Category Archives: Psychology

ARFID

Community, General paediatrics, Nutrition, OPD, Psychology

=Avoidant restrictive food intake disorder.

Extreme fussy eating, low appetite, slow eating, rigid eating behaviours eg brand-specific or position of food on plate. Often related to sensory issues (texture, colour, temperature) but also anxiety about potential choking or vomiting (emetophobia). But often food/eating is the only issue.

BPSU study 2024 described 300 cases across the UK. Slightly more boys than girls, 71% white. Comorbidity (anxiety and autism spectrum disorder) common.

Case definition from BPSU was:

  • Nutritional deficiency that requires additional clinical investigation or treatment (e.g., anaemia, micronutrient deficiency, weight loss or poor growth, not fully accounted for by poverty or neglect, cultural practice or an existing medical condition or another mental disorder
  • AND/OR Interference with day-to-day functioning due to eating behaviour
  • Not explained by ANY of the following:
    • Lack of available food (e.g., from poverty, famine, or neglect)
    • Culturally sanctioned practice (e.g., endorsed religious and cultural practice)
    • Other known diagnosis e.g., Allergy, Constipation, Swallowing difficulties, anorexia/bulimia

If known medical/mental disorder, the severity of eating disturbance should exceed that routinely associated with the particular condition/disorder.

In practice, consider where:

  • Weight for age or weight for height <2SDs below median
  • Absence of entire food groups from diet
  • Reliance on nutritional supplementation
  • Extreme/frequent distress about eating
  • Unable to eat at school, with peers, or out of home

Catatonia

General paediatrics, Mental health, Neurology, Psychology

Reminds me of a certain 90s album, and the book “Awakenings” by Oliver Sacks, but still used to describe a dramatic presentation of neurological regression.

Classically stupor, mutism, rigidity (or “waxy flexibility”), but can also be “excited”, particularly in children, where it presents with agitation, catalepsy, sterotypies, echolalia/praxia.

Many of these features are seen in autism anyway, but could present in autism too.

Associated with psychiatric (eg schizophrenia) but also wide spectrum of medical conditions. Some of these are obviously differentials as well.

  • Neurological – Anti-NMDA receptor encephalitis, MS, SLE
  • Space occupying lesion
  • Infection – encephalitis, cerebral malaria, HIV, syphilis, SSPE
  • Medication – withdrawal, alcohol, benzodiazepines, gabapentin, Zolpidem
  • Metabolic – DKA, hepatic encephalopathy, hypercalcaemia, porphyria, pellagra
  • Endocrine – Addison, Cushing, hyperthyroidism, phaeochromocytoma

Management

Assessment includes full history and examination obviously, with particular consideration to possible toxins/drugs, also DVT and pressure ulcers as complications.

Rating scales available.

EEG is important to exclude non convulsive status. “Extreme delta brush” suggests anti-NMDAR encephalitis.

Benzodiazepine challenge test – usually lorazepam – can produce responsiveness. IV or IM can be used if oral administration tricky. Zolpidem has been used for challenge too.

Escalating benzodiazepine doses used for treatment. Electroconvulsive shock therapy has traditionally been used.

[J Psychopharm 2023]

Adverse Childhood Experience

Child protection, General paediatrics, Nutrition, Psychology, Sociology

Associated with range of negative outcomes.

Later lifestyle

Adverse childhood experiences increase probability of smoking in adulthood. Physical harm in Eastern European countries increases the probability of heavy drinking by about 3.4%, but not in other regions. Exposure to child neglect (little understanding) increases the probability of alcohol abuse by 2.7% in Nordic Countries but not other macro-regions. The experience of a poor relationship with parents is a strong predictor of alcohol abuse for the female subsample in Latin countries (2% higher).

While ACE does not appear to have a substantial effect on excess weight in any macro-region, childhood trauma (physical harm) appears to have a major impact on the likelihood of being obese later in life. Obesity has a more obvious impact on chronic illness than poverty, smoking or alcohol.

Trauma informed care

Recognising the impact of adverse experiences (“trauma”) on providing effective care.

Northwestern INFORMED toolkit suggests:

Work to establish trust and safety: Sit down. Demonstrate active listening. Use non-
threatening body language. Make sure the physical space feels safe and comfortable.

