Psychology diagnosis+management Flashcards
Depression and risk factors
Characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical and behavioural symptoms
Multifactorial: biological, psychological and social factor
No definitive cause
Dysthymia or dythymic disorder is a chronic form of long term depression
Risk factors: Chronic conditions (Diabetes, COPD, CVD) Female Older age Medicines Psychological issues (divorce, unemployment, poverty, homelessness etc) Personal history of depression Genetic and family history Adverse childhood experience Personality factors (neuroticism) Past head injury (including hypopituitarism following trauma)
Depression presenation
Low mood (feel down, depressed, hopeless)
Anhedonia (lack of interest or pleasure in their normal activities)
Disturbed sleep
Decreased or increased appetite
Fatigue and loss of energy
Agitation or slowing of movement
Poor concentration of indecisiveness
Feeling of worthlessness or excessive or inappropriate guilt
Suicidal thoughts or acts
Depression investigations/diagnosis
DSM-5 (diagnostic and statistical manual of mental disorders)
Presence of at least 5 out of 9 defining symptoms for at least 2 weeks or severe enough to impair social, occupational or other important areas of functioning. Classified as mild, mod or severe, determined by both number of symptoms, persistence, presence of other symptoms as well as degree of functional and social impairment
PHQ9 (patient health questionnaire 9) rates severity: 0-4 = none. 5-9 mild. 10-14 mod. Mod severe 20-27. 28+ severe.
Depression categories
Subthreshold: between 2-5 symptoms
Mild: >5 symptoms but only result in minor functional impairment
Mod: if symptoms or functional impairments between mild and severe
Severe: Most symptoms and markedly interferes with functioning. Can occur without psychotic symptoms
Dysthymia (persistent subthreshold depression): subthreshold symptoms for more days than not for at least 2 years which is not consequence of partially resolved major depression
Seasonal affective disorder: episodes of depression which recur annually at same time each year with remission in between (usually appearing in winter and remitting in spring)
Depression management (medications)
Medications:
Selective serotonin reuptake inhibitor (SSRI): sertraline (tends to have less side effects), citalopram, fluoxetine (start on any drug there is no first line, discuss what’s best for pt and start on low dose and work up)
Serotonin-norepinephrine reuptake inhibitors (SNRIs): venlafaxine, duloxetine
Tricyclic antidepressants TCA: amitriptyline
Monoamine oxidase inhibitors MAOIs: not used much
Consider medications for mod/severe depressions.
Consider drug interactions with other medications and patient preference (side effects disturb sleep etc)
Pt compliance is extremely important: must take OD for effectiveness, impress importance on pt
May feel worse in first week of taking
Can take 2-4 wks to feel benefit
Need to be taken daily ideally for at least 4 wks before dose change
Regularly review esp for suicidal pts
Side effects: usually settle after a few wks
Depression management (psychological interventions)
Cognitive behavioural therapy CBT
High intensity therapies: interpersonal therapy (IPT) or behavioural activation
Counseling and short term psychodynamic therapy
Electroconvulsive therapy (ECT)
CBT: help to change the way people think, feel and behave
Problem focused and practical
Can be delivered to individuals, couples, families or groups
ECT: reserved for severe depression if persons life at risk and need urgent treatment
OR mod-severe depression when no other treatment has helped
ECT involved passing electric current through the brain so is always given in hospital under general anaesthetic
Some people have temporary memory problems after ECT
Suicide risk: important to ask and clarify thoughts, plans, intent
Assess would pt need same day admission
If actively suicidal review medications that may worsen this (SSRIs and SNRIs are associated with increased risk of suicidal thinking and self harm particularly <30 years)
Abuse of alcohol or drugs also increases
Acute reaction to stress
Acute reaction following an unexpected life crisis; serious accident; sudden bereavement or other traumatic event
Symptoms develop and resolve quickly
Events triggering are usually very severe and acute stress reaction typically occurs after unexpected life crisis
Trigger can include: Assault, serious accident, sudden loss, traumatic events
Difference between this and depression would be large life factor trigger and acute duration of symptoms
Acute reaction to stress presentation
Acute onset
Psychological : anxiety, low mood, irritability, emotional ups and downs, poor sleep, poor concentration, want to be alone
