Panic disorder
    - Social phobia
75
Q

etiology of Anxiety disorders

A
  1. Genetic vulnerability
  2. Temperament
    - Behaviour inhibition
  3. Anxious attachment
  4. Negative Life events
  5. Dysregulation of serotonin (5-HT) and Noradrenaline (NA) systems
76
Q

classifications of anxiety disorders in young people

A
  1. Generalized anxiety disorder (GAD)
  2. Obsessive compulsive disorder (OCD)
  3. Panic disorder
  4. Phobias
  5. PTSD
  6. Selective mutism
  7. Separation anxiety disorder
77
Q

discuss separation anxiety disorder

A
  • excessive anxiety concerning separation from attachment figures at home
  • presentation;
    1. refusal to go to school because of these fears
    2. persistent refusal to sleep without parent
    3. repeated nightmares about separation
    4. Excess distress at times of separation from parent
    5. Physical (somatic) complaints at times of separation

*common - 3.5% of children

78
Q

discuss selective mutism

A
  • <1 %
  • usually presents in early childhood
  • associations: social anxiety, oppositional behaviour
  • selective speaking: person speaks in some situations but not others
  • typically speaks at home with friends and/or family but fails to speak in school
79
Q

discuss generalized anxiety disorder

A
  • more common in female adolescents
  • 2/3 do not seek treatment
  • comorbidity 90%
  • developmentally inappropriate and excessive worry most days
  • difficult controlling worry
  • diagnostic criteria;
    1. accompanied by at least 3 of the 6 symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance)
    2. the symptoms cause significant distress or impairment in functioning
    3. the symptoms are not due to another condition (medical or psychiatric)
80
Q

discuss obsessional-compulsive disorder

A
  • mean age of onset 10 years
  • M>F (3:2) in childhood
  • M=F in adolescence
  • comorbidity (70%): mood disorder, other anxiety disorders, ADHD, substance misuse, eating disorders, learning disability or tic disorder e.g tourette’s syndrome
  • rating scale: CY-BOCS (children’s Yale-Brown Obsessive compulsive Scale)
  • Obsessions: unwanted, egodystonic, intrusive thoughts, urges or images causing distress. they try to resist
  • compulsions: repetitive behaviours or mental acts done to reduce distress or prevent an unrealistic feared event
  • time-consuming: more than 1 hour per day or significantly impairing
  • ## not due to another medical condition or mental disorder
81
Q

Discuss PANDAS

A
  • Paediatric autoimmune neurological disorder associatd with streptococcus
  • associated with OCD/tics
  • onset before puberty
  • symptoms occur episodically in association with group A beta hematolytic streptococcal infection
82
Q

discuss panic disorder

A
  • onset in late adolescences typically 15-19 years of age
  • 3-6% prevalence
  • F>M
  • recurrent unexpected panic attacks (duration of 5 mins - 1 hour)
  • symptoms;
    1. fear of dying
    2. dizziness
    3. palpitations
    4. sweating
    5. chest pain
    6. nausea and vomitting
    7. shortness of breath
  • exclude organic causes
83
Q

discuss agoraphobia

A
  • F > M
  • onset in late adolescence
  • marked fear or anxiety about 2 or more specific situations (e.g open spaces, public transportation).
  • the fear is based on the idea that escape might be difficult or help unavailable if panic-like symptoms occur
  • these situations consistently trigger fear or anxiety
  • the situations are avoided or endured with stress
  • the fear is disproportionate to the actual danger
  • the symptoms are persistent for 6 months or more
  • the fear or avoidance causes significant impairment in daily functioning
  • the fear is not better explained by another disorder
84
Q

Specific (simple) phobias

A
  • animal/insect phobias, blood/needle phobias common
  • common
  • F>M
85
Q

overview of Social anxiety disorder

A
  • fear of scrutiny by other people, leading to avoidance of social situations
  • usually starts in adolescence
  • M=F
  • may be discrete (e.g fear of eating in public, public speaking) or diffuse (most social situations)
  • 5-15% adolescents
86
Q

criteria for social anxiety disorder?

