Human Life Cycle Flashcards
1
Q
What is the definition of foetal growth?
A
Increase in mass that occurs between the end of embryonic period and birth
2
Q
What 2 components does foetal growth depend on?
A
1) Genetic potential
- derived from both parents
- mediated through growth factors e.g. insulin like growth factors
2) Substrate supply
- essential to achieve genetic potential
- derived from placenta which is dependent upon both uterine and placental vascularity
3
Q
What 3 phases in normal foetal growth characterised by?
A
1) Cellular hyperplasia
2) Hyperplasia and hypertrophy
3) Hypertrophy alone
4
Q
What is the foetal growth velocity between 14-15 weeks?
A
5g/day
5
Q
What is the foetal growth velocity at 20 weeks?
A
10g/day
6
Q
What is the foetal growth velocity at 32-35 weeks?
A
30-35g/day
7
Q
How does the foetal growth velocity change at >34 weeks?
A
Growth rate decreases
8
Q
What is symphysis fundal height?
A
Distance over the abdominal wall from the symphysis to the top of the uterus
9
Q
Where is the fundal height landmark at 12 weeks?
A
Symphysis pubic
10
Q
Where is the fundal height landmark at 20 weeks?
A
Umbilicus
11
Q
Where is the fundal height landmark at 20-34 weeks?
A
Gestational age +/- 2 cm
12
Q
Where is the fundal height landmark at 36-38 weeks?
A
Gestational age +/- 3 cm
13
Q
Where is the fundal height landmark at >38 weeks?
A
Gestational age +/- 4 cm
14
Q
For what reasons could a baby be measuring as having a small fundal height?
A
- Wrong dates
- Small for gestational age
- Oligohydramnios
- Transverse lie
15
Q
For what reasons could a baby be measuring as having a larger fundal height?
A
- Wrong dates
- Molar pregnancy
- Multiple gestation
- Large for gestational age
- Polyhydramnios
- Maternal obesity
- Fibroids
16
Q
What are the pros and cons of symphysis fundal height?
A
Pros: - Simple - Inexpensive Cons: - Low detection rate: 50-86% - Great inter-operator variability - Influenced by a number of factors (BMI, foetal lie, amniotic fluid, fibroids)
17
Q
Why is dating by last menstrual period inaccurate?
A
- Irregular periods
- Abnormal bleeding
- Oral contraceptives
- Breastfeeding
18
Q
Why is correct dating important?
A
- Small for gestational age or large for gestational age confusion
- Inappropriate inductions
- Steroids in preterm deliver
19
Q
How should all pregnancies be dated?
A
Crown Rump Length
- EXCEPT IVF pregnancies
20
Q
When is head circumference dating used?
A
If the first scan is done after 14 weeks (CRL>84mm)
21
Q
Which 4 biometrical parameters assess foetal growth when using an ultrasound?
A
1) Biparietal diameter
2) Head circumference
3) Abdominal circumference
4) Femur length
Combination = Estimated foetal weight
22
Q
How are normaltive growth curves constructed from ultrasound measurements expressed?
A
Centiles
- Used clinically to identify a normal intrauterine growth and detect risk of obstetric and neonatal complications
23
Q
What maternal factors influence foetal growth?
A
- Poverty
- Age
- Drug use
- Weight
- Disease (hypertensiom, diabetes, coagulopathy)
- Smoking and nicotine
- Alcohol
- Diet
- Prenatal depression
- Environmental toxins
24
Q
What foeto-placental factors affect foetal growth?
A
- Genotype (genetic potential)
- Gender (B>G)
- Hormones
- Previous pregnancy
25
What are the foetal hormones and from where are they secreted?
```
Pituitary
- Somatrophin
- Prolactin
- FSH/LH
Pancreas- Insulin
Adrenals - Androgens
Gonads- Androgens
Thyroid- Iodothryonines
```
26
By which principles does the customised growth charge define individual foetal growth potential?
