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Yr 4 - Paediatrics > Mental Health: Eating Disorders, Depression, Anxiety > Flashcards

Mental Health: Eating Disorders, Depression, Anxiety Flashcards

1
Q

What is the diagnostic criteria for anorexia nervosa (as per the DSM-5)?

A

1) Restriction of energy intake relative to requirements, leading to significantly low body weight

2) An intense fear of gaining weight, or persistent behaviours that prevent weight gain

3) Disturbance in the perception of one’s own body weight or shape

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2
Q

What are the 4 key clinical features of anorexia?

A

1) Reduced BMI

2) Bradycardia

3) Hypotension

4) Enlarged salivary glands

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3
Q

How is HR affected in AN?

A

Bradycardia

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4
Q

How is BP affected in AN?

A

Hypotension

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5
Q

How does AN affect salivary glands?

A

Can cause enlarged salivary glands

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6
Q

What are the physiological abnormalities seen in AN?

A

1) Hypokalaemia

2) Low FSH, LH, oestrogens and testosterone

3) Raised cortisol and GH

4) Impaired glucose tolerance

5) Hypercholesterolaemia

6) Hypercarotinaemia

7) Low T3

Note - everything is RAISED except K+, T3, FSH, LH, oestrogens & testosterone.

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7
Q

What is hypercarotinemia?

A

Characterised by yellow pigmentation of the skin (xanthoderma) and increased beta-carotene levels in the blood.

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8
Q

How is K+ affected in AN?

A

Hypokalaemia

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9
Q

How are sex hormones affected in AN?

A

Low FSH, LH, oestrogens and testosterone

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10
Q

How is cortisol affected in AN?

A

Raised

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11
Q

How is GH affected in AN?

A

Raised

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12
Q

How is glucose tolerance affected in AN?

A

Impaired

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13
Q

How is cholesterol affected in AN?

A

Raised

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14
Q

How is T3 affected in AN?

A

Low

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15
Q

What is the 1st line treatment for AN in children and young people?

A

Family therapy

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16
Q

What is the 2nd line treatment for AN in children and young people?

A

CBT

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17
Q

What is considered for management of AN in adults?

A

NICE recommend we consider one of:

1) Individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)

2) Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)

3) Specialist supportive clinical management (SSCM).

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18
Q

What % of patients with AN will die as a result?

A

Up to 10%

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19
Q

What is bulimia nervosa (BN)?

A

A type of eating disorder characterised by episodes of binge eating followed by intentional vomiting or other purgative behaviours such as the use of laxatives or diuretics or exercising.

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20
Q

What is the DSM 5 diagnostic criteria for BN? (6)

A

1) Recurrent episodes of binge eating

2) A sense of lack of control over eating during the episode

3) Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise.

4) The binge eating and compensatory behaviours both occur, on average, at least once a week for three months.

5) Self-evaluation is unduly influenced by body shape and weight.

6) The disturbance does not occur exclusively during episodes of anorexia nervosa.

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21
Q

What 2 signs may recurrent vomiting in BN cause?

A

1) erosion of teeth

2) Russel’s sign (calluses on the knuckles or back of the hand)

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22
Q

What is Russel’s sign?

A

Calluses on the knuckles or back of the hand due to repeated self-induced vomiting.

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23
Q

What is 1st line management of BN in adults?

A

Bulimia-nervosa-focused guided self-help for adults

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24
Q

If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, what is the next step?

A

Consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED).

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25
Q

Management of BN in children?

A

Children should be offered bulimia-nervosa-focused family therapy (FT-BN)

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26
Q

Features of BN?

A
  • Alkalosis, due to vomiting HCl from the stomach
  • Hypokalaemia
  • Erosion of teeth
  • Swollen salivary glands
  • Mouth ulcers
  • Gastro-oesophageal reflux and irritation
  • Russel’s sign
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27
Q

Do all patients with BN have a reduced BMI?

A

No

Unlike with anorexia, people with bulimia often have a normal body weight. Their body weight tends to fluctuate.

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28
Q

What is binge eating disorder?

A

Binge eating disorder is characterised by episodes where the person excessively overeats, often as an expression of underlying psychological distress.

This is not a restrictive condition like anorexia or bulimia, and patients are likely to be overweight.

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29
Q

Typical weight in binge eating disorder?

A

Typically overweight

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30
Q

What may ‘binges’ involve in binge eating disorder?

A
  • A planned binge involving “binge foods”
  • Eating very quickly
  • Unrelated to whether they are hungry or not
  • Becoming uncomfortably full
  • Eating in a “dazed state”
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31
Q

What is refeeding syndrome?