A
  1. intense fear of social situations where the person could be judged or scrutinized
  2. the fear is about being negatively judged
  3. consistent anxiety triggered by these situations
  4. avoidance of social situations or endures them with great distress
  5. the fear is out of proportion to the actual threat posed
  6. the fear, anxiety and avoidance is persistent (lasting 6 months or more0
  7. the symptoms are not due to a substance, medical condition, or better explained by another mental disorder
87
Q

Post traumatic stres disorder?

A
  1. must be preceded by a traumatic event
    - person must have witnessed/experience a traumatic event in which there was actual or a threat or serious harm or death to self or others
    - the individuals response involved intense fear, helplessness or horror
  2. clinical features
    - re-living trauma
    - avoidance - tendency to avoid reminders of the event
    - hyperarousal
    - feeling numb
    *symptoms in children: repetitive play involving traumatic event. Loss of developmental skills (e.g language, toilet training). New separation and behavioural problems.
88
Q

Management of Obsessive Compulsive disorder (OCD)

A
  1. Psychological
    - cognitive Behavioural therapy e.g manualized
    - involves graded exposure and response prevention
    - involve family in preventing rituals
    - psychoeducation for parents and child
  2. Biological
    - SSRI (e.g sertraline)
    - treatment for 1-2 years
    - high relapse rates on discontinuation
89
Q

Management of simple (specific) phobias

A

treat with CBT (e.g graded exposure)

90
Q

management of agoraphobia?

A
  1. explain the symptoms, teach relaxation techniques, graded exposure
  2. CBT +/- SSRIs
91
Q

management of social anxiety ?

A
  1. treatment: explain the symptoms, teach relaxation techniques
  2. can use CBT +/- SSRI
92
Q

Management of PTSD?

A
  1. play therapy helpful in assessment and treatment
  2. parents major role. the better they cope with trauma the better the child copes
  3. anxiety management techniques
  4. CBT
  5. SSRIs
93
Q

what are the 2 core symptoms of depression ?

A
  1. depressed mood
  2. loss of interest in previously pleasurable activity (anhedonia)
94
Q

what are the non-core symptoms of depression?

A
  1. attention and concentration impairment
  2. feeling of worthlessness or guilt. Feeling like a burden to people
  3. hopelessness for the future
  4. recurrent thoughts of death or suicidal ideation (self harm ideation also).
  5. Poor sleep. Insomnia or hypersomnia
  6. weight loss or failure to make weight gain - in context of poor appetite and low mood
  7. psychomotor agitation or retardation
  8. decreased energy level
95
Q

what is comorbid with depression in children ?

A
  1. anxiety disorders
  2. neurodevelopmental disorders (ADHD, ASD)
  3. eating disorders
  4. conduct disorder
  5. pervasive developmental disorder, learning difficulties
  6. alcohol misuse
  7. substance misuse, especially cannabis
  8. may have psychotic features
96
Q

prevalence of depression in children ?

A
  • 2% children
  • 5% of teenagers
  • more common in girls, but prevalence in boys is increasing
97
Q

etiology of depression

A

*no single cause
1. genetic vulnerability
- family history

  1. life events/ trauma
    - living with a depressed parent/ family member
    - loss
    - conflict
    - chronic physical illness
    - history of abuse including bullying (**always ask about bullying in the history)
98
Q

depression - history (individual)

A
  • ask about symptoms
  • ask about other co-morbid states, i.e anxiety, mania, substance misuse
  • pre-morbid personality and behaviour - can identify change
  • assess risk: sensitively but thoroughly (suicide attempts survived and not previously reported)
  • ask about functioning
  • coping styles
99
Q

depression history (family)

A
  1. family environment and parenting
    - loving, critical, dysfunctional, harsh, or abusive parenting
    - any stressors affecting parents which have impact on child
  2. Family history of mood disorder
100
Q

depression history (medical)

A
  1. biological symptoms of depression
    - loss of appetite
    - weight
    - change in sleep pattern (insomnia/ hypersomnia)
    - loss of libido
    - poor concentration
  2. any co-ocurring medical condition
    - viral
    - thyroid
    surgery
    -*and impacty on life
101
Q

depression history (environment)

A
  1. progress at school
    - coping well or not
    - learning difficulties
    - attention/ concentration
    - grades - had been doing better?
    - any bullying (social media, exlusion from groups?_
  2. peer group - supportive or not?
  3. any stressors
    - pressure to do well ? (sporting or academic)
    - sexuality? gender? (pressure)
102
Q

treatment of depression in children (IF-ME model)