Recurrent flash backs
Trigger avoidance
Reckless or aggressive
Flat affect (no emotion)
Physical symptoms: palpitation, nausea, chest pain, headaches, abdominal pains, dyspnoea
Acute reaction to stress management and complications
Watch and wait to see if resolve
CBT: help improve functioning during episode
Counselling
Medications: beta blockers (propranolol), benzodiazepines (diazepam) use very very sparingly: very addictive and easily develop tolerance for them
Complications:
Symptoms persisting several wks (consider PTSD)
St johns wart
Herbal remedy OTC medication pts can try as alternative medications
Used to treat mild/mod depression, SAD, mild anxiety and sleep problems
Non-standardised dose so not recommended as different brands/areas will have different doses and elicit different response
Multiple drug interaction must warn pt to let you know if they are taking so can check with current medications
Uncomplicated bereavement and presentation
More common in ‘expected’ death e.g. chronic conditions or elderly
Loss of family members, pets
Presentation:
Shock/numb
Loneliness, sadness, crying
Tired, exhausted
Sleep disturbance
Anger
Guilt about things unsaid, being unable to help
Symptoms fluctuate and vary day to day (may not be there at all some days)
Symptoms tend to come over in waves and fluctuate
Stages of bereavement
Acceptance
Embracing pain of grief
Adjusting to life without deceased
Channelling energy away from grieving into something new
*These are not fixed stages and vary in duration for all individuals
Uncomplicated bereavement management
CBT/counselling - cruse bereavement care
Medication: sedatives (sleep)/benzodiazepines (short term and CI in previous dependency), antidepressants
Exercise
Sleep hygiene: no blue light 1 hr before bed, routine, dark room
Mindfulness apps
Monitor for persistent or developing symptoms (depression)
Bipolar disorder
AKA bipolar affective disorder or manic depressive disorder
Long term illness characterised usually by manic and depressive episodes
Known as a heritable mental disorder (those with 1st degree relative affected 5 x more likely to also experience)
Characterised by episodic depressed and elated moods and increased activity (hypomania and mania)
Cause:
Thought to have genetic link as well as environmental triggers or influences
Environmental stressors: maternal death before <5 years, childhood trauma, childhood abuse, emotional neglect or abuse
Toxoplasma gondii exposure
Drug abuse
Manic/hypomanic episode (bipolar) diagnosis
Period of abnormally and persistently elevated or irritable mood lasting at least 1 wk accompanied by at least 3 additional symptoms resulting in: marked simpaired social or occupational function or necessitate hospitalisation OR psychotic features (delusions or hallucinations)
Usually lasts around 1 wk
Hypomanic episodes are similar to manic episode except that diagnosis only needs symptoms lasting >4 days and symptoms are not severe enough to cause marked impairment in social or occupational functioning or necessitate hospitalisation and there are no psychotic features
Mania (bipolar) presentation
Abnormally elevated mood, extreme irritability, sometimes aggression
Increased energy or activity, restlessness and decreased need for sleep
Pressure of speech or incomprehensible
Flight of ideas and racing thoughts
Distractibility, poor concentration
Increased libido, disinhibition and sexual indiscretions
Extravagant or impractical plans (financial)
Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices)
Symptoms usually begin abruptly and need to be present for at least 7 days
Hypomania (bipolar) presentation
Symptoms of mania no severe enough to cause marked impairment in social/occupational functioning and absence of psychotic features
May have mild mood elevation or irritability
Increased energy and activity which may lead to increased performance socially or at work
Feeling of well-being or physical and mental efficiency
Increased sociability, talkativeness and over familiarity
Diagnosis requires at least 4 days persistence of symptoms
Depressive period of bipolar diagnosis and presentation
Usually around 2 wks
Depressed mood or loss of interest in nearly all activities (or irritability in children and adolescents) with at least 4 additional symptoms
Depressive presentation:
Feelings of persistent sadness or low mood
Loss of interest or pleasure
Low energy
Poor concentration
History is important:
‘Do you currently (or have you in the past) experienced a mood that is higher than normal, or do you feel much more irritable than usual, and have others noticed?’
‘At the same time, do you have increased energy levels so that you are much more active or do not need as much sleep?’