1) Adjusted to reflect maternal constitutional variation. Maternal height, weight, ethnicity, parity
2) Optimised by presenting a standard free from pathological factors such as diabetes and smoking
3) Based on foetal weight curved derived from normal pregnancies
27
What is covered in obstetric ultrasound examination?
- Assessment of foetal 'wellness' not just size
- Looking at trends in growth
- Predicting foetal metabolic compromise
- Anticipating the need to deliver prematurely
- Liaising with neonatal services
28
When is a foetus considered small for gestational age (SGA)?
Birth weight
29
What is the definition of foetal growth restriction (FGR)?
Failure of the foetus to achieve its predetermined growth potential for various reasons
30
What is a severe SGA ( small for gestational age)
EFW or AC
31
What is considered a low birthweight?
less than 2500 g
32
What is considered a very low birthweight?
less than 1500 g
33
What do epidemiological studied use?
- Use birth weight alone, not gestastional age
34
What is the increase in perinatal mortality in FGR babies?
3-10 fold increase
35
When choosing centiles, which is the most sensitive and which is the most specific?
```
Sensitive= 10th
Specific= 3rd
```
36
Why will you get a number of false positives with the tenth centile?
It captures all babies with FGR but will also include those babies that are just small for gestational age
37
Why will you get a number of false negatives with the third centile?
All babies recorded using the third centile will have FGR, but some FGR babies may be missed
38
What are the short term problems of LBW/FGR/ Prematurity?
- Respiratory distress
- Intraventricular haemorrhage (cannot fight infection)
- Sepsis (cant fight infaction)
- Hypoglycaemia
- Necrotising enterocolitis
- Jaundice
- Electrolyte imbalance
39
What are the medium term problems of LBW/FGR/Prematurity?
- Respiratory problems
- Developmental delay ( brain damage)
- Special needs schooling
40
How will premature babies with electrolyte imbalance appear?
Have thin porous skin, not fat
| approx 34 weeks
41
Why would premature babies be jaundice?
Immature liver pathways
42
What is the long term problem with LBW/FGR/Prematurity?
Foetal programming
| IHD, CHD, diabetes are more common due to compensatory pathways initiated due to poor growth
43
What are the differential diagnoses of smallness?
- Not small at all
- Normal small
- Abnormal small
- Starved small
44
What is the type of growth seen in abnormal small fetuses?
Symmetrical or asymmetrical
45
What is preeclampsia?
- Normal pregnancy: spiral arteries that reside in the endometrium open to form a funnel which allows trophoblasts to invade the maternal vascular system
- In preeclampsia, this doesn't happen. The placenta is not perfused properly therefore the mother compensates by throwing blood down the arteries at higher and higher pressure. The mother therefore becomes increasingly ill whilst their is no growth in the foetus
46
What maternal medical factors are associated with FGR and SGA foetus?
- Chronic hypertension
- Connective tissue disease
- Severe chronic infection
- Diabetes mellitus
- Anaemia
- Uterine abnormalities
- Maternal malignancy
- Pre-ecamplsia
- Thrombophilic defects
47
What foetal factors are associated with FGR and SGA foetus?
- Multiple pregnancy
- Structural abnormality
- Chromosomal abnormalities
- Intrauterine (congenital) infection
- Inborn errors of metabolism
48
What maternal behavioural factors are associated with FGR and SGA foetus
- Smoking
- Low booking weight (35 years at delivery
- Alcohol
- Drugs
- High altitude
- Social deprivation
49
What placental factors are associated with FGR and the SGA foetus?
- Impaired trophoblast invasion
- Partial abruption or infarction
- Chorioamnionitis
- Placental cysts
- Placenta praevia
50
When is the period of placentation?
10-12 weeks
51
What are the functions of the placenta?
- Maintains immunological distance between mother and the foetus
- Special endocrine organ: produces protein-peptides and steroid hormones and functions as a 'transient hypothalamo-pituitary-gonadal axis'
- Responsible for exchange of nutrients, gases and metabolic waste products between maternal and foetal circulation
52
What does preeclampsia result from?
A combination of impaired trophoblast differentiation and invasion during the first trimester.
