Perinatal and Childhood Psychiatry Flashcards
Clinical features of postnatal depression
-Develops within 3 months of delivery (peak onset at 3-4 weeks)
-Low mood, loss of interest / pleasure, fatigability, suicidal ideation
-Sleeping difficulties, weight loss, decreased libido can be normal postpartum
-Anxious preoccupation with baby’s health, feelings of guilt and inadequacy
-Reduced affection for baby, possible impaired bonding
-Obsessional phenomena (recurrent, distressing thoughts about harming baby)
-Infanticidal thoughts (thoughts of killing the baby that are not experienced as distressing) require urgent psychiatric assessment
Epidemiology and aetiology of post natal depression
-Most common complication of childbirth in high-income countries
-Psychosocial factors
=lack of close relationship
=intimate partner violence
=low income
=young maternal age
-Previous history of depression
-Obstetric complications in women with history of depression
-Biological factors
-Birth trauma, FH BPAD, poor family support, previous PND or depression
Differential diagnosis of postnatal depression
-Postnatal ‘blues’ a.k.a. ‘maternity blues’ or ‘baby blues’
-Presents within 10 days post-delivery (peak days 3-5), resolves within 2 weeks
-Episodes of tearfulness, mild depression, emotional lability, anxiety, irritability
-Up to 50% of postpartum women
-Biological cause (e.g. sudden fall in progesterone)
-Resolves spontaneously and usually only requires reassurance
-Suspect depression if symptoms ≥ 2 weeks
Management of postnatal depression
-Primary care (diagnosis and management)
-Edinburgh Postnatal Depression Scale
-Psychosocial and social measures
=Mother-and-baby groups, relationship counselling, problem solving
=Midwives and health visitors
-Mild: facilitated self-help
-More severe: high-intensity CBT and antidepressants (risk vs benefit)
-Severe with suicidal or infanticidal ideation:
=Admit with baby to mother-and-baby unit in hospital
=ECT may be indicated
-Assessment should include infant’s well-being
Prognosis of postnatal depression
-Most women respond to standard treatment
-Most episodes solve within 3-6 months, some take longer
-Disturbances in mother-infant relationship
-Child’s cognitive and emotional development
-40% increased risk for similar illness following childbirth in future
Prescribing in pregnancy
-Use the drug with the lowest known risk to mother and foetus
-Use the lowest effective dose
-Use a single drug rather than multiple drugs if possible
-Risk of stopping medication when pregnant often outweighs risk of continuing
-BUMPS, LactMed
Clinical features of postpartum (puerperal) psychosis
-Abrupt onset with rapid deterioration
-~50% begin on postnatal days 1-3, vast majority within 2 weeks
-Begin with insomnia, restlessness, perplexity
-Progress to suspiciousness, marked psychotic symptoms (often with content related to baby)
-Symptoms can be polymorphic and frequently fluctuate dramatically
-Prominent mood symptoms: elation, depression or mixed
-Often retain some insight
-May not disclose bizarre delusions or suicidal/homicidal thoughts
-Thought disorder, abnormal perceptions in all sensory modalities, restlessness, insomnia, elevated or labile mood, irritability, thoughts of harming self or baby
Epidemiology and aetiology of postpartum puerperal psychosis
-1/500 childbirths
-Risk factors
=Primiparous women
=Personal or family history of bipolar disorder or postpartum psychosis
=Delivery associated with caesarean section or perinatal death, prolonged labour, instrumental delivery, infection, sleep deprivation, birth trauma
=Diagnosis of bipolar/schizoaffective disorder (25%)
-Psychosocial factors less important (unlike postnatal depression)
-May be precipitated by obstetric complication (e.g. preeclampsia, puerperal infection) or medication. Delirium is an important differential
Risks of postpartum puerperal psychosis
-No mental illness, mother/sister had PPP: 3%