Mixed episode (bipolar)
Rapidly flips between manic and depressive episodes
OR period of time (1> wk) criteria met for either manic or hypomanic episode and at least 3 symptoms of depression present during majority of days)
OR period of time (2> wk) in which criteria for major depressive episode met and at least 3 manic or hypomanic symptoms are present during majority of days of current or most recent episode of depression
Possibly shows psychotic symptoms also
Rapid cycling bipolar disorder is defined as experience of at least four depressive, manic, hypomanic or mixed episodes within 12 month period
Bipolar disorder investigations and classifications
Investigation:
DSM-5
Classification:
Bipolar I: at least one manic episode with/without history of major depressive episodes
Bipolar II: one or more major depressive episodes and by at least one hypomanic episode but no evidence of mania
Bipolar management
primary care:
Referral to mental health team to confirm diagnosis
Refer urgently for mental health assessment if severe mania, severe depression or danger to themselves or others
Assess safeguarding of pt and any defendants - vulnerable to exploitation or violence
Review medications - antidepressants can worsen mania episodes
Secondary care:
1st line oral antipsychotic: haloperidol, olanzapine, quetiapine or risperidone
2nd line: lithium or sodium valproate (caution women at childbearing age) risk of foetal malformations and adverse neurodevelopmental outcomes after any exposure during pregnancy.
During depressive episode: quetiapine alone (mood stabiliser) or fluoxetine with olanzapine or olanzapine alone or lamotrigine alone
Constantly have to take these medications. Review all regularly (unlikely to change doses; more for psychiatrists)
Generalized anxiety disorder
Disproportionate, pervasive, uncontrollable and widespread worry and range of somatic, cognitive and behavioural symptoms that occur on continuum of severity
Is one of a range of anxiety disorders which includes acute stress disorder, OCD, panic disorder, PTSD, social phobia and specific phobias
Most common in those aged 35-55 years
More common in women (rate is 1.5-2.5 x more likely)
Cause:
Multifactorial with both genetic and environmental factors
More common in women
Generalised anxiety disorder risk factors
Females
Family History of psychiatric disorders
Childhood adversity such as maltreatment, parental problems (alcohol, drugs, violence), bullying, exposure to overprotective or overly harsh parenting
Bullying or peer victimisation
Environmental stressors: physical or emotional trauma, domestic violence, unemployment, low socioeconomic status
Substance dependence or exposure to organic solvents (exacerbators)
Chronic and/or painful illness
Generalised anxiety disorder presentation
Irritable Trouble relaxing Nausea Chest tightness Tachycardia SOB/dyspnoea Trembling Exaggerated startle response
Generalised anxiety disorder diagnosis/investigations
DSM-5 criteria:
At least 6 months of excessive, difficult to control worry about everyday issues that is disproportionate to any inherent risk and causes distress or impairment
Worry is not confined to features of another mental disorder or as result of substance abuse, general medical condition
Person experiences at least 3 of following symptoms most of the time: restlessness, nervousness, easy fatigue, poor concentration, irritability, muscle tension, sleep disturbance
ICD-10 criteria:
anxiety generalised and persistent but not restricted to or even strongly predominating in any particular environmental circumstances
Variable symptoms include: nervousness, trembling, muscle tension, sweating, light headed, palpitations, dizziness and epigastric discomfort
Expression of fears such as that the person or relative will shortly become ill or have an accident
GAD-7 questionnaire:
Allow assessment to see if you do have anxiety and how severe (5-9 mild; 10-14 mod, 15+ severe)
Questions ask how the person has felt over the last 2 wks
Generalised anxiety disorder management
Mild: CBT low intensity (self guided or group etc)
Moderate: CBT high intensity and medications: SSRI, SNRI, pregabalin can be offered is other meds are CI or not tolerated
Severe: refer for specialist treatment (complex drug and/or psychological interventions).