Results in the failure of trophoblast cells to destroy the muscularis layer or the spiral arterioles which causes the development of a poorly perfused placenta
53
Where do spiral arteries sit in non-pregnant women?
Within the endometrium
54
What is seen in pre-eclampsia?
- Hypertension
- Oedema
- Proteinuria
55
What is the definition of pre-eclampsia?
Gestational hypertension of at least 140/90 mmHg on two separate occasions > 4 hours apart
- Significant proteinuria of at least 300 mg in a 24- hour collection of urine, arising de novo after the 20th week of gestation in a previously normotensive woman and resolving completely by the 6th postpartum week
56
What foetuses need growth monitoring?
Those with bad obstetric history
- Previous maternal hypertension
- Previous FGR
- Stillbirth
- Placental abruption
Those with concerns in index pregnancy as they arise
- Abnormal serum biochemistry
- Reduced symphysis fundal height
- Maternal systemic disease e.g. hypertension, renal, coagulation
Antepartum haemorrhage
Multiple pregnancy e.g. monochorionic twins
57
Why may foetal movement counting be of value?
A reduction in foetal movements may precede foetal death by a day or more
58
What is the most used method for foetal movement counting?
Cardiff kick method
59
What is needed for women who report a reduction or absence of foetal movements?
Cardiotocography
| and/or ultrasounds assessment of the foetus to reassure the mother and ensure foetal wellbeing
60
What is the use of the Doppler ultrasound?
To determine the pattern of waveforms on the umbilical artery
61
Where is the ductus venosus?
- Longitudinal through upper abdomen
| - Parallel, anterior to the right of the aorta
62
What is the purpose of the ductus venosus?
- Receives 40% of umbilical venous flow
| - Direct oxygenated blood to the left ventricle
63
Which maternal risk factors may contribute to a foetus becoming growth restricted?
- Poor obstetric history
- Primips
- Obese
- Afro-Carribean/ African
- Strong family history
- Essential hypertension
- Diabetes/impaired glucose tolerance
- Systemic vascular disease
- Renal disease
- Thrombophilias
64
What should be administered at gestations
Corticosteroids
65
What does the mode of delivery depend upon?
- Gestation of the pregnancy
- Condition of the pregnancy
- State of the cervix
- Presentation of the foetus
- Other factors: oligohydramnios (labour may be poorly tolerated due to cord compression)
66
What stage is a blastocyte?
9 days
| Approx 0.1cm
67
What stage is an embro?
5-6 weeks
| Approx 1 cm
68
What stage is a foetus?
3 months
| Approx 7cm
69
What is the concentration of oxygen in the first trimester?
3%
70
What occurs in the 3rd week of the first trimester?
- Formation of the trilaminar disc (mesoderm)
- CNS and somites
- Blood vessel initiation
- Initiated of placental villi (3mm)
71
What occurs in the 4th week of the first trimester?
- Closure of the neural tube
- Heart, face and arm initiated
- Umbilical cord
- Elaboration of placental villi (4mm)
72
What occurs in the 5th week of the first trimester?
- Face and limbs continue
| 5-8mm
73
What forms in the 6th week of the first trimester?
Face, ears, hands, feet, liver, bladder, gut, pancreas
| 10-14mm
74
What forms in the 7th week of the first trimester?
Face, ears, hands, fingers, toes
| 17-22mm
75
What forms in the 8th week of the first trimester?
Lungs, liver, kidneys
28-30mm
- Placental elaboration continues, development of villi
- Placental endocrinology becomes dominant
76
How does foetal nutrition change at 10 weeks GA?
Maternal enters placental intervillous spaces
| - Increase in oxygen tension to approx 8 %
77
At which week is the foetus 50g?
12-13 weeks
78
At which weeks is the foetus 1050g?
28-29 weeks
79
At which weeks is the foetus 3000g?
37-40 weeks
80
How does the embryo develop in week 1 (pre-implantation development)?
```
Day 1- I cell is fertilised
Cleavage stages:
Day 2- 2 cells to 4 cells
Day 3- 8 cells
Compactation and differentiation:
Day 4- Morula
Cavitation:
Day 5- Blastocyte
```
81
What happens on day 6 of embryonic development?