A
  1. Individual
    - change distorted cognitive set
    - treat any co-morbid conditions
  2. family
    - enable family to cope
    - family treatment
  3. Environment
    - group therapy or support groups
    - school psycho-education and support
    - address bullying or learning problems
    - housing benefits
  4. Medical
    - Medication: SSRI, antipsychotics, mood stabilisers for BPAD
103
Q

prescribing for depression in child and adolescent psychiatry

A
  • in children: generally use either fluoxetine or sertraline
  • start low, go slow
  • provide information leaflets (child and parent)
  • **must get consent from parent to prescribe
104
Q

Fluoxetine use in depression

A
  1. adequate trial
    - duration minimum 6 weeks but preferably 10-12 weeks
    - takes up to 2 weeks (usually 3-4) before derived benefits is achieved if at correct dose
  2. Start low and go slow
    - want to avoid effects (and in worse case scenario serotonin syndrome)
    - available in liquid form 1 ml= 4mg and can titrate to a max dose up to 60 mg if necessary/ tolerated
  3. check compliance at medication reviews - can check parents are supervising properly = risk!
  4. ensure co-morbidities are treated
105
Q

side effects of SSRIs (fluoxetine)

A
  1. Headache, nausea, vomitting, diarrhea (take in the morning with food)
  2. constipation
  3. agitation, nervousness
  4. sedation (10-20% risk)
  5. suicidal risk - controversial (ideation/urges - black box warning)
  6. rare: convulsions, parkinsons, bleeding
  7. Interactions with caffeine, theophylline, St Johns wort
  8. antibiotics can change absorption
106
Q

very common side effects of SSRIs? and advice to patient

A
  1. feeling sick or being sick or stomach pain
    - taking it after food may help
    - it usually wears off in a few weeks
    - if not, tell doctor
  2. cant sleep (insomnia)
    - make sure you take the dose early in the day
    - let your doctor know as a change in dose may help
  3. Sex
    - finding it hard to have an orgasm
    - no desire for sex
    - discuss with your doctor
107
Q

Common side effects of SSRIs?

A
  1. Headache
    - if your head is painful paracetamol usually helps
  2. Diarrhea
    - going to the toilet more than usual “having the runs”
    - drink plenty of fluids
    - get advice from your pharmacist
    - if it lasts for more than a day or so, contact your doctor
  3. Not feeling hungry
    - usually get appetite back in a week
    - if not, let your doctor know
  4. feeling more anxious or nervous
    - usually only lasts for a few weeks while you get used to your SSRI
    - if not, tell your doctors next time, you meet
108
Q

rare side effects of SSRIs (see your doctor if you get any of these rare side effects)

A
  1. thoughts of harming yourself
    - feeling anxious, restless, poor sleep and feeling you might want to harm yourself
    - see your doctor in the next day, especially if you are under about 20 years old, started the medicine in the last few weeks, have had a dose change, or may have bipolar depression
  2. Rash
    - this can be a rash or itching seen anywhere on the skin
    - if this happens, stop taking your SSRI and contact your doctor in the next day
  3. serotonin syndrome
    - you may feel confused, agitated, restless, sweaty, feverish, fast heart beat, twitching, shivering, and shaky
    - it may happen if you have just started, had a dose increase, overdose, or start to take any other medicines
    - see your doctors in the next few hours if this happens
  4. hyponatremia
    - aka SIADH
    - you do not pass much urine, are tired confused, muscle cramps, and you get a headache
    - this can be dangerous so contact doctor now
109
Q

serotonin syndrome

A
  • a serious drug reaction caused by medicines that change level of serotonin in the body
  1. altered mental status
    - confusion
  2. autonomic instability
    - fever and sweating, blood pressure, heart rate, resp rate
  3. others
    - headache, insomnia
  4. neuro-muscular
    - loss of muscle co-ordination or twitching
    - seizures

*very very rare - but does occur (mostly overdose attempts)