Regular exercise and sleep hygiene can really improve symptoms
Psychosis and risk factors
Alteration in persons mood, behavior
Precise cause unknown but multifactorial from social, environmental and genetic factors
May be preceded by prodromal period can last from few days to 18 months, followed by acute psychotic episode often including hallucinations, delusions and behavioural disturbances often with agitation and distress
Risk factors:
+ve family history (particularly first degree relative with psychosis or schizophrenia)
Recent or past stressful or traumatic experiences
Psychosis prodromal period
Characterised by emotional and behavioural changes leading to deterioration in personal functioning and social withdrawal leading to deterioration in personal function and social withdrawal
Transient low intensity psychotic symptoms <1wk (hallucinations, perceptual experiences, unusual thoughts, paranoia)
Reduced interest in daily activities
Problems with mood, sleep, memory, concentration, communication, affect and motivation
Anxiety, irritability or depressive features
Incoherent speech suggestive of thought disturbance
Psychosis presentation (positive symptoms)
Seeing/hearing things that aren’t there
Hallucinations: perceptions in absence of stimulus, auditory are most common, voices heard may be running commentary on actions, argue with self, commanding, or echoing thought. Visual hallucinations, smell, taste or tactile occur less commonly
Delusions: fixed or falsely held beliefs. Delusion of reference (belief that ordinary events, objects or behaviour of others has a meaning specifically for them), delusions of control (belief that thought, feelings, behaviour are controlled by others. May include thought insertion, thought withdrawal and thought broadcasting). Delusions of persecution (belief that others are plotting against them)
Disorganised behaviour, speech, thoughts (thought disturbance)
Psychosis presentation (negative symptoms)
Emotional blunting/affective flattening (lack of spontaneity or reactivity of mood) Reduced/ impoverishment speech Avolition (loss of motivation) Self-neglect Social withdrawal Anhedonia (lack of pleasure) Attention deficit
Psychosis investigations
Suspect frank psychosis in person with +ve symptoms and -Ve symptoms. Positive symptoms may not be readily disclosed by the person so must ask directly
Medication review: anticonvulsants, high dose steroids, levodopa and dopamine agonists or opioids may cause
Urine drug screen: recreational drugs
HIV and/or syphilis screening as both infections can cause psychosis symptoms
FBC for anaemia as potential cause of negative symptoms
Psychosis prognosis
With intervention many symptoms will regress or resolve however some negative symptoms may remain and psychotic episodes may recur
Factors associated with poor prognosis: longer duration of untreated psychosis, early or insidious onset of schizophrenia, Male sex, negative symptoms, family history of schizophrenia, low IQ, low socioeconomic status or social isolation, significant psychiatric history, continued substance misuse
*best to know where to signpost pts: hospital admission, psychiatry referral etc.
Psychotic disorders
Schizoaffective disorder — where symptoms of schizophrenia and a mood disorder (depressed or manic) are equally prominent.
Drug-induced psychosis — substance-induced and usually remits within a month of cessation of use.
Persistent delusional disorder — where the most pervasive symptom is delusion.
Schizophrenia
Schizophrenia and risk factors
Most common psychotic disorder
Hereditary around 85% from twin studies
7.5 fold increased risk of disorder in people with parent with schizophrenia
Risk factors:
Stressful life events
Childhood adversity
Family heritage - south asian and black populations
Migration (esp from developing country)
Urban living
Cannabis use (40% increased risk)
Other substance use
Medications (high dose steroids)
Early life factors (in-utero meds, maternal stress, nutrition deficiency)
Parental age >40 years or <20 years
Exposure to protozoan parasite toxoplasma gondii (cat little and pork; pregnancy women advised to not handle cat litter)
Schizophrenia diagnosis
ICD-10 criteria: symptoms present most of time for at least 1 month with one or more of following features:
Hallucinatory voices
Thought echo, thought insertion or withdrawal and thought broadcasting
Delusions of control, influence, passivity, clearly referred to body or limb movements or specific thought, actions or sensations
Persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, superhuman powers and abilities or being in communication with aliens
Or any two of the following:
Persistent hallucinations in any form, when accompanied by fleeting or half-formed delusions without clear affective content, or by persistent overvalued ideas (similar to preoccupations), or when occurring every day for weeks or months on end.
Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms (invented words).
Catatonic behaviour, such as excitement, posturing, or waxy flexibility; negativism; mutism; and stupor.
Negative symptoms, such as marked apathy, reduced speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to antipsychotic medication.
A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
Schizophrenia management
CBT and family intervention with oral antipsychotics (1st or 2nd generation)
Arts therapies particularly to help -ve symptoms
Inform person they must not drive during acute episodes and must tell DVLA about their illness
Common anti psychotics
Haloperidol (1st gen) Prochlorperazine (1st gen) Aripiprazole (2nd gen) Clozapine (2nd gen) Olanzapine (2nd gen) Quetiapine (2nd gen) Risperidone (2nd gen)
Anti-psychotic guidance
There is no first-line antipsychotic drug suitable for all people with psychosis, and (bar clozapine) little meaningful difference in efficacy.
• Clozapine is generally offered to people who do not respond adequately to two other antipsychotics and is always initiated and monitored in secondary care.
Response to antipsychotics is variable
Dosage and intervals are decided on case by case basis according to persons response
1st gen: thought to work by blocking dopamine 2 receptors in brain and can cause extrapyramidal symptoms (EPS) and wide range of other adverse effects
2nd gen: act on range of receptors and associated with fewer EPS than 1st gen. Associated with several other important adverse effects: weight gain, glucose intolerance, hyperprolactinaemia
Have significant effects on acetylcholine, histamine, noradrenaline and serotonin pathways! Never quickly remove drugs, always taper off!!
