Psychiatry

Question 1

What is fabricated or induced illness?

Answer 1

Broad term used to describe a group of behaviours by parents (or carers), but usually the mother (>80%), which cause harm to the children. It fulfils the parents (or carers) own needs.

Question 2

What is verbal fabrication?

Answer 2

Parents fabricate symptoms and sings in the child, telling a false story to healthcare professionals, leading them to believe the child is ill and requires investigation and treatment

Question 3

What might induction of the fabricated illness include?

Answer 3

Suffocation of the child, which may present as an acute life-threatening event
Administration of noxious substances or poisons
Excessive or unnecessary administration of ordinary substances (e.g. excess salt)
Excess or unnecessary use of medication (prescribed for the child or others)
Use of medically provided portals of entry (such as gastrostomy buttons, central
lines)
Organic illness may coexist with fabricated or induced illness, thus making the fabrication more difficult to identify

Question 4

What are the features of anorexia nervosa?

Answer 4

Self-induced weight loss resulting in a low BMI (<17.5) or 15% below normal
Distorted perception of own body, which increases with weight loss
Determined attempt to lose weight or avoid weight gain by either restricting good
intake, self-induced vomiting, laxative abuse, excessive exercising or combination
of these
Halted pubertal development and return to prepubertal state
Sense of control of shape and development to increase self-worth and self-effectiveness
Dreams of food and cooking
Wanting to unite parents (i.e divorce imminent)

Question 5

What is seen on examination in anorexia nervosa?

Answer 5

Slow-to-relax tendon reflexes
Reduced peripheral circulation
Bradycardia
Amenorrhea
Lanugo hair (meszek) over trunk and limbs
Low serum T3
Low plasma proteins, giving rise to ankle oedema

Question 6

What is the management for anorexia nervosa?

Answer 6

First step is to restore near-normal body weight by refeeding. This is usually done in hospital settings and may involve NG feeding
Individual psychological treatment and family therapy
CBT- 20-24 sessions (self control, perfectionism)
IPT ( social functioning and interpersonal skills)
Psychodynamic psychotherapy

Question 7

What is seen on examination in bulimia?

Answer 7

Wide fluctuations in weight and metabolic abnormalities such as hypokalaemia and alkalosis
Russell’s sign- calluses on the back of hands when hand has been used to induce vomiting
Manage with TCAs, SSRI (fluoxetine)

Question 8

What are the features of school refusal due to anxiety?

Answer 8

Complaints of nausea, headache, hyperventilation or otherwise being unwell, which are confined to weekday, term-time mornings and clearing by midday. It may be rational (e.g. when child is being bullied or there is education underachievement) or disproportionate to stresses at school

Question 9

What are the common causes of school refusal?

Answer 9

Separation anxiety persisting beyond toddler years- typical in children under 11 and more common following a major life event (such as death of a relative or moving houses)
Anxiety provoked by some aspects of schools- true school phobia

Question 10

What is truancy?

Answer 10

Child leaves to go to school but never arrives or leaves early. It is often accompanied by other behavioural difficulties

Question 11

How do you analyse tantrums using the ABC paradigm?

Answer 11

Antecedents- what happened in the minutes before the episode Behaviour- exactly what did the episode consist of
Consequences- what happened as a result, including what you did and outcome

Question 12

What can be the causes of temper tantrums?

Answer 12

Global or language delay
Hearing impairment
Medication with bronchodilators or anticonvulsants

Question 13

How are temper tantrums managed?

Answer 13

1.Affection and attention before the tantrum
2. Distraction
3. Avoiding antecedents
4. Ignoring: no surrender as when parents give in, tantrums become harder to deal
with
5. Time out from positive reinforcement: walk away and come back when the child
quietens down and separate them from siblings
6. Holding firmly if the child is putting themselves or others in danger
7. Star chart to prevent future episodes and reward child for complying with parental
requests. Stars shouldn’t be taken away for bad behaviour

Question 14

What are the features of depression in children?

Answer 14

Apathy, boredom and an inability to enjoy oneself rather than depressed mood
Separation anxiety which reappears, having resolved in earlier life
Decline in school performance
Social withdrawal
Hypochondriacal ideas and complaints of pain in chest, abdomen and head
Irritable mood or frankly antisocial behaviour

Question 15

What is chronic fatigue syndrome?

Answer 15

Persisting high levels of subjective fatigue, leading to rapid exhaustion on minimal physical or mental exertion. Also known as myalgic encephalomyelitis (ME)
Sometimes recent coxsaxkie B, EBV, hepatitis

Question 16

What are the features of chronic fatigue syndrome?

Answer 16

Myalgia
Migratory arthralgia
Headache
Difficulty getting off to sleep
Poor concentration
Irritability
Stomach pains
Scalp tenderness
Eye pain and photophobia
Tender cervical lymphadenopathy 
Depressive symptoms

Question 17

What is the management for chronic fatigue syndrome?

Answer 17

Majority of cases remit spontaneously with time, but this can take months or sometimes years.
Recommended treatment involves graded exercise therapy with potential use of CBT. This requires involvement of physiotherapist to achieve gradual increase in exercise tolerance

Question 18

What are the features of night terrors?

Answer 18

Occur about 1.5 hours after settling to sleep
Parents find the child sitting up in bed, eyes open, seemingly awake but obviously disorientated, confused and distressed and unresponsive to their questions and reassurances.
The child settles back to sleep after a few minutes and has no recollection of the episode in the morning.
May co-exist with sleepwalking due to same underlying pathology

Question 19

What re the prognoses for eating disorders?

Answer 19

Anorexia: up to 50% of patients recover and return to a normal weight, 25% of patients go on to develop normal weight bulimia. a third of all patients fail to recover and the mortality is over 10% (half due to complications, third due to suicide)
Bulimia: 50-70% if patients making a recovery after 2-5 years, no increase in mortality