Attachment of blastocyst to decidualising endometrial epithelium
82
What happens on day 8-9 of embryonic develoment?
Implantation and formation synctiotrophoblast contact with maternal tissue
83
What happens of day 12- 13 of embryonic development?
Synctiotrophoblast invasion and contact with maternal capillaries (2mm)
84
When does the foetal genome become pluripotent?
Day 4
85
What changes occur during cell proliferation?
- Changes in response to growth factors
- Changes in receptor expression
- May be due to changes in cell survival
- All paracrine or autocrine regulation
86
What causes movement of cells?
1) Chemo-attractants
- Local production
- Paracrine effects
2) Cognate receptors
- Expressed on target cells
87
What causes the production and activation of proteases?
```
Matrix metalloproteinases (MMP)
Tissue Inhibitor of metalloproteinases (TIMPs)
```
88
How is differentiation regulated
Paracrine regulation
| - Receptor expression which is necessary in target cells
89
What controls apoptosis?
Paracrine factors
90
What is cleft lip and palate?
Failure to correctly form the face
| - Defects mostly in the mouth and nasal area
91
How do cleft lip and palate differ?
Cleft lip= One side of the face or the other. Or both
| Palate= Mostly central
92
When do cleft lip and palate defects happen?
Carnegie stage 18
93
How does the face form?
As two separate halves, they move and fuse during developments
- Cleft lip and palate reflect failures in this process
94
What is spina bifida?
Birth defect where there is incomplete closing of the backbone and membranes around the spinal cord
CNS defect
95
When does neurulation begin?
Week 3 post fertilisation
96
When does spina bifida present as a problem?
Within 4 weeks of fertilisation
97
What is the primary problem which causes spina bifida?
Failure to complete neurulation ( closure of posterior neuropore)
98
What are the different types of spina bifida?
Occulta
Meningocele
Myelomeningocele
99
What is anencephaly?
Absence of a major portion of the brain, skull that occurs during embryonic development
- Female babies are affected more commonly than male
- Folic acid shows benefit which implies similar causes to spina bifida
100
How can spina bifida be prevented?
Give folic acid to help the closure of the neuropore
101
What is the meaning of spina bifida?
2 spines
102
What is spina bifida occulta?
'Hidden'
There is a defect in the formation of the spine but the defect is modest
- Mostly internal
103
What may signal spina bifida occulta on the surface of the skin?
A patch of hair towards the base of the spine
104
What is spina bifida meningocele?
The membrane over the spinal column have bulged out.
The bulge mostly contains liquid- CSF, not much neural tissue
- Effects are limited
105
What is spina bifida myelomeningocele
- The neural tissue bulges out
| - Nervous system function is deranged as is not connected to peripheral nerves
106
What are the different phases in lung development?
Embryonic Pseudoglandular (6-16 weeks)
Canalicular (16-26 weeks)
Saccular (26 weeks-birth)
Alveolar (8 months-childhood)
107
What precautions are taken to detect FGR?
Foetal movements count
CTG
Serial growth scans
Foetal Dopplers and liquor volume
108
How do the lungs develop in weeks 3-4?
Simple outgrowth from the pharynx as the lung develops
Trachea starts to divide off
Tracheoesophageal septum (days 18-28)
109
How do the lungs develop in weeks 5-8?
5 weeks) Lung buds
6 Weeks) become more elaborate with bronchi
8 Weeks) Lungs mostly formed
110
What is respiratory distress syndrome?
When surfactant levels are low or absent
111
How can production of surfactant be increased in utero?
By 1 injection of glucocorticoids (2-3 days)
| - May be better to delay delivery in premature so glucocorticoid can have time to take effect
112
What does surfactant consist of?
```
Lipids
Proteins
Glycoproteins
40-45% DP-PC
40-45% phospholipids, other PC
5% surfactant associated proteins
5% other proteins
Cholesterol
Trace components
```
113
What is the half life, source and primary function of surfactant?