110
Q

SSRI discontinuation syndrome

A
  • side effects of stopping suddenly (or dose reduction beyond what is recommended)
  • symptoms
    1. dizziness/ lightheadedness
    2. nausea/vomitting
    3. headache, lethargy
    4. sensory disturbance - sometimes described as electric shock feelings
    5. insomnia and vivid/ disturbing dreams
    6. mood changes - anxiety, depression, mania, psychoses
111
Q

prognosis of depression in children

A
  1. most recover but many (50%) relapse
  2. risk of chronic illness and transition to Bipolar affective disorder
  3. Mania
    - new onset symptoms for at least 1 week (antidepressant hypomania and mania is possible too)
  4. can be difficult to diagnose in children
  5. those with SSRI induced mania or family history of mania at risk of developing BPAD
    - course in children less episodic often mixed with depression and ‘irritability’
112
Q

prevalence of BPAD - children

A
  1. 1% of population BPAD type 1
  2. 1% for BPAD type 2
  3. 1.5 % for cyclothymia
  4. 3-5% for Bipolar spectrum
    *rare pre-pubertally
113
Q

age of onset in Bipolar affective disorder

A
  • adolescent (12-18): 36%
  • adult (over 18): 32%
  • late onset (after 30): 19%
  • childhood (<12 years): 14%

*up to 60% of adults with bipolar disorder onset of mood symptoms occured before age of 20

114
Q

comorbid disorders associated with bipolar affective disorder in children and adolescents

A
  1. oppositional defiance disorder: 75%
  2. ADHD: 49-87%
  3. substance abuse: 8-39%
  4. Conduct disorder: 12-41%
  5. Anxiety disorders (OCD, Panic disorder, GAD, Social anxiety)
115
Q

Mania (persistent elated mood) - DSM-5

A
  1. Criteria A (present most of the day, nearly every day)
    - distinct period
    - persistently elevated, expansive or irritable mood/energy
    - one week (4 days in hypomania)
    - causes of marked impairment in occupational or social functioning, or hospitalization (not present in hypomania)
  2. Criteria B (3 or more) (represent a noticeable change from usual behaviour)
    - inflated self esteem/ grandiosity
    - decreased need for sleep
    - more talkative than usual
    - flight of ideas or racing thoughts
    - distractibility
    - increase in goal directed activity or psychomotor agitation
    - excessive involvement in pleasurable activities
    - potential for painful consequences
116
Q

Hypomania

A
  1. Hypomania is a less extreme form of mania, which means it is less severe and last for a shorter period of time. During these periods people can be very productive and feel very creative, so might see their hypomania as a positive thing
  2. However, if hypomania is left untreated it can become more severe and develop into mania
  3. Mania, or hypomania, is commonly followed by an episode of depression
117
Q

Differences in Clinical presentation in Children and Adolescents

A
  1. Elation
    - can be developmentally normal
    - episodic, inappropriate for the context, beyond expected for the age of the child, and impairing functioning
  2. Grandiosity
    - it is normal for children to overestimate their abilities and believe they are the best at a particular sport, smarter than others or will be very important
    - suspicion that grandiosity is pathological include:
    – persistent/ exaggerated thoughts that one is by far the best in an activity, despite clear evidence to the contrary
    – repeatedly commanding teachers, parents, and coaches to do what one wants despite getting in trouble for this behaviour
    – thoughts that one has superpowers and acting upon these thoughts and doing things that most kids of the same age would not, even if they fantasize about them (e.g. trying to fly from a tall tree)
  3. Increased goal directed activity
    - to be counted as a symptom of mania in children, has to be;
    – exaggerated
    – represent a change in functioning
    – recognized by others as excessive given the developmental age of the child
    - examples
    – has uncharacteristically extended periods of driven creative activity such as drawing, painting, writing, or building things
    – takes on many tasks simultaneously (e.g school work while playing video games, watching television, and communicating with friends)
    – is driven to rearrange and redecorate his/her room, or to spontaneoulsy complete many household chores well beyond expectations, particularly if the child typically does not engage in these activities or perform them at
118
Q

Bipolar type 1

A
  • at least one high or manic episodes that lasts for longer than a week (usually much longer)
  • some people with bipolar 1 will only have manic episodes, but most people with bipolar 1 also have low or depressive episodes
  • if the person does not receive treatment, the manic episode will generally last between 3 and 6 months, while the depressive episode might last 6-12 months
119
Q

Bipolar type 2

A

where someone has at least one depressive episode and a less extreme manic episode (called ‘hypomania’)

120
Q

Cyclothymia

A
  • where someones mood swings are less severe than people with bipolar 1 or 2, but last for longer. over time, this can develop into ‘full’ bipolar disorder
121
Q

what is rapid cycling with regard to bipolar affective disorder?