Choice depends on: Patient preference Medication history, Degree of sedation required, Risk of particular adverse effects Degree of negative symptoms (2nd-generation antipsychotics may be more beneficial).
Extrapyramial symptoms (EPS)
Caused by antipsychotics
Dystonic reactions (abnormal movement of face and body) and pseudoparkinsonism (tremor, bradycardia, rigidity) these can be alleviated by antimuscarinic drugs like procyclidine (not routinely prescribed)
Akathisia (motor restlessness): improved by reducing dosage
Tardive dyskinesia: rhythmic involuntary movements, usually lip-smacking, tongue rotating, although can affect limbs and trunk.
Late onset symptoms that can worsen on treatment withdrawal!
Antipsychotic monitoring
BMI at 6 wks then 3 months then every 12 months or more
U+Es/FBC/LFTs annually
Blood lipids/BG/HbA1c 3 months after starting then annually
Pulse and BP during dose titration and at each dose change (not for amisulpride, aripiprazole, trifluoperazine and sulpiride)
ECG: after dose change and ideally annually too (mandatory for haloperidol, pimozide, sertindole but not needed for antipsychotics with no/low to mod effect on QT interval with no other arrhythmia risk factors
Prolactin: 6 months after starting treatment then annually. Not needed for aripiprazole, clozapine, quetiapine or olanzapine (less than 20mg daily)
Creatine kinase if neuroleptic malignant syndrome is suspected - rare but potentially fatal
Schizophrenia complications
Premature death
Increased suicide risk
Increased risk of disorders including: CV disease, T2DM, smoking related illness, cancers, infections such as HIV, hep C and TB
Social exclusion
Compulsory admission/screening acts
If pt. Needs to be admitted to hospital it is better they are encouraged to go voluntarily
If admission is needed but person declines, compulsory admission may be arranged under sections 2, 3 or 4 of the mental health act
Mental health act 1983/2007 allows compulsory admission of those who:
Have mental disorder of nature or degree warranting assessment or treatment in hospital and
Needs to be admitted in interests of their own health and safety or for protection of others
Section 2: for 28 days for assessment. Needs application from approved mental health professional or persons nearest relative and recommendations from two Drs (one section 12 approved and one acquainted with pt)
Section 3: for up to 6 months for treatment. Needs application from approved mental health professional or persons nearest relative, recommendations from two Drs (one section 12 approved and one acquainted with pt)
Section 4: for up to 72 hrs in exceptional urgent cases where delay while trying to arrange admission under normal procedure
Section 136: may be used by police to take people from public place to place of safety where they can be assessed
Self-harm
Deliberate act undertaken by someone mimicking the act of suicide but not resulting in fatal outcome
Multicentre study on self harm shows 57% pts female,
66% <35 years
Largest numbers by age group are 15-19 years females and 20-24 years males
F:M ratio decreases with age
Approx. 80% self harm episodes involve self poisoning (paracetamol common, antidepressants, benzodiazepines and sedatives, alcohol)
Common presentation in hospital between 10pm and 2am
Two main methods:
Drug overdose
Self injury
Drug overdose and investigations
Medical emergency
Common causes: paracetamol, alcohol, salicylate (commonly aspirin), opioid overdose
Caustic agents: agents with potential to cause tissue destruction, alkaline substances cause liquefactive necrosis, resulting in deep tissue penetration
Investigations: Bloods: paracetamol, salicylate levels, blood glucose ABG U+Es LFTs and eGFR Urine sample Gastric aspirate or vomitus ABCDE assessment of pt status
Drug overdose management
ABCDE: Eyes (dilated pupils indicate tricyclics, cocaine, amphetamine; pinpoint pupils indicate opiates; nystagmus indicates alcohol, benzodiazepines, phenytoin) Breath (bitter almond smell of cyanide indicates alcohol or organic solvents) burns around mouth (corrosive substances like paraquat, glue) hyperventilation (salicylates) needle marks (recreational drug abuse)
Identify substance: if pt is unconscious, third party evidence of what has been taken. Time of ingestion, associated alcohol consumption, past and current medical history (esp if renal or liver disease), symptoms noticed since poisoning (vomiting may have removed some substance already, hematemesis caused by iron overdose, salicylates, alcohol)
Elimination: activated charcoal (decontamination) decreases absorption within 1 hr of digestion (preferred), antidote administration, gastric lavage (no longer recommended due to aspiration risk; only indicated in life threatening amount ingested within previous hr and poison cannot be removed via other methods. May be useful for drugs such as lithium and iron which aren’t charcoal absorbed), dialysis (peritoneal, haemodialysis), diuresis (alkaline, acid change urinary pH to increase substance excretion in urine) whole bowel irrigation (when substance would not be absorbed by activated charcoal)
Specific and general treatment of pt condition
Period of observation
Psychiatric assessment
Charcoal for drug treatment
Single-dose activated charcoal is the preferred method of decontamination in many cases.