Half life: 5-10 hours
Source: Type II cells (pneumocytes)
Primary function: low surface tension in alveoli
114
What are the layers of the bilaminar disc of the blastocyst?
Outer layer= Epiblast that consists of columnar cells
Inner layer= Hypoblasts that consists of cuboidal cells
- Bilaminar disc forms 9 days post fertilisation
115
What is gastrulation?
- When the embryo changes from having a bilaminar disc to a trilaminar disc
- Occurs at day 15/16 post fertilisation
- Primitive streak on epiblast surface through which cells move
116
What happens inside the embryo during gastrulation?
- Epiblast proliferates and differentiates to give rise to mesoderm cells (gives rise to most tissues in our bodies)
- Mesoderm cells replace hypoblast cells (apoptosis) and become endoderm cells
- Proliferation, differentiation, movement and apoptosis
117
What 3 layers does gastrulation result in and what are their fates as organs?
Ectoderm - skin, nervous system
Mesoderm - skeleton, muscle, kidney, heart, blood
Endoderm - gut, liver, lungs
118
What is the notochord?
Tube of cells which directs the formation of the central nervous system
119
What do Hox genes control?
- Establish A-P axis
- Differences in the vertebrae
- CNS divisions
- Pattern in the limbs
120
What signal controls the activation of Hox genes?R
Retinoic acid
| - A derivative of Vitamin A
121
How do limbs develop?
- Forelimb bud appears at day 27/28
- Hindlimb bud at day 29
- Grow out from lateral plate mesoderm rapidly under control of special signalling regions
- Fully formed and patterned by day 56
122
What regulates limb development
```
Sonic hedgehog (Shh)
Fibroblast-like growth factor-8
```
123
What did thalidomide deform?
- Limbs
- Deformed eyes and hearts
- Deformed alimentary and urinary tracts
- Blindness and deafness
- Used in some leprosy and cancer treatments
124
What is the most rapid phase of growth?
Antenatal growth
| - Important influences are the placenta and maternal nutrition
125
What are the variables in growth?
- Starting point
- Speed of growth
- Time over which growth occurs
126
How is height velocity calculated?
height now - height last visit/
| age now-age last visit
127
What determines adult height?
- Genetic contribution: parental height and inherited conditions
- Events during growth: nutrition, illness
128
What factors influence growth?
- Nutrition
- Hormones: growth hormone, thyroxine, sex steroids
- Illnesses: inflammation
- Drugs: steroids: etc
129
What is increased growth velocity related to?
GH and sex steroids
| Sex steroids stimulate increased GH secretion
130
In what order to parts of the body stop growing?
- Hands and feet stop, then long bone
- Last growth in height is in the spine
- Last epiphyses to fuse are in the pelvis
131
How is growth hormone secretion controlled?
- Controlled by somatostatin and GHRH from the hypothalamus
- Individual pulses of secretion will return to baseline in return
- Influenced by a range of factors including day and night, nutrition and stress
- Secretion falls as we get older
- Most of its action is through IGFI
132
How does Insulin like growth factor I act?
- Action of GH stimulates IGFI secretion in many cells of the body
- Acts as a paracrine hormone as well as a circulating endocrine hormone
- At least 6 different binding proteins modulate the action
133
How do sex steroids stimulate growth?
- Both oestrogen and testosterone stimulate growth
- Sex steroids also stimulate GH secretion
- Oestrogen is responsible for fusion of the epiphyses in both sexes
134
What are the causes of short stature with normal patterns of growth?
- Genetic (short parents)
- Random variation
- Low birth weight
- Medical or nutrition problems in the neonatal period or infancy
135
What are the causes of short stature with abnormal growth pattern- growing too slowly?
- Chronic medical conditions
- Hormone deficiency- GH, thyroid, IGF I
- Skeletal abnormality
136
What deficient hormone can cause short stature?
- GH deficiency
- Hypothyroidism impairs GH secretion
- Leads to a failure to generate IGF I
137
What are the consequences of GH deficiency?