  • Recognize the signs of re-traumatization (sudden anxiousness, restlessness, social isolation, physical expressions of such including fatigue, inability to control emotions) or emotional distress related to medical care.
  • Acknowledge that trauma or difficult experiences impacts health care eg “Hospital can be hard for many people, especially if they have had difficult experiences in the past.”
  • Ask open-ended questions, such as:
    o “Is there anything we should know to help make your time here more comfortable
    and make you feel safe?”
  • If a patient discloses a trauma or difficult experiences, respond empathetically, for
    instance:
    o “Thank you for trusting me with this.”
    o “I can see how hurtful that must have been for you.”
  • Navigate the emotions – normalize (“We would expect anyone in your shoes to respond this way after what you have been through”). Be present. “I would really like to understand more.” Respect – “you’ve really made the most of what you’ve been given”.
  • Ask what could be done to support, while not being unrealistic. Check information can be shared and reassure around privacy. Get a team together!
  • Empower – “what has helped you move forward in the past?” “Who has been there for you?”
  • Monitor and feedback to team

Medically unexplained symptoms

Clinical, Common, General paediatrics, Mental health, OPD, Psychology

“Persistent physical symptoms” preferred term? Chronic pain overlaps.

“Functional disorder” is used for various gastro and neurological problems, preferred by some adults, but needs explained!

Chronic fatigue syndrome and PANDAS are health disorders that appear to have a physical/scientific cause but disputed.

Health anxiety, malingering, or factitious illness, different from a psychological point of view.

Bleed the symptoms dry! [John Stone, Glasgow].

In a 1965 paper by Eliot Slater, more than half of patients diagnosed as having “hysteria” later turned out to have “organic” disease – but John Stone’s study of adult neurology referrals found very few who turned out to have an occult disease.

Louise Stone in Australia has done a lot of work in primary care. She identifies negative feelings and a lack of diagnostic language and frameworks as barriers to managing these patients effectively. The negative feelings (such as frustration, shame and helplessness), are shared between doctors and patients…

Managing your own feelings and frustrations, and finding ways of understanding and managing the therapeutic relationship important.

Let family feel validated for all concerns – at least in the first instance. Helps develop a therapeutic alliance.

Commit to the patient, which includes advocacy and support.

Family response to symptoms?

Explore beliefs, specific worries (eg cancer). May then allow broadening out to more general worries. 

Manage uncertainty – including managing the need for a disease name! Not having a predictable outcome is hard.

Harm minimisation. Shift from diagnosis to coping with ongoing symptoms.

Good to offer a tentative preamble to difficult conversations! “This is something we as doctors have to deal with every day – signs and symptoms that are very real, with a real impact on a child/family, but where physical examination and investigations do not offer any clues to what the underlying problem might be…”

Paed psychology if issues mostly seem related to child and this is a new problem; CAMHS if new problem adding to existing child/parent issues.  

Can be rewarding in the long term!

[Louise Stone, Aust Fam Physician 2013 Jul;42(7):501-2]

Long COVID

General paediatrics, Infectious disease, Mental health, OPD, Psychology

Doesn’t seem to be associated with severity of initial illness.

Long COVID is less common if you are vaccinated already. In a community based study of adults aged 18 to 69 years infected with SARS-CoV-2 before vaccination against covid-19, the odds of experiencing long covid symptoms decreased by an average of 13% after a first covid-19 vaccine dose, with a further 9% decrease in the odds of long covid after a second dose. [https://doi.org/10.1136/bmj-2021-069676] 

If you already have long COVID, further COVID immunisations seem to be beneficial, rather than harmful:

  • In a non-controlled study of 900 social media users with long COVID, more than half experienced an improvement in symptoms after vaccination compared with 7% who reported a deterioration.19
  • A study of 44 vaccinated patients and 22 unvaccinated controls previously admitted to hospital with covid-19 in the UK, which inevitably had limited power to detect clinically relevant effects, found no evidence for vaccination being associated with worsening of long covid symptoms or quality of life.20
  • A French study of 455 self-selected participants found reduced long COVID symptom burden and double the rate of remission at 120 days in vaccinated participants compared with unvaccinated controls.

All about symptoms, excluding treatable conditions, then self management. For adults:

https://www.yourcovidrecovery.nhs.uk/

Chronic pain

General paediatrics, OPD, Psychology

Gate theory useful – it’s not just about the stimulus coming to your nerve endings. That signal has to pass through a gate, to register in your brain, and different things affect whether the gate is more or less open or closed.

A feature of many chronic health conditions, eg juvenile idiopathic arthritis, migraine. Often a feature of chronic fatigue syndrome. Can be part of a functional disorder such as functional abdominal pain. In a limb, can lead to reflex sympathetic dystrophy. But often unexplained.

Think about PTSD – it’s all “in your head” but that doesn’t mean it’s nothing. Or phantom limb pain – there isn’t even a true signal coming from the limb, but you still feel pain.

Pain is performative – no one gets credit for trying to cope and hide it. But you can be accuse of “laying it on thick”.

Having a diagnosis helps socially. 

Pain can make you a different person from who you were. Impatience and irritability can be understood, besides an inability to do some activities that might be important to identity (and to relieving stress). Social isolation is common.

Chronic pain also steals any sense of your future because it is too intolerable to imagine more pain. 

Fear needs to be detached from pain. 