A
  • rapid cycling is a ‘sub category’ of bipolar 1 and bipolar 2
  • someone with rapid cycling bipolar has 4 or more episodes (manic, depressive or mixed) within a year
  • this affects around 1 in 10 people with bipolar disorder
122
Q

treatment of bipolar affective disorder in child - IF-ME model

A
  1. Individual
    - change in distorted cognitive set
    - treat depressed thoughts if present
    - treat any co-morbid conditions
  2. Medical
    - mood stabilizers if BPD
    - if depressed lithium or lamotrigine (cautious and covered use if SSRI)
  3. Family
    - enable family to cope
    - family treatments
  4. Environment
    - group therapy or support groups
    - school psycho-education and support
    - address bullying or learning problems
    - housing benefits
123
Q

treatment of bipolar affective disorders - NICE guidelines

A
  1. psychoeducation: CBT, family therapy, interpersonal therapy
  2. Psycho-pharmacology
    - acute mania, e.g second generation antipsychotic (aripiprazole, olanzapine, quetiapine, risperidone), lamotrigine, lithium
  3. Bipolar depression
    - antipsychotic plus antidepressant e.g olanzapine plus fluoxetine or quetiapine
  4. mood stabilizers (e.g lithium)
124
Q

Treatment of bipolar affective disorder

A

Initial therapies (Mania/ hypomania/ Mania with psychosis)
1. atypical antipsychotics
– likely 2-3 trials of same
– if treatment resistant, consider switching/ addition of lithium
– agitation
– benzodiazepines

  1. Comorbities
    - anxiety: psychotherapy. if not effective, SSRI (carefully) + antimanic agent
    - depression: psychotherapy. if not effective, SSRI (carefully) + antimanic agent
  2. Maintenance
    - in principal, continue the same treatment that worked
125
Q

Psychotherapies for treatment of BPAD

A
  1. Cognitive behavioural therapy
    - emphasizes psychoeducation, medication adherence, mood monitoring, cognitive restructuring, sleep hygiene, and family communication
  2. Dialectical behaviour therapy
    - mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance
    - individual skills training (which target problematic behaviours such as nonadherence to medications) and family therapy (psychoeducation, tolerating distress, emotion regulation, and interpersonal effectiveness)
  3. Family therapy
    - improved communication, decreasing high expressed emotions, problem solving
126
Q

psychosis is an umbrella term, which is the differential

A
  1. bipolar manic psychosis
  2. delusional disorder
  3. drug-induced psychosis
  4. organic psychosis e.g epilepsy
  5. psychosis not otherwise specified
  6. psychotic depression
  7. schizoaffective disorder
  8. schizophrenia
127
Q

brief psychotic symptoms

A
  • Brief psychotic symptoms common:
    – 10-28% general population (adults)
    – 8% children-transient hallucinations
    – self reported psychotic symptoms by 11 years but few developed psychosis by 26 years
    ** whilst brief psychotic symptoms are common but childhood psychotic disorder is not !
128
Q

Risk factors for early onset psychosis

A
  1. genetic
    - monozygotic twins 30-40% concordance
    - 10-15% concordance for dizygotic twins
  2. Gestational
    - antenatal infection
    - complications in pregnancy
    - prematurity
    - seasonality
    - low birth weight
  3. Environmental
    - urban > Rural
    - migration
    - social exclusion
    - Early/ frequent cannabis use
  4. Ethnicity
    - Afro-Caribbean x18 times greater
  5. Early childhood history
    - solitary play
    - social skills deficits
    - speech delay
    - receptive language difficulties
    - motor delay
    - minor physical anomalies
    - hypersensitive
    - behavioural difficulties
    - academic difficulties and lower premorbid IQ
    - early disturbances in parent-child relationship (insecure attachment with associated paranoia)
129
Q