- Reduced growth velocity
- GH secretion is reduced in standard tests
- Severe deficiency will present in the first year
- Some have normal pituitary MRIs and other pituitary hormones, or it can be associated with pituitary developmental disorders
- Stimulation test to diagnose
138
How is growth hormone deficiency treated?
With recombinant GH- daily injection are needed throughout growth
139
What are the causes of short stature with skeletal abnormality?
Genetic conditions
- Achondroplasia
- Turner syndrome
- Down syndrome
140
What are the characteristics of Turner syndrome
Many girls show features
- Webbed neck
- Wide carrying angle of arms
- Hypoplastic nails
141
What is Turner syndrome?
- Causes by absence of one complete or partial copy of the X chromosome in some or all of the cells
- 45XO Karyotype or mosaic of this
- Short stature with normal growth hormone
- Ovarian failure resulting in failure to progress in puberty
142
What are abnormal causes of tall stature?
- Marfan syndrome and a few other syndromes
| - Pituitary tumours are rare causes of tall stature
143
What treatments are available for growth problems?
- Treat underlying non endocrine medical problems
- Thyroxine in hypothyroidism
- GH in GH deficiency and some other growth disorders
- IGF I in GH insensitivity
144
What is GH treatment used for?
- GH deficiency
- Turner syndrome
- Prader Willi syndrome
- Short stature secondary to low birth weight
- Short stature secondary to renal failure
- SHOX deficiency
- Requires daily injections throughout the growing period
145
What intrauterine environment factors affect height?
- Low birth weight
| - Preterm delivery
146
What is leptin?
- Hormone secreted by fat with receptors in the hypothalamus
- Increased fat mass correlates with increased leptin concentrations
147
Alleles of what gene are associates with risk of obesity?
FTO
148
What is Prader Willi syndrome?
- Syndrome associated with development delay and poor muscle tone
- Loss of function of a number of paternally imprinted genes on chromosome 15
- Associated with an increased appetite
149
How do patients with Prader Willi syndrome act with regards to food?
- Increased interest in food and food seeking
- Tantrums in denied food
- Will eat without boredom and will eat raw, frozen and discarded food
- Stealing, hiding and hoarding food
- Risk of gastric rupture and necrosis as well as of obesity
150
What are the complications and associated features of obesity?
- Acanthosis nigricans
- Impaired glucose tolerance/type 2 diabetes
- Orthopaedic problems
- Polycystic ovarian disease
- Cardiovascular disease
- Psychological problems
151
What is Acanthosis nigricans?
- Marker of insulin resistance
| - Acanthosis nigricans means that insulin levels will be high- but no acanthosis does not mean that insulin is normal
152
What are the risk factors for type 2 diabetes?
- Obesity
- Family history
- Ethnic origins
- PCOS
- Low birth weight
153
What is seen in polycystic ovarian disease?
- High androgens, Hyperinsulinaemia, elevated LH levels
- Amenorrhoea or irregular periods
- Infertility
- Hirsutism
- Acne
- Male pattern baldness
- Increase risk of diabetes, hypertension, heart disease
154
How can obesity be managed?
- Information and education
- Making healthy choices more available
- Public attitudes
- School and local initiatives
- Changes in food manufacture and advertising
155
How is obesity medically managed?
- Bariatric surgery
| - Psychological input, dietary advice, risk factor screening
156
What are the possible investigations into short stature?
- Thyroid function
- Coeliac screen
- Full blood count, CRP, serum iron
- IGF 1
- Bone age
157
Why is measurement of frailty important?
Frailty predicts:
- Falls
- ED visits and hospitalisation
- Entry into residential care
- Death
158
Why does frailty occur?
No single process has been identified
- Comorbities are important, but 25% of frail have no identified chronic disease
- Sarcopaenia (decreased muscle mass)
- Inflammatory markers, hormones, coagulation factors are important
- 10% to 30% of frail people are obese
159
How can frailty be treated?
- Improve physical functions
- Improve nutrition
- Ameliorate deficits
- Treat disease
- Improve physiological reserve
160
What are the hyper-acute frailty syndromes?