A

Describes the metabolic abnormalities which occur on feeding a person following a period of starvation.

It occurs when an extended period of catabolism ends abruptly with switching to carbohydrate metabolism.

32
Q

What are the 3 key metabolic complications of refeeding syndrome?

A

1) Hypokalaemia

2) Hypophosphataemia

3) Hypomagnesaemia

33
Q

What is the hallmark symptom of refeedig syndrome?

A

Hypokalaemia

34
Q

How may hypokalaemia present in refeeding syndrome?

A
  • muscle weakness e.g. cardiac failure from weakness of myocardial muscle, respiratory failure from weakness of diaphragm
35
Q

What can hypomagnesaemia predispose to?

A

Torsades de pointes

36
Q

What are the clinical consequences of hypophosphataemia in refeeding syndrome?

A

1) Cardiac dysfunction

2) Respiratory failure

3) Neurological complications e.g. confusion, seizures, coma

4) Haematological effects e.g. tissue hypoxia, haemolysis

5) Rhabdomyolysis

37
Q

How can hypophosphataemia affect the heart?

A

Can impair myocardial contractility, leading to heart failure.

It may also cause arrhythmias.

38
Q

How can hypophosphataemia lead to respiratory failure?

A

Phosphate is essential for ATP production, necessary for respiratory muscle function.

Severe hypophosphatemia can lead to muscle weakness, including the diaphragm and intercostal muscles, potentially resulting in acute respiratory failure.

39
Q

How can hypophosphataemia lead to hypoxia?

A

Reduced 2,3-diphosphoglycerate levels in erythrocytes affect oxygen release from haemoglobin, leading to tissue hypoxia.

40
Q

How can hypophosphataemia lead to rhabdomyolysis?

A

Phosphate depletion impairs ATP production in muscles, which can lead to muscle breakdown and rhabdomyolysis.

41
Q

When are patients considered at risk of refeeding syndrome? (4)

A

If one or more of the following are present:

  • BMI <16
  • Unintentional weight loss >15% over 3-6 months
  • Little nutritional intake > 10 days
  • Hypokalaemia, hypophosphataemia or hypomagnesaemia prior to feeding (unless high)

OR if two or more of the following are present:

  • BMI < 18.5 kg/m2
  • Unintentional weight loss > 10% over 3-6 months
  • Little nutritional intake > 5 days
  • History of: alcohol abuse, drug therapy including insulin, chemotherapy, diuretics and antacids
42
Q

NICE recommend that if a patient hasn’t eaten for > 5 days, what should your refeeding aim be?

A

Aim to re-feed at no more than 50% of requirements for the first 2 days.

43
Q

How is risk of refeeding syndrome reduced?

A

1) Slowly reintroducing food with restricted calories

2) Magnesium, potassium, phosphate and glucose monitoring along with other routine bloods

3) Fluid balance monitoring

4) ECG monitoring may be required in severe cases

5) Supplementation with electrolytes and vitamins, particularly B vitamins and thiamine

44
Q

What are 2 tools that can be used to assess the degree of depression?

A

1) Hospital Anxiety and Depression (HAD) scale

2) Patient Health Questionnaire (PHQ-9).

45
Q

Give the breakdown of the scores for PHQ-9

A

0-4: none

5-9: mild

10-14: moderate

15-19: moderately severe

20-27: severe

46
Q

What is the DSM-5 criteria for major depressive disorder? (9)

A

5 (or more) of the following symptoms have been present during the same 2-week period, at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1) Depressed mood most of the day, nearly every day

2) Anhedonia

3) Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day

4) Insomnia or hypersomnia

5) Psychomotor agitation or retardation (observable by others)

6) Fatigue or loss of energy

7) Feelings of worthlessness or excessive or inappropriate guilt

8) Diminished ability to think or concentrate, or indecisiveness

9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

47
Q

What is a key differential for depression?

A

Dementia

48
Q

what are some factors suggesting the diagnosis of depression over dementia?

A
  • short history, rapid onset
  • biological symptoms e.g. weight loss, sleep disturbance
  • patient worried about poor memory
  • reluctant to take tests, disappointed with results
  • mini-mental test score: variable
  • global memory loss (dementia characteristically causes recent memory loss)
49
Q

1st line management of moderate to severe ddepression in children & adolescents?

A

Referral to CAMHS

1st line –> psychological therapy e.g. CBT, non-directive supportive therapy, interpersonal therapy and family therapy

50
Q

What is the 1st line antidepressant in children?