Patients should have had a significant overdose, be co-operative, without impairment of consciousness and not thought to be likely to fit imminently.
Ideally it is used in a 10:1 ratio with the ingested drug - the usual dose is 50 g for an adult (children: 1 g/kg).
It may be repeated in one hour if necessary (oral, nasogastric tube). Its large surface area adsorbs many drugs but has its limitations.
It may not be be effective if given after the first hour or in cases of poisoning with iron, lithium, boric acid, cyanide, ethanol, ethylene glycol, methanol, malathion, DDT, carbamate, hydrocarbon or strong acids or alkalis.
Common antidotes for drug toxicity
Given for certain poisons which can either prevent poison working or reverse it’s effects
N-Acetylcysteine for paracetamol
Digoxin-specific antibody fragments for digoxin
Flumazenil injection for benzodiazepines. Reverses CNS and respiratory depression. However if person has also taken tricyclic antidepressant or has epilepsy must be cautions as can cause seizures or arrhythmias
Glucagon injection for insulin and beta-blockers
Naloxone injection for heroin, opiates. Administration of IV used for rapid diagnosis of opiate poisoning. Should show significant improvement in condition within 1-2 mins
Fomepizole for ethylene glycol or methanol
Deliberate self harm assessment and management
Is there an immediate suicide risk?
Is there subsequent risk of further deliberate self harm or suicide?
What are the current medical and social problems?
*Always refer for psychiatric assessment
management: referral to specialist after stabilisation and treatment as needed
Assessment to be done by specialist mental health professional:
Events preceding episode
Reasons
Assessment of possible suicide intent (plan/not)
Current personal difficulties and life issues
Whether they have a psychiatric disorder
Personality traits
Family history
Psychiatric history and history of self harm
Whether they have been exposed to self harm in others eg family or friends or through social media
Risk of further self harm and suicide
Persons social support and coping resources
Whether person is willing to accept help and what would benefit them the most
Child abuse and risk factors
Actions towards a child that violates social definitions of acceptable caretaking practice
Unacceptable in degree and/or in type ad represent an end point of actions towards children
Types: Physical Neglect Emotional Sexual
Risk factors:
Parental or carer drug or alcohol misuse
Parental/carer mental health problem
Intra-familial violence or history of violent offences
Previous child mistreatment in members of family
Known maltreatment of animals by parent/carers
Vulnerable and unsupported parents or carers
Pre-existing disability in child
Physical abuse/non-accidental injury presentation
Commonly find multiple soft tissue bruises and skin lesions
May involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to child
Mouth injuries: torn lips, gums, frenulum
Ear injuries/recurrent ear infections (although this is common in children normally)
Genitalia injury
Bilateral black eyes/black eyes or eye bruising
Intra Ocular or retinal haemorrhage
Recurrent UTI in infants <1 years
Buckle fracture
Multiple bruisings on difficult to injure sites
Skull fractures
Multiple bilateral posterior and lateral rib fractures
Psychological or emotional abuse
Commonly defined as injury to psychological capacity or emotional stability of child leading to changes in behavior or cognition
Signs include: behavioral extremes, delayed development or learning delays, suicide attempts, lack of parental attachment
Caregivers may poverty reject or blame children, view them as worthless or be unconcerned about the child’s wellbeing. Also will deny obvious problems
All forms of abuse place the individual at increased risk for life of alcoholism, smoking, PTSD, depression and drug use
Clinical approach to maltreatment
Listen and observe:
Any history given: social, educational, living arrangements
Reports of maltreatment or disclosure from child or young person or third person
Child’s appearance
Child’s behaviour
Symptoms of maltreatment
Physical signs
Results of investigation
Interaction between parent or carer and child/young person
Seek an explanation:
In non-judgemental manner form both parent or carer and child
Record:
Note in clinical record exactly what has been observed and heard from whom and when
Record why this is of concern
Consider, suspect or exclude maltreatment
Fabricated or induced illness
If there are discrepancies in child’s history, physical or psychological presentations or findings of assessments, examinations or investigations and one or more of the following is present
Reported symptoms and signs only appear or reappear when parent/carer is present
Reported symptoms only observed by parent/carer
Inexplicably poor response to medications or treatments
New symptoms reported as soon as previous have resolved
History of events biologically unlikely (eg infants with history of large blood losses who do not become anaemic or unwell)
Parent/carer may manipulate test results eg add glucose to urine to indicate diabetes
Deliberately induces symptoms of illness eg poisoning with unnecessary medications or substances
WHY?