- Immobility
- Falls
- Delirium
- Fluctuating disability
- Incontinence
161
What is the comprehensive geriatric assessment?
A multidimensional and usually interdisciplinary diagnostic process designed to determine a fail older person's medical conditions, mental health, functional capacity and social circumstances.
- The purpose is to plan and carry out a holistic plan for treatment, rehabilitation, support and long term follow up.
162
What are the domains of the comprehensive geriatric assessment?
1) Medical
- Active medical problems
- Significant past medical problems
- Surgical history
2) Functional
- Physical function
- Gait and mobility
- Sensory impairments
3) Psychosocial
- Cognitive and effective state
- Living situation/social supports
- Financial issues
163
What is age associated with?
- Normal ageing processes resulting in the loss of physiological reserve
- Increasing number of co-morbidities
- Polypharmacy
- Problems with communication
- Late presentation
164
What does it mean when a person is 'frail'?
Loss of physiological reserve that makes a person susceptible to disability from minor stresses
- Weakness, weight loss, muscle wasting, exercise, intolerance, frequent falls,, immobility, incontinence, instability of chronic diseases
165
What are the possible conditions a patient may be suffering from when presenting with weakness, lethargy, confusion, agitation?
- Myocardial infarction, congestive cardiac failure
- Pneumonia, urinary tract infection, biliary disease
- Bacteraemia
166
What are the possible conditions a patient may be suffering from when presenting with fall/collapse?
- Osteoarthritis, proximal myopathy, visual problem
| - Stroke, atherosclerosis, heart block
167
What is the Montreal Cognitive Assessment?
- Precise in measuring cognitive impairment
- Sensitive in order to detect early stages of impairment for the most common neurodegenerative conditions such as Alzheimer's disease
- Specific so that it would not falsely label someone who is normal as being impaired
168
What is the criteria for anorexia nervosa?
- Body weight at least 15% below expected
- Avoidance of fattening foods
- Psychopathology-morbid dread of fatness, aims for weight lower than premorbid or healthy
- Endocrine disturbance
169
What is the criteria for bulimia nervosa?
- Persistent preoccupation with eating, binges
- Weight losing behaviours
- Purging: by vomiting, taking a laxative, diuretic or stimulant and/or excessive exercise
- Psychopathology: morbid dread of fatness, aims for weight lower than premorbid or healthy
170
What are the characteristics of pubertal development in boys?
- Associated with increase increase in height and muscle development
- Dissatisfaction related to height and musculature
- Early maturing boys feel more attractive, more popular and relaxed
171
What are the characteristics of pubertal development in girls?
- Associated with increase in height and body fat
- Ambivalent attitude to menarche (first menstruation)
- Dissatisfaction strongly related to weight and fat
- Puberty may lead to lower self-esteem
- Being slim perceived as desirable
172
What is the aetiology of anorexia nervosa?
1) Genetic
2) Puberty
- Increase in body fat
- Negative attitudes to puberty
- Late maturing girls at a lower risk of eating disorders
Personality)
- Perfectionist
- Obsessional
173
What are the possible mechanisms of anorexia nervosa with regards to neuropsychology?
1) Distorted body image- somato-sensory cortex
2) Increased anxiety- amygdala
3) Obsessional drive- basal ganglia
4) Enhanced sense of reward- nucleus accumbens
5) Visuo-spatial deficits- parietal cortex
6) Executive impairments- frontal lobe
174
What are the environmental factors which contribute to anorexia nervosa?
1) Family factors
- Parental negative attitudes to body fat/shape
- Maternal dieting and eating disorders
- Family interaction
2) Adverse experiences
- Sexual abuse and other adverse life events
3) Sociocultural factors
- Ethnic group
- Institutions
- Media-role unclear
175
How do patients with anorexia nervosa present?
- Self starvation, weight loss, abnormal growth
- Symptoms related to self starvation e.g. nausea, abdominal distension, fainting and dizziness
- Selective eating- fat avoidance
- Other weight controlling strategies e.g. vomiting, exercising, laxatives
- Low mood, irritability
- Later: withdrawal, poor concentration, sleep disturbance
176
What are the differential diagnosis of anorexia nervosa?