-BP1/ schizoaffective, 1st pregnancy: 20%
-BP1/schizoaffective, 2nd pregnancy: 10%
-Previous PPP: 50%
Postpartum puerperal psychosis management
-Psychiatric emergency
-Hospitalisation in all cases, joint admission to mother-and-baby unit preferred
-Risk assessment
=Thoughts of self-harm or harming the baby
=Severe depressive delusions (e.g. belief that baby is/should be dead)
=Command hallucinations instructing mother to harm herself or baby
-Detention under mental health legislation may be necessary
-Antipsychotics, antidepressants, mood-stabilisers depending on presentation
-Benzodiazepines for severe behavioural disturbance
-ECT effective in severe or treatment-resistant cases
-Psychosocial interventions, may include support for partner
-Social Work referral
Prognosis of PPP
-Most recover by 3 months (75% within 6 weeks)
-50% risk of recurrence after future childbirths, can be reduced with prophylactic therapy
-1/6 with 1st episode of mood disorder following delivery will develop bipolar disorder
-Women who had both puerperal and nonpuerperal mood disorders have up to 85% chance of puerperal psychotic episodes
Examples of Child and Adolescent Mental Health Services
-Tier 1: Universal services GPs, social workers, health visitors, school nurses, teachers, youth justice workers, voluntary agencies
-Tier 2: Mental Health Practitioners CAMHS trained (paediatric nurses, mental health nurses, OT, SW).Manage mild conditions.
-Tier 3: Specialist CAMHSMDT. Manage more complex/severe disorders
-Tier 4 Highly specialist CAMHS Intensive support (e.g. inpatient unit, day programmes, sexual trauma team)
Epidemiology of childhood mental health
10% young people
-Intellectual disability infancy/preschool: 3%
-ASD (pre/primary): 1%
-ADHD (pre/primary): 5%
-Anxiety disorders (primary+): 5%
-Conduct disorder (primary+): 8%M, 4% F
-Oppositional defiant disorder (adol): 4%
-Eating disorders (adol): 1%
-Depression (adol): 4%
-BPAD, schizophrenia, PD (late adol): rare
Child vs adult attachment styles and behaviours
-Child secure (2/3rd): responsive, understanding, consistent caregiver= happy curious child
-Adult autonomous= able to self-soother, but also able to maintain relationships
INSECURE (1/3rd)
-Avoidant (21%)
=Caregiver: aloof, unresponsive, ridiculing= emotionally distant and withdrawn child
=Dismissive adult: desire to be independent, avoidance of intimacy
-Ambivalent/resistant (16%)
=Caregiver: at times sensitive, at times ignore= anxious, uncertain, angry child
=Preoccupied adult: hypersensitive to rejection, care-seeking
-Disorganised (rare)
=Caregiver: abusive, scary, scared= sad, angry, fearful child
=Disorganised adult: fearful, abusive, dissociative
Overview of childhood anxiety disorders
-Exaggeration of normal development trends
-Good prognosis, rarely persist into adulthood
-Psychological therapy (e.g. behavioural and family therapy) is first-line
Types of childhood anxiety disorders
-Separation anxiety disorder
=Anxiety about separation from attachment figures persisting beyond usual age period or excessive anxiety (normal in 6 months – 2yo)
-Phobic anxiety disorder
=Phobic object is age inappropriate or creates excessive anxiety(e.g. 9yo afraid of monsters under bed)
-Obsessive-compulsive disorder
=Very intense/frequent ritual or habit impairing ability to function or causing distress
-Social anxiety disorder
=Persistent and recurrent fear and/or avoidance of strangers persisting beyond usual age period (normal in 8 months – 1yo), common in children with neurodevelopmental disorders e.g. autism and ADHD
Types of disorders of social behaviour
-Conduct disorder
=repetitive and persistent pattern of aggression to people and animals, destruction of property,
deceitfulness/ theft and major violations of age-appropriate societal expectations /rules
=87% young offenders, 2 male: 1 female
=Aetiology: genetics, parental psychopathology, child abuse/neglect, poor socioeconomic status, poor educational attainment