A

Fluoxetine, starting at 10mg and increasing to a maximum of 20mg

51
Q

Wht are the 2nd line antidepressants in children? (2)

A

1) Sertraline
2) Citalopram

52
Q

What questionnaire can help establish the severity of the diagnosis?

A

GAD-7

53
Q

What is defined as the central feature of anxiety?

A

Excessive worry about a number of different events associated with heightened tension

54
Q

Clinical features of anxiety?

A
  • Excessive and persistent worry about various events or activities, occurring more days than not for at least 6 months
  • Difficulty controlling the worry
  • Restlessness or feeling keyed up or on edge
  • Fatigue
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
  • The anxiety and worry are associated with significant distress or impairment in social, occupational, or other important areas of functioning
55
Q

What 3 conditions is it important to rule out in GAD?

A

1) Hyperthyroidism

2) Cardiac disease

3) Medication-induced anxiety e.g. salbutamol, theophylline, corticosteroids, antidepressants & caffeine

56
Q

What is conduct disorder?

A

A recurrent or persistent pattern of behaviour that violates the rights of others or violates major age-appropriate societal norms or rules.

57
Q

What are some risk factors for conduct disorder?

A

Parents of adolescents with conduct disorder often have engaged in substance use and antisocial behaviors and frequently have been diagnosed with ADHD, mood disorders, schizophrenia, or antisocial personality disorder.

THC has been reported to be a risk factor for physical violence.

However, conduct disorder can occur in children from high-functioning, healthy families.

58
Q

Clinical features of conduct disorder?

A
  • Children lack sensitivity to the feelings and well-being of others
  • May misperceive the behavior of others as threatening
  • May act aggressively e.g. bullying, weapon use, physical cruelty, forcing someone into sexual activity, cruelty to animals
  • Lying & stealing
  • Commonly reckless, violating rules and parental prohibitions (eg, by running away from home, being frequently truant from school).
59
Q

Diagnostic criteria for conduct disorder?

A

≥ 3 of the following behaviors in the previous 12 months plus at least 1 in the previous 6 months:

1) Aggression toward people and animals

2) Destruction of property

3) Deceitfulness, lying, or stealing

4) Serious violations of parental rules

60
Q

Prognosis of conduct disorder?

A

Usually, disruptive behaviors stop during early adulthood, but in about one third of cases, they persist.

Many of these cases meet the criteria for antisocial personality disorder.

Early onset is associated with a poorer prognosis.

61
Q

What disorder in adulthood is conduct disorder associated with?

A

Antisocial personality disorder

62
Q

What does substance dependence require?

A

At least two of the following:

1) Impaired control over substance use

2) Increasing priority over other aspects of life or responsibility

3) Psychological features suggestive of tolerance and withdrawal

63
Q

What is a common screening tool that looks at the risk of dependency of alcohol misuse?

A

AUDIT-C questionnaire

64
Q

What is 1st line for alcohol detox?

A

Benzodiazepines e.g. chlordiazepoxide

65
Q

What benzo is indicated for alcohol withdrawal in patients with hepatic failure?

A

Lorazepam

66
Q

Name some medications used in alcohol detox

A

1) Chlordiazepoxide (or lorazepam)

2) Naltrexone

3) Acamprosate

4) Disulfiram

5) Carbamazepine

67
Q

What is the role of naltrexone in alcohol detox?

A

It is an opiate blocker that makes alcohol less enjoyable and less rewarding.

68
Q

Common side effects of naltrexone?

A
  • N&V
  • Decreased appetite
  • Pain at injection site
  • Increased liver enzymes
69
Q

What are the 2 contraindications of naltrexone?

A

1) Opiate use

2) Liver failure

70
Q

What is the role of acamprosate in alcohol detox?

A

‘Anti-craving’

Increases GABA and decreases glutamate (this reduces cravings).

71
Q

Role of disulfram in alcohol detox?

A

‘Deterrant’

Inhibits acetaldehyde dehydrogenase which causes the accumulation of acetaldehyde with alcohol.

It causes unpleasant symptoms such as flushing, sweating, headache, nausea and vomiting, arrhythmias, and hypotensive collapse.

72
Q

How long should patients avoid alcohol for before taking disulfiram?

A

24 hours

73
Q

How long should patients avoid alcohol for after cessation of disulfiram?

A

1 week

74
Q

Contraindications of disulfiram? (3)

A

1) Heart disease
2) Psychosis
3) Those felt to be at high risk of suicide

75
Q

Features of opioid withdrawal?

A

Rhinorrhoea, lacrimation, diarrhoea, pupillary dilation, piloerection, tachycardia, and hypertension.

76
Q
A

Yr 4 - Paediatrics (78 decks)

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