Transcript As easy as ABC? - the Peninsula MRCPsych Course

(As easy as ABC?)
Ruth Brand Flu
Locum Consultant developmental Child
and adolescent Psychiatrist
Introduction
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Interactive
Problem based learning
Evidence based? And own examples
I want you to be critical
Distress/ disorder
Formulation
Somatoform disorders
Questions and answers
Distress/disorder
Distress
Within normal limits:
• Duration
• Intensity
• Quality
• Within cultural boundaries
• Developmentally appropriate
• Frequency
• Quality
Considering context and situation
Distress/ disorder
Disorder:
physical or mental anguish or suffering A derangement or abnormality of
function, a morbid physical or mental state. Impairment not always
included in the definition
Abnormal in :
• Duration
• Intensity
• Quality
• Within cultural boundaries
• Developmentally appropriate
• Frequency
• Quality
Out of context and beyond explanations of situational factors
Normal/disorder examples
A four year old who drowned her baby brother in
the bath
A cough
A 16 year old who sucks his thumb
A 6 month old baby who sleeps three hours per
day
Distress/disorder examples
A child whose mood can swing in a split
second
A child complaining of tummy ache
A child who tells you that an alien is living in
his tummy
A child who cries at the sound of thunder
A child who scratches his face open at the
sound of thunder
A baby who bangs his head
Formulation
Components:
Bio psycho social
Developmental
Predisposing,
precipitating,
perpetuating
Strength, weakness
Prognosis
Protective factors ,
internal (strength) or
External
Impairment
Risks, Continuity in
adulthood
Formulation continued
SIRSE
• Symptom
• Impact
• Risks
• Strength
• Explanatory
• (State , trait, pattern)
Formulation continued
Aetiological
Nurture /nature
Genetic or trans-generational
Developmental: physically, emotionally, neurocognitively and socially
Environment at home/school and extra-curricular
activities
Formulation: example
Adrian is a 12 year child who was adopted from birth. , His birthmother
overdosed on cocaine and mescaline during pregnancy. He was born
prematurely and due to cardiac complications spent 9 months of his first
year in hospital. He has mild global delay, his coordination is way below
par and he displays a significant degree of attentional and impulsivity
features and explosive outburst in school, but never in the home
environment. Despite that he has got a large circle of friends from early
primary school and except for maths he is consistently performing low
average in school. He was referred for marked anxiety features
nightmares, clinginess and bedwetting following a burglary at home,
which he witnessed. He was initially quite anxious at the assessment, but
with some reassurance and structure he calmed down quickly with good
rapport. He displayed some PTSD features when the burglary was
discussed
Considering his impressive insight into his problems, with minimal
counselling, progress in school and his warm an boundaried adoptive
family his prognosis short term and long term is considered good. Risks of
harm to others and self-harm short and long terms are minimal
(A multimodal summarised narrative of the patient
Somatoform disorders (F45)
Unexplained physical symptoms (UPS)
Abnormal illness behaviour
General differences DSMIV/ICD10
Co-morbidity
• Somatisation disorder (genuine symptoms)
• Hypochondriacal disorder (interpretation and
fear to conviction of having an illness)
• Somatoform autonomic dysfunction (the
sense of.. .Being flushed)
• Persistent somatoform pain disorder
• Undifferentiated somatoform disorder
A mixture and incomplete
• Other somatoform disorder (isolated i.e.
Globus hystericus)
• Somatoform disorder unspecified
Somatisation disorder
• At least 2 years duration
• Persistence refusal to accept reassurance by
physician, (in younger kids) not making a
psychological link
• Some degree of impairment of social and
family life... How do you separate between
primary and secondary problems
DD Physical/affective/anxiety disorder, but often
co-existence
0.1% year and life time prevalence – true value?
More about somatisation disorder
Subculture in family
Internalisation tendencies of too much stress
Nervous disposition
More in girls
More frequent and complex in adolescents
• In small children just headaches, tummy ache
and fatigue 25% neurological
• 23% with low energy: 21% with sore muscles
17% with abdominal discomfort
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Aetiology
Internal: alexithymia, learning disabilities, low
self esteem, personality: perfectionistic,
worried, previous abuse, genetic component
in somatisation tendencies? Co-existing
physical illness: Pseudo-epilepsy
External: Pressure from environment: too much
stress: marital problems, bullying in school,
academic achievement
Somatisation still continued
‘Primary illness gain’: Internal gain, i.e.
Distraction from the original psychological
pain or awareness of what is going on in the
person’s life
Secondary gain: reaction of the environment:
Less responsibilities, more nurtured
Sustaining factors: internal and environmental,
reaction by environment
External factors
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• Family factors;
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• Family history of
anxiety and
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depression
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• A family experience of
illness
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• High expectations of
the child
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Systematic family
dysfunction
Social factors:
Lower socio economic
status
Predisposition may
vary culturally
diff
Psychiatric disorder? Impact
• Psychiatric disorder? Depends
• Impact?
• Defense mechanism?
State to trait
Hypochondriacal disorder F45.2
• More about the appraisal of bodily feelings
than the sensations
• Can be delusional,
• More persistent in continuation into
adulthood?
• Media overload?
• Otherwise similar in aetiology, illness gain
Somatoform autonomic
dysfunction F45.3
A certain system or organ fully under that
autonomous control such as the heart,
gastrointestinal:
F45.30 Heart and cardiovascular Cardiac
neurosis, Da Costa syndrome, neurocirculatory neurasthenia
F45.31 Upper gastro-intestinal: psychogenic
aerophagia, hiccough, pyloro spasm
Somatoform autonomic
dysfunction continued
• F45.32 Lower gastro-intestinal tract:
psychogenic flatulence, IBS, diarrhoea gas
syndrome
• F45.33 respiratory Psychogenic forms of
cough and hyperventilation
• F45.34 Genito-uterine Micturition and
dysuria
Treatment
• Treatment of the environment
• Removing abusive situations, tackling bullying,
academic adjustments
• Solution focussed
• Behaviour therapy
• CBT
• Family therapy, narrative therapy
• Psychotherapy
• Play therapy?
BIBLIOGRAPHY
All major child and adolescent Psychiatry textbooks, i.e.
Royal college, also paediatric textbooks
Coghill D. 2008 Oxford Child and adolescent psychiatry
Oxford, Oxford University press
Scott, S. 2002 Classification of psychiatric disorders in
childhood and adolescence: building castles in the
sand? Adv. Psychiatr. Treat., May 2002; 8: 205 - 213.
Tsuang: M. Texbook in psychiatric epuidemiology Wiley
New York Eminson D. 2001advances in psychiatric
treatment somatising in children and adolescents 7 266274