Acceptance therapy – not to accept eternity of pain but to focus on progress and function. 

[Haider Warraich podcast with Kate Bowler]

Screen time

Child protection, Community, General paediatrics, Mental health, OPD, Psychology, Sociology

Sedentary time spent in front of screens programs metabolism and brain neurochem.  Similar to addiction.

But it’s complicated! Partly because there are so many different kinds of activity that can now be done with mobile phones and tablets, and because it’s difficult to control or randomize.

How people interact with screens is changing too. In the mid-2000s in the US, children over 8 spent an average of 6.43 hours a day on electronic media, but this was mainly watching TV.  Evidence of stress response (reduced cortisol increase) on waking after using screens for average 3 hours a day.

But now mobile devices are the centre piece of young people’s social lives.  Boys tend to spend more time gaming, girls more time on social networking.

UK government advice 2026 is 1hr a day but pref less under 5 years, and under 2 only if joint watching/activity with adult.

Effect of high levels of screen time does not seem to be attenuated by equivalent exercise.

High levels of screen time (over 4 hours daily) is associated with poorer school performance. Social skills are poorer. These children tend to form cliques with shared interest, that create further social isolation.

Violent games and media are associated with aggression in children as young as pre-school. Aggression in children can be manifest physically, or verbally, or relationally (ignoring, excluding, spreading rumours). There is also significantly more hostile attribution bias, where you interpret behaviour (such as not being invited to a party) as hostile, even when it is not, or at least ambiguous.

Parental involvement matters – how frequently parents watch TV with their children, discuss content with them, and set limits on time spent playing video games.

Exposure to media violence must also be seen within a risks/resilience approach. [Gentile and Coyne, Aggressive Behaviour 2010] ]

Some evidence that some “social” games themed around cooperation and construction eg Animal crossing have benefits. Similarly, links between media and relational violence pretty weak, but that could be because relational violence content isn’t really examined! Actual content probably more important than time spent playing. Note that in that study of Animal Crossing, background mental health problems seemed to reduce benefit.

Health anxiety

General paediatrics, Medical, Patients, Psychology

DSM-5 has “illness anxiety disorder”, defined as preoccupation with the idea that you’re seriously ill, based on normal body sensations (such as a noisy stomach) or minor symptoms (such as a minor rash), to the degree that it gets in the way of normal life. Other features are persistence of such ideas over 6 months, finding little or no reassurance from negative test results or a doctor’s reassurance, repeatedly checking body, avoiding people, places or activities for fear of health risks.

In other words, hypochondriasis. Which gets its name from the idea that such feelings came from liver/spleen/gall bladder (“melancholy” – black bile).  William Cullen, in Edinburgh in the 1790s, appeared to take a particular interest in this.

For the sake of diagnosis, this disorder requires the absence of symptoms, which excludes the large group of people who have similar preoccupation and fears about non-specific or unexplained signs and symptoms.

Health anxiety is therefore a broader concept, and can include anyone who is more desperate for relief from worry, than for relief from actual symptoms.

Cyberchondria = combination of increased pathologisation of society, and ability to browse the internet.  Because provides the opportunity to find very serious, extremely unlikely explanation for problems.

Diagnosis of health anxiety is well accepted by patients if explained respectfully!

[BMJ 2016;353:i2250]

Constipation

Common, Gastro, General paediatrics, OPD, Psychology

Consider constipation if:

  • episodes of faecal incontinence (stains or smears in pants, potentially larger accidents),
  • retentive posturing (standing or sitting with their legs straight and stiff or crossed legs, some will sit on their own heel),
  • occasional massive but soft stools that virtually obstruct toilet.

Not just hard painful infrequent stools! Beware also dyschezia, where baby appears to strain at stool but not actually hard/large.

In a population-based prospective birth cohort, where dietary types were extracted from questionnaire, adherence to a ‘Western-like’ dietary pattern was associated with a higher prevalence of constipation up to 48 months [aOR 1.39; 1.02-1.87], which was not mediated by overweight or sedentary behaviour. Adherence to a ‘Health Conscious’ dietary pattern was only associated at short term, with a lower prevalence of constipation at 24 months (aOR; 0.65; 0.44-0.96). This suggests that specific dietary patterns in early childhood could be associated with higher or lower risks for constipation, but these effects are time-dependent. [Maternal & Child Nutrition. 9(4):511-23, 2013 PMID: 22288911]

Straining is not a criteria, in NICE, interestingly, although it is in Rome III criteria!

Red flags:

  • multiple anal fissures,
  • gross abdo distension,
  • tenderness with guarding,
  • abnormal lumbosacral or lower limb findings,
  • failure to thrive
  • ribbon like stools (?anal stenosis)
  • etc

“Do not use dietary interventions alone as first-line treatment for idiopathic constipation” – because no evidence that it helps! But yes, adequate hydration and fibre important (whole grains, fruit/veg, pulses).