phases of early onset psychosis

A
  1. premorbid
  2. prodrome
    - decrease in functioning
    - beginning of mild but not yet psychotic symptoms
  3. Active
    - within duration of untreated psychosis if a key element for prognosis
130
Q

prodromal symptoms for early onset psychosis

A
  1. non-specific symptoms
  2. subthreshold psychotic symptoms
    - symptoms not seriously disorganizing or dangerous
    - insight present
    - lack of conviction in reality of symptom
131
Q

discuss the prodrome in relation to acute onset psychosis

A
  • child is AT RISK OF developing psychosis in the next year
  • there is usually a change the year before psychosis develops (change in emotion, behaviour, symptom or level of functioning)
132
Q

prodromal symptoms in acute psychosis

A
  • confusion: real or imaginary
  • hearing and seeing things that are not present
  • world seems unreal/ strange
  • withdrawl/ isolation from family and friends
  • staying in bedroom for long periods
  • social difficulties/ decline
  • poor hygiene
  • odd thinking or behaviour
  • Bizzare appearance
  • poor school attendance
  • reduced concentration
  • hypervigilance (chronic state of heightened alertness and awareness)
  • reduce activity/ motivation
  • drop in grades/ increased effort needed in school
  • emotional outbursts or lack of emotion
  • mood changes
  • sleep disturbance
  • anxiety
  • irritability
  • suspiciousness/ mistrust of others
  • more sensitive to noise
  • changes in the way things look or sound
  • difficulty getting point across
  • difficulty following multiple directions
  • deja vu
  • seeing shadows/ vague figures out of the corner of eye
133
Q

course of prodromal symptoms - acute psychosis

A
  1. symptoms continue but remain unchanged
    OR
  2. remit spontaneously
    OR
  3. progress to a psychotic illness
134
Q

Assesment of symptoms - acute psychosis child

A
  1. description
  2. Onset
  3. Duration
  4. Frequency
  5. level of associated distress
  6. Interference with functioning? Does symptom change behaviour?
  7. Degree of conviction: any doubt? can the interviewer induce doubt?
  8. When do they occur? (may increase in stressful situations e.g term time; outrule hypnopompic and hypnogogic hallucinations).
135
Q

early onset psychosis - general points (M vs F, premorbid, onset)

A
  1. Insidious onset common
  2. males > females
  3. Many have premorbid abnormalities E.g developmental problems and poor social adjustment
136
Q

Biological investigations - early onset psychosis

A
  1. weight, height (especially if considering antipsychotic treatment)
  2. blood tests if indicated e.g suspected thyroid disease
  3. EEG (suspected seizures e.g peri-ictal psychosis)
  4. CT/MRI brain for first episode psychosis or unusual presenting features
137
Q

psychological investigations - early onset psychosis

A
  1. Risk assessment: any risk to self or others (command hallucinations)
  2. psychological assesment: IQ (lower IQ with early onset psychosis)
  3. Interviews: SIPS/CAARMS, SAPS+SANS (schedule of assessment of positive and negative symptoms)
138
Q

social investigations - early onset psychosis

A
  1. collateral history from GP, teacher, and relatives
  2. lisase with involved agencies or professionals
  3. school report or visit: Social and academic abilities. Behaviour
  4. Assess family dynamics and social background
139
Q

Treatment - early onset psychosis (general)

A
  • treatment based on comprehensive assessment of needs of individual child and family
  • determine appropriate treatment setting: OPD, child and adolescent mental health clinic, Day hospital or in-patient unit
  • evidence-based treatment, multimodal + Multidisciplinary in nature
  • short, medium, long-term goals
140
Q

Biological treatments - early onset psychosis

A
  1. atypical antipsychotics and monitoring for side effects
  2. side effects
    - weight gain
    - sedation
    - hyperprolactinemia
    - diabetes
    - EPSE
    - seizures
  3. Treat any comorbid disorders (mood and anxiety disorders, substance misuse)
141
Q

Prevalence rates of psychosis

A
  1. very early onset (<13 years): rare
  2. Adolescence: increases with age (0.009% at 13 years and 0.2% at 18 years)
  3. general population
    - 3% psychotic disorders
    - 1% schizophrenia (commonest psychotic disorder)
142
Q

monitoring for second generation antipsychotics ?