=Psychosocial management: Parental skills training programme. Cognitive-behavioural problem solving programmes. Multimodal interventions e.g. multisystem therapy. Social work
-Oppositional defiant disorder
=Persistent pattern of negative, defiant, hostile and disruptive behaviour but does NOT violate the law or basic rights of others e.g. theft, cruelty, bullying, assault
=Management same as conduct disorder
-Reactive attachment disorder
=< 5 yo who have been severely neglected and unable to form a secure form a secure attachment to primary caregiver
=Fearfulness and hypervigilance, withdrawal (or indiscriminately warm/disinhibited)
-Elective mutism (selective mutism)
=Selective in vocal communications depending on social circumstances
=Language comprehension and ability usually intact
=Usually < 5yo girls, associated with stress, social anxiety, oppositional behaviour
Disorders arising in adolescence
Psychological therapy is first-line
-Eating disorders: family-based therapy
-Depression
=If mild: watchful waiting
=If moderate/severe: Individual CBT, IPT, family therapy or psychotherapy +/- fluoxetine(SSRI: low dose + weekly monitoring for suicide ideation in 1st month or after dose ↑ )
-Bipolar affective disorder and schizophrenia
=Uncommon to be fully symptomatic or diagnosed in late adolescence
=Psychological or family intervention (except pharmacological in acute mania or psychosis)
-Personality disorder
=Personality traits are emerging in adolescence but are more malleable
=Only give diagnosis if helpful for understanding/ treatment
Overview of child abuse
-Physical, sexual, emotional mistreatment or neglect or deprivation
-Features: physical manifestation, failure to thrive, mental health problems
-1 in 4 adults report severe abuse as child, 1 in 20 children sexually abused
-Risk factors:
=Parent: abused, substance abuse, mental illness, step-parent, young, immaturity, criminality, low socioeconomic status, overcrowding
=Child: low birth weight/prematurity, early maternal separation, unwanted child, intellectual or physical disability, challenging behaviour, excessive crying
-If suspected
=Refer child protection guidelines
=Tell senior. Involve police, social workers, duty paediatrician as per protocol
=Keep comprehensive notes
CAMHS Assessment
-History
=Collateral from parents or carers
=Psychiatric, neurodevelopmental, education, medical
=Educational/psychological reports and teachers
-Examination
=observe in play situations for younger children
-Instruments
=Structured or semi-structured interviews e.g. Kiddie Schedule for Affective Disorders and Schizophrenia
=Objective assessment instruments e.g. Autism Diagnostic Observation Schedule
=Parent/teacher/self-rating scales e.g. strength and difficulties questionnaire
Epidemiological differences
-W
=Higher lifetime prevalence of anxiety, depression suicide attempts
=Later age onset of schizophrenia and slightly lower incidence than men
-M
=Higher lifetime prevalence of conduct disorder, ADHD (changing?)
=Higher rates of death by suicide
Why is there epidemiological differences?
-Sex
=Reproductive hormones
=Adrenal axis response to stress
=Genetics
-Gender
=Forms of gender-based violence
=Illness behaviour (men less likely to admit mental illness)
=Societal role
Premenstrual Dysphoric disorder
-Associated with significant impairment of function
-Onset following ovulation, resolution with menstruation
-Gynaecological condition presenting with psychiatric symptoms
=Increased mood lability, irritability, low mood, anxiety
=Increased suicidal ideations, suicide attempts, risk
=Poor concentration, forgetfulness
-Joint pain, lethargy, hypersomnia overeating, breast tenderness, swelling of extremities
=Affects 5.5% women of reproductive age, heritable, not the same as PMS
=SSRIs= continuous or during luteal phase
=COCP
=GnRH analogues (induce temporary menopause)
=Hysterectomy with bilateral salpingo-oophorectomy