NICE recommends Movicol/Laxido (macrogol) as first line, combining with a stimulant (picosulfate, biscodyl, senna) as second line. If macrogol not tolerated, use stimulant +/- softener (lactulose, docusate).

Warn that pain and soiling gets worse before getting better!

Review of adherence and dose important.

Toilet training eg diary, reward system, regular post prandial sitting 5 mins +/- feet on hard surface eg stool.

“Poo should be as soft as toothpaste and should come out like a snake” (Snakes and ladders booklet, Kidney Kids Scotland). Tell your teacher if no toilet paper/soap or broken seat/locks etc.

Soiling

Typically, episodes of soiling (large and small) are due to overflow of liquid stool past a large impacted stool in the rectum.  The child is unable to control, due to the distortion of the rectum.

However, children often try to deny being aware of soiling, despite the obvious smell or discomfort – this is simply a coping method, and normal sensation is usually easy to demonstrate.

The diagnosis is easier in the presence of a large suprapubic mass, or a rectal mass on digital examination.  Some children however soil for attention, without any bowel or rectal disorder.

The presence or implication of a large rectal mass requires disimpaction – an escalating regimen of a paediatric formulation of macrogol (Laxido or Cosmocol are cheaper than Movicol) as per NICE guideline 99 (doses and licensing may differ from product literature):

  • Child under 1 year: ½-1 sachet daily (non-BNFC recommended dose)
  • Child 1-5 years: 2 sachets on 1st day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily (non-BNFC recommended dose)
  • Child 5-12 years: 4 sachets on 1st day, then increased in steps of 2 sachets daily to maximum of 12 sachets daily (non-BNFC recommended dose)
  • If macrogol not tolerated, use stimulant laxative eg picosulfate +/- lactulose

If no progress after 2 weeks add stimulant laxative eg senna, picosulfate, bisacodyl, docusate.

Enemas eg citrate can prevent megarectum where prolonged medical treatment fails.

Polyethylene glycol licensed for distal intestinal obstruction!?

Maintenance

I suggest half disimpaction dose for maintenance.

Preferred treatment is paediatric formulation of macrogol (Laxido or Cosmocol are cheaper than Movicol) as per NICE guideline 99 (doses and licensing may differ from product literature).

  • Child under 1 year: ½–1 sachet daily (non-BNFC recommended dose)
  • Child 1–6 years: 1 sachet daily; adjust dose to produce regular soft stools (maximum 4 sachets daily) (for children under 2, non-BNFC recommended dose)
  • Child 6–12 years: 2 sachets daily; adjust dose to produce regular soft stools (maximum 4 sachets daily)
  • If macrogol not tolerated, use a stimulant laxative eg sodium picosulfate (5mg/5ml, NICE recommended doses):
    • Child 1 month to 4 years: 2.5–10 mg once a day
    • Child/young person 4–18 years: 2.5–20 mg once a day
    • Add lactulose or docusate if stools hard

For babies, Senna and lactulose from age 1/12.

At least 3/12 of maintenance before weaning if disimpaction required initially.

I always highlight that laxative use does not induce dependency, rather, that chronic constipation is unlikely to improve without adequate treatment.

Review regularly – symptoms, toileting, taking medication.

Continue maintenance treatment until regular bowel habit established for at least a few weeks or until toilet trained. Do not stop dose abruptly.

General advice re balanced diet including fruit, vegetables, high-fibre bread/breakfast cereals, baked beans, regular toileting, exercise, sufficient fluid intake (1000-1400ml age 4-8yrs, 1200–2100ml age 9–13yrs).

Involve Health Visitor in pre-school group.

Consider trial of milk exclusion (to rule out cow’s milk protein allergy if intractable (ESPGHAN 2023).   Coeliac disease, hypothyroidism, cystic fibrosis, Hirschsprung’s disease and hypercalcaemia also come into the differential.

Surgery

Rectal biopsy indicated if delayed meconium at birth (ie >48hrs), Downs, enterocolitic episodes.

Anal fissures have high spontaneous healing rate with medical treatment.

Manual evacuation under GA may be required if resistant. No benefit on RCT for anal dilatation. Small RCT found botox as good as internal sphincter myectomy for refractory constipation.

Appendicostomy or caecostomy antegrade colonic enema (where bowel irrigated using catheter) has a role in refractory cases after age 6yrs. QOL, continence improve but appreciable morbidity.

Relapses more common in boys, under age 4, background of psychosocial or behavioural probs, encopresis. 1/3 of post pubertal children continue to have severe problems.  See also parenting and constipation.

Parent information

ERIC website – www.eric.org.uk

[NICE clinical guideline 99 – constipation in children and young people (Published 2010)]

[BMJ 2012]