Personality disorders? Playing role of caring mothers
Psychological and behavioural problems, self-harming, drug and alcohol abuse
Domestic violence
Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between people aged 16 or over who have been intimate partners, or family members
Vulnerable adults:
Adults with care or support needs who may be at increased risk/less able to protect themselves from harm
Safeguarding is protection of rights to those at risk
Care act 2014 sets out duties for local councils to protect these rights by preventing abuse, stopping abuse and neglect in children or vulnerable adults
If you suspect abuse then raise concern with NHS safeguarding team
Neglect
Can occur if carer is not giving person the necessary help and attention required
Can led to medical side effects if medication is missed and worsening psychological harm for elderly person in question
Can be unintentional and may be a sign the caregiver is suffering in their role. Third party witnesses may want to speak to carer to check up on them if neglect suspected (common in care home settings)
TYPES OF ABUSE/NEGLECT:
Financial: fraudulent scams, money or property misuse or theft
Physical
Psychological
Sexual
Discriminatory: harassment, racial, disability, sexual orientation, religion
Domestic abuse
Domestic violence indicators
Frequent appointments for vague symptoms
Frequently missed appointments including antenatal clinics
Non-concordance with treatment or premature discharge from hospital
Repeated health consultations with no clear diagnosis. Person may describe themselves as accident prone or silly and provide vague explanation of injuries
Injuries inconsistent with explanations
Repeated injury all at different stages of healing all with vague explanations
Traumatic injury esp if repeated (burns, bites, cutes, fractures)
Unexplained chronic gastrointestinal symptoms
Unexplained genitourinary symptoms including frequent bladder or kidney infections
Chronic unexplained pain
Problems with CNS (headaches, cognitive problems, hearing loss)
Domestic violence management
Facilitate disclosure in private with no third parties present (ensure they feel safe)
Advise person that discussion is confidential and information will only be shared with consent, subject to adult safeguarding and child protection (only share with those who must know)
If suspected abuse in NHS facility eg care home or specialist NHS nursing home, raise matter with safeguarding team for that service or local authority safeguarding team
•Explain that you are concerned (or, if it is a routine enquiry, that you ask everyone), and ask direct questions, such as:
•’Has anyone ever hit you? Who was it? What happened? When? What help did you seek?’
•’Are you afraid of your husband (or partner)?’
•’Has your husband (or partner) or someone else at home ever threatened to hurt you or physically harm you in some way? If so, when has it happened?’
•’Does your husband (or partner) or someone at home bully you or insult you?’
•’Does your husband (or partner) try to control you, for example, not letting you have money or go out of the house?’
Autism spectrum disorders ASD
Broad range of phenotypes which include ‘strict’ autism, atypical and asperger syndrome
Characterised by: impaired reciprocal social interaction and communication, stereotyped (rigid and repetitive) behaviour and interests, onset typically before age 3
Mostly affects children (1%); 2-8% prevalence among siblings
More boys diagnosed than girls
More heritable of childhood onset neuropsychiatric disorders (90%)
70% those diagnosed have other impaired psychological functioning such as ADHD and Anxiety disorders
Can be diagnosed in young people and adults if meet criteria (ICD-10 and DSM-5)
DSM-5 refers to autism spectrum disorder as a single condition with different levels of symptom severity in 2 core domains:
•1) deficits in social communication and social interaction and
•2) restricted repetitive behaviours (RRBs), interests, and activities and sensory anomalies
Learning disability: IQ <70 occurs in approx 50% people with autism
Others may not have learning disability or learning delay but just need special educational needs (SEN)
ASD risk factors
Sibling affected
Birth defect associated with CNS malformation or dysfunction including CP
Gestational age <35 wks
Parental schizophrenia like psychosis or affective disorder
Maternal use of sodium valproate in pregnancy
Learning disability
Attention deficit hyperactivity disorder (ADHD)
Neonatal encephalopathy or eipleptic encephalopathy, including infantile spasms
ASD presentations
Preschool child if any of following signs and symptoms present: language delay, babbling, speech regression or loss of speech.