A
  1. weight and waist circumference
    - every visit
  2. blood pressure
    - olanzapine - 6 monthly
    - all others - annually
  3. fasting serum lipids
    - olanzapine - 6 monthly
    - all others - annually
  4. fasting blood glucose
    - olanzapine - 6 monthly
    - all others - annually
  5. electrocardiogram
    - annually
  6. ask about EPSE and examine for rigidity, tremor, and abnormal involuntary movements (tardive dyskinesia)
    - every 6 months
  7. ask about menstrual and sexual problems, gynecomastia and galactorrhea. Test prolactin levels if symptoms suggest hyperprolactinemia
    - annually
  8. ask about any other adverse events e.g sedation, anticholinergic effects
    - every visit
  9. ask about smoking status
    - every visit
  10. ask about alcohol and illicit drug consumption
    - every visit
143
Q

Psychological treatments - early onset psychosis

A
  1. risk management
  2. develop collaborative relationship with young person and family
  3. psychoeducation
  4. consider CBT for psychosis
  5. enhance and develop coping strategies
  6. social skills training
  7. activity scheduling (remember the OT too - structure and routine)
144
Q

social treatments - early onset psychosis

A
  1. family support and therapy (reduced high expressed emotion - linked to relapse)
  2. liaise with school and other involved agencies/ professionals
  3. Local support group if appropriate e.g schizophrenia ireland
145
Q

prognosis - early onset psychosis

A
  • 50% continuous course
  • 50% negative symptoms
  • poor prognosis than adult onset, especially if:
    – premorbid impairments
    – negative symptoms at onset
    – prolonged period without treatment
146
Q

conclusion – early onset psychosis

A
  1. 12-18 years vulnerable age for prodrome
  2. psychosis is increasingly common in adolescence
  3. early symptoms are non-specific
  4. Diagnostic uncertainty is common
  5. high rates of underdiagnosis/ misdiagnosis
  6. usually a deterioration the year before psychosis develops
  7. comorbidity is common
147
Q

define suicide

A

the action of killing oneself intentionally

148
Q

define self-harm

A
  1. an act with non-fatal outcome where an individual ;
    - initiated behaviour with intention to cause self harm
    - ingested a substance in excess of the generally recognizable therapeutic dose
  2. intended outcome:
    - may or may not be linked with wish to end life
    - may not know reason
    - a coping strategy (maladaptive)
149
Q

define non-suicidal self injury (NSSI):

A

an act of self harm but without any intent to end one’s life

150
Q

define suicidal ideation

A

thoughts and/or plans of wanting to end one’s life
- active
- passive death wish (PDW)

151
Q

prevalence of self harm - youth risk behaviour surveillance survey (YRBSS) CDC

A
  • suicidal ideation: 22%
  • making a suicidal plan: 18%
  • self harm: 10%
  • injured in a suicide attempt that had to be treated by a doctor or nurse: 3%
152
Q

self harm prevalence ireland and europe

A
  1. last month: 8% F, and 3% M
  2. SH ever: 15% F, 5% M
  3. F:M 2:1
153
Q

NSHRI 2021 data 20th report published 2024

A
  • rates of self harm increased over years for Females and reduced for Males
  • highest rate of self harm 15-19 F
  • ## highest Male rate in 20-24
154
Q

suicide and self harm stats ireland

A
  • annual suicide rate 10/100,000 (M>F x6)
  • annual incidence rate of hospital treated SH 344/100,000 (F>M x2)
  • rate of self report community SH 5,551/100,000 (F>M x4)
  • for every boy who died by suicide 16 presented to hospital with SH and 146 reported SH in the community
  • for every female suicide 162 girls presented to hospital with SH and 3,296 reported Self harm
155
Q

types of self harm

A
  1. cutting +++
  2. overdose
  3. Burning
  4. punching self or wall
  5. scratching
  6. pulling hair or eyelashes out
  7. banging head or throwing body against something
  8. inhaling/ ingesting harmful substances
  9. suffocation and strangulation
  10. also
    - substance abuse
    - eating disorders
    - risk behaviours: e.g disregard personal safety, multiple sexual partners, poor relationships
156
Q

why to people self harm?