1) Physical
- Gastro-intestinal disorder e.g. Crohn's disease
- Metabolic e.g. diabetes
- Pituitary
2) Psychiatric
- Bulimia nervosa
- Depression
- Psychosis
- Obsessive compulsive disorder (OCD)
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How is anorexia nervosa treated?
- Admission for weight restoration in a minority of cases
- Family therapy
- Nutritional counselling
- Cognitive behaviour therapy (CBT)
- Treatment of persistent depression etc
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What are the principles of cognitive behavioural therapy?
- Psychoeducation
- Self-monitoring
- Behavioural goals
- Modify abnormal cognitions
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What are the symptoms of depression?
- Persistent sadness or low mood
- Loss of interests of pleasure (anhedonia)
- Fatigue/low energy (anergia)
And associated symptoms:
- Disturbed sleep
- Poor concentrations or indecisiveness and libido
- Low self-condifence
- Appetite/weight
- Suicidal thoughts or acts
- Agitation/slowing of movements
- Guilt or self blame
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How is the degree of depression defined?
The degree of symptoms experienced
| - Not depressed ( symptoms with or without psychotic symptoms)
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How does childhood depression clinically present?
- Persistent and pervasive sadness
- Anhedonia
- Boredom or irritability that is functionally impairing
- Relatively unresponsive to pleasurable activities, interactions and attention from other people
- Functional impairment is an important distinguishing factor from the normal mood fluctuations of childhood
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What are the types of pre-pubertal depression?
Type 1:
- More common
- Presentation is with co-morbid behavioural problems, parental criminality, parental substance abuse and family discord
- No increased risk of recurrence in adult life
Type 2:
- Less common
- Highly familial with multigenerational loading for depression
- High rates of anxiety and bipolar disorder
- Recurrences of depression in adolescence and adulthood
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How does normal adolescent angst differ from the psychiatric disorder?
- Normal adolescent angst involves mastering the tasks of development, physical, cognitive, social, emotional and moral changes
- Psychiatric disorders involves symptoms of serious suffering/impairment relating to person life, family, peers and education/work
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What is adolescent depressive disorder?
- Irritability instead of sadness/low mood (especially in boys)
- Somatic complaints and social withdrawal are common
- Psychotic symptoms rare before mid-adolescence
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What are the biological factors contributing to depression?
1) Genetics
- Family history of major affective disorders, usually depression
2) Biochemical changes
- Anime hypothesis suggests that depression results from hypo-activity of monoamine neurotransmitter reward systems
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How can puberty affect mood?
1) An increase in gonadal hormones can have a direct CNS effect.
Low levels of oestrogen in women is associated with
- Premenstrual syndrome
- Postnatal depression
- Post-menopausal depression
2) Change in body shape can be a negative experience
3) The timing of puberty
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How can cognitive and emotional developmental changes affect mood?
1) Brain development
- Prefrontal cortex: synaptic pruning, myelination, changes in grey matter (cell bodies) and white matter (axones)
2) Cognitive changes:
- Thoughts more logical, abstract, reasoning
- Alternative outcomes, consequences, ambiguity
- Ability to ruminate and ask 'what if'
3) Establishment of identity
- Reflect on own thoughts and perspectives in relation to others
- Sense of self across time
- Reputation with peers
4) Increase intensity of mood states
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How do developments in social relationships affect mood
1) Family
- Relationship transformed
- Shift to autonomy and independence
- Less time with family
- Cognitive: discussion/arguments
- Question rules
2) Peers
- Spend more time and they become more important
- Romantic and sexual relationships
3) Social world
- Exposure to media stereotypes
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How is depression treated?
1) Mild depression
- Cognitive behavioural therapy (CBT)
- Interpersonal psychotherapy for adolescents
2) Moderate-severe depression
- Antidepressants e.g. SSRIs- FLUOXETINE
- Could be SSRI and CBT