Delayed response to others: when called, non-smiling no response to others facial expressions and unusual response to others when requesting or rejecting
Reduced social interaction with others: annoyed to share space, intolerant of people entering personal space, prefer to play alone, absent social play, absent enjoyment like other children
Reduced eye contact, pointing, special gestures: reduced or absent imagination from play, unusual or restricted interests and/or rigid and repetitive behaviours, excessive insistence on their own agenda
Over or under reaction to sensory stimuli eg sounds, smells, taste, textures
*be aware there are many differentials such as learning or cognitive impairments that may also present like this.
*be aware of children from deprived backgrounds and those with history of maltreatment which can also caused delayed development
ASD management
Arrange immediate referral to autism team if available (or pediatrician or child adolescent psychiatrist dependent on local referral policy) if child is < 3 years, language impairment or developmental delay
Consider immediate referral to autism team if there is significant concerns of parents and/or carer about development or functioning
Arrange immediate referral to pediatrician or pediatric neurologist of having ASD or another neurodevelopmental conditions
If no concerns ‘watch and wait’ and review any symptom progression
If referral to be made then include the following information: antenatal and perinatal history, developmental milestones, any risk factors for ASD, information from previous assessments
ADHD
At least six (five in adults) inattention symptoms and/or at least six (five in adults) hyperactivity-impulsivity symptoms that have:
Started before 12 years of age.
Occurred in two or more settings such as at home and school.
Been present for at least 6 months.
Clearly interfered with, or reduced the quality of social, academic or occupational functioning.
Not occurred exclusively during course of a psychotic disorder
Types of ADHD
Inattentive only: person has difficulty paying attention but does not tend to be disruptive
Hyperactive and impulsive: person may be able to focus well, but hyperactive and impulsive behaviours can cause disruption
Combined: person has all symptoms
Females with ADHD
Most likely to have inattentive form of ADHD and may be missed due to this. Main ADHD symptoms can apply to both sexes, but hyperactivity symptoms often present differently in girls than boys. Studies show they are more likely to show ‘internal’ symptoms making it difficult to pick up or for others to notice
*Other problems girls may experience include: Chronic stress Higher risk of stress related diseases Low self esteem Underachievement Anxiety and depression
Symptoms of inattention ADHD
Include: Failing to give close attention to detail or making careless mistakes in schoolwork, work, or other activities.
Difficulty in maintaining concentration when performing tasks or play activities.
Appearing not to listen to what is being said, as if the mind is elsewhere, without any obvious distraction.
Failing to follow through on instructions or finish a task (not because of oppositional behaviour or failure to understand).
Difficulty in organizing tasks and activities.
Reluctance, dislike, or avoidance of tasks that require sustained mental effort.
Losing items necessary for tasks or activities such as pencils, mobile phones, or wallets.
Easy distraction by extraneous stimuli
Forgetfulness with regards to daily activities
Girls may show distractibility easily by things around them or their own thought
Organisational skills may be challenging: poor time management, hard to follow multi step directions or complete a task. May often lose items
Symptoms of hyperactivity-impulsivity ADHD
Include: tapping hands or feet, or squirming when seated.
Leaving the seat where remaining seated is expected, such as in a classroom.
Running about or climbing in situations where inappropriate. In adolescents or adults this may be limited to a feeling of restlessness.
An inability to play or engage in leisure activities quietly.
Being ‘on the go’ or acting as if ‘driven by a motor’. Others may experience the person to be restless or difficult to keep up with.
Talking excessively.
Blurting out an answer before a question has been completed.
Difficulty waiting his or her turn.
Interrupting or intruding on others.
Girls are likely to move around and fidget more quietly, shuffling in chairs, doodling etc.
Girls may experience strong emotions and this may leave them unable to slow own or think about what they say. Can be hard for them to know the difference of what is and isn’t socially appropriate leading to difficulty making and keeping friends
ADHD management
If ADHD is suspected in a child:
Assess the social and educational impact of their symptoms
Assessment using the Strengths and Difficulties questionnaire or the Conners’ rating scale.
Watchful wait (10 wk-few months) & Family support and encouraging self-help , offer referral to group-based ADHD-focused support. Usually school teachers offer helpful records of progressions and behavioural symptoms also.
If symptoms severe, refer to child psychiatrist , specialist pediatrician