A
  1. get relief from a terrible state of mind
  2. to die
  3. punish myself
  4. others
    - wanted to show how desperate I was feeling
    - i wanted to find out whether someone really loved me
    - I wanted to get my own back on someone
    - I wanted to get some attention
    - I wanted to frighten someone
157
Q

in general …

A
  • 1 in 10 self harm
  • 1 in 10 repeat
  • 1 in 10 of young person with self harm die by S in 10 years
  • rates of suicide decreasing in most countrie, including ROI, But increasing in the USA
158
Q

risk factors of suicide

A
  1. family history of suicide
    - maternal x 5
    - paternal x 2
  2. family history of self harm or suicidal ideation
  3. Parenteral psychopathology
    - especially depression and substance use disorder
  4. Divorce/ separation
  5. Parent child conflict
  6. Mental illness
    - majority (90%) youth suicides > 1 diagnosis
    - most common are depression (60%), substance use disorder, Conduct disorder
    - a psychiatric disorder may be a necessary but not a sufficient risk factor
    - mental illness less linked in China as lethal methods/pesticides/ rural, poor emergency care
  7. Other factors
    - child sexual or physical abuse
    - slight increase in homosexual
159
Q

self harm and risk of completed suicide

A
  • rates of completed suicide amongst attempters is 0.5-1% per year
  • 4% adolescents with self harm died by suicide within 6 years
  • risk of death among self harm:
    1. males (5 times greater than females)
    2. repeaters (3 risk with regard to non repeaters)
    3. clear communication of suicidal intent
    4. active method
    5. presence of depression
    6. greater psychiatric disturbance at initial presentation
  • greatest risk within first 3 months, but median 3 years post 1st attempt
160
Q

Post self harm assessment guidelines

A
  1. identify specific factors associated with increasing/ decreasing risk for S/SI/SH which may serve as modifiable targets for both acute and on-going interventions
  2. Assess and manage the patient’s immediate safety including most appropriate setting for treatment
  3. develop a multi-axial differential diagnosis to guide further treatment
  4. Use IFME model of assessment and management (FMcN)
161
Q

assessment of self harm

A
  1. assess individual current suicidality
    - assess SH, specific methods/ suicidal intent or not/ lethality/ expectation about lethality/ access to lethal means
    - actions post SH
    - Current thoughts, plans, behaviours, and intent, remorse/regret, reasons for living/ future orientated plans
    - evidence of hoplessness, impulsiveness (ADHD), anhedonia, panic/ anxiety
    - alcohol/ other substances associated with current SI/SH
    - thoughts, intentions other violence
  2. Mental/ psychiatric illnesses
    - any psychiatric disorders especially mood disorders (MDD BPD), schizophrenia, SUD, anxiety, and personality disorders (EUPD)
    - previous psychiatric diagnoses and treatments
    - past SH/ SI and context
    - family history of suicide, suicide attempts, self harm, or mental health diagnoses
    - medial diagnosis
    - developmental vulnerability
  3. Family/ psychosocial situation
    - acute psychosocial stressors crises or chronic stressors; family or partner discord, peer difficulties, bullying, financial difficulties, past or current abuse/ neglect, education, living situation
    - any life changing events
    - cultural or religious/ peer beliefs about death or suicide
    - extent of supportive network
  4. Individual strengths and weaknesses
    - coping skills
    - personality traits
    - past response to stress
    - capacity for reality testing
    - ability to tolerate psychological pain and satisfy psychological needs
162
Q

clinical risk assessment following SH, especially overdose

A
  1. predisposing, precipitating, and perpetuating
  2. 3 W’s:
    - what?
    - when?
    - why?
  3. past, present future
    - past self harm, present remorseful or not, future plans and suicidality
163
Q

risk factor assessment table developed from all known risk factors

A
164
Q

what must you do when assessing self harm

A
  1. conduct a good mental health assessment
  2. individual assessment of SH act:
    - why?
    - past SH, present, future
    - Identify any treatable mental health diagnoses
  3. family
    - risk and protective factors including past SH/SI/S
  4. Medical
    - what and when
    - any medical illnesses/ medications/ substance use disorder
  5. environment
    - risk and protective factors, including peer SH/S, bullying, abuse, stressors, ACE
165
Q

safety and contingency planning at all levels - management of self harm

A
166
Q
A

Psychiatry (22 decks)

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