1. Internalising Disorders Dr Neelo Aslam & Dr Hilary Strachan SpRs Child and Adolescent Psychiatry Dr Neelo Aslam & Dr Hilary Strachan SpRs Child and Adolescent Psychiatry

2. Classification  ICD – 10  Standardised classification of all diseases  Especially useful in psychiatry as there are no diagnostic tests  F32 Depressive episode  ICD – 10  Standardised classification of all diseases  Especially useful in psychiatry as there are no diagnostic tests  F32 Depressive episode

3. Epidemiology  Isle of Wight Studies  10% of 10-year-olds miserable reported by parents  40% of 14-year-olds by own account  0.2% 10 year olds depressed  2 % 14 year olds depressed  Isle of Wight Studies  10% of 10-year-olds miserable reported by parents  40% of 14-year-olds by own account  0.2% 10 year olds depressed  2 % 14 year olds depressed

4. Core Symptoms  Depressed mood  Loss of interest/pleasure  Decreased energy/increased fatigability  Depressed mood  Loss of interest/pleasure  Decreased energy/increased fatigability

5. Other Symptoms  Loss of confidence/self esteem  Excess self reproach/guilt  Recurrent thoughts of death/suicide or suicidal behaviour  Decreased concentration  Change in psychomotor activity-agitation or retardation  Sleep disturbance  Change in appetite-weight change  Loss of confidence/self esteem  Excess self reproach/guilt  Recurrent thoughts of death/suicide or suicidal behaviour  Decreased concentration  Change in psychomotor activity-agitation or retardation  Sleep disturbance  Change in appetite-weight change

6. Somatic Syndrome  Loss of pleasure  Lack emotional response  Waking 2 hours before morning time  Depression worse in morning  Objective evidence of psychomotor retardation  Marked loss of appetite  Weight loss-loss of 5% body weight  Loss of libido  Loss of pleasure  Lack emotional response  Waking 2 hours before morning time  Depression worse in morning  Objective evidence of psychomotor retardation  Marked loss of appetite  Weight loss-loss of 5% body weight  Loss of libido

7. Presentation in Childhood and Adolescence  But when does sadness become depression?  What is the significance of childhood misery?  Persistence  Severity  Quality of mood  Social incapacity/impact on function  But when does sadness become depression?  What is the significance of childhood misery?  Persistence  Severity  Quality of mood  Social incapacity/impact on function

8. Over 8 Years (similar to adult)  Less sleep and appetite disturbance  Less guilt and hopelessness  More somatic complaints-abdominal pain, headache  Irritability  School refusal/reluctance  Academic/behaviour problems  Less lethal/less complex suicidal plans-head under bath  Less sleep and appetite disturbance  Less guilt and hopelessness  More somatic complaints-abdominal pain, headache  Irritability  School refusal/reluctance  Academic/behaviour problems  Less lethal/less complex suicidal plans-head under bath

9. Adolescents  Above symptoms plus  Increased guilt and hopelessness  More complex suicidal plans Co-morbidities Anxiety/behaviour disorders/substance misuse  Above symptoms plus  Increased guilt and hopelessness  More complex suicidal plans Co-morbidities Anxiety/behaviour disorders/substance misuse

10. Management Biological  Selective Serotonin Reuptake Inhibitors (SSRI)  CSM advice: Fluoxetine is first line  “ Risks and benefits considered unfavourable in others ”  May lead to increased suicidal ideation  Selective Serotonin Reuptake Inhibitors (SSRI)  CSM advice: Fluoxetine is first line  “ Risks and benefits considered unfavourable in others ”  May lead to increased suicidal ideation

11. Psychosocial  Cognitive Behavioural Therapy Up to 12-14 1 hour sessions Here and now focus Works on: Cognitions and Behaviours “I’m no good,” “no one will love me if I’m not perfect”  Psychodynamic Psychotherapy  Family Therapy  Interpersonal Therapy  General Parenting Work  Cognitive Behavioural Therapy Up to 12-14 1 hour sessions Here and now focus Works on: Cognitions and Behaviours “I’m no good,” “no one will love me if I’m not perfect”  Psychodynamic Psychotherapy  Family Therapy  Interpersonal Therapy  General Parenting Work

12. Suicide and Deliberate Self harm Epidemiology  Suicide rare<12 years of age  In UK suicides/million children aged 10-14 years=5 aged 15-19 years=30  Male excess-especially violent methods-hanging shooting, electrocution  Female-poisoning  Rates increased between 1950-1980 but 20% down since 1980  Suicide rare<12 years of age  In UK suicides/million children aged 10-14 years=5 aged 15-19 years=30  Male excess-especially violent methods-hanging shooting, electrocution  Female-poisoning  Rates increased between 1950-1980 but 20% down since 1980

13. Associated Factors  Disrupted home circumstances  Family history of: Psychiatric disorders depression, suicide and DSH, addiction  Psychiatric disorder in young person o >90%  disorder o Affective disorder M=F o Conduct Disorder/Substance abuse M>F o >50% contacted professionals regarding mental health  Models of successful/attempted suicide (family, friends and media)  One or more previous episodes of DSH-many made suicidal threats in last year  Availability of highly lethal means  Disrupted home circumstances  Family history of: Psychiatric disorders depression, suicide and DSH, addiction  Psychiatric disorder in young person o >90%  disorder o Affective disorder M=F o Conduct Disorder/Substance abuse M>F o >50% contacted professionals regarding mental health  Models of successful/attempted suicide (family, friends and media)  One or more previous episodes of DSH-many made suicidal threats in last year  Availability of highly lethal means

14. Deliberate Self Harm Epidemiology  1000 times more than suicide  Teenagers F:M=2:1Under 12 M=F  UK 15-16 year olds o 22% suicidal ideation over last 12/12 o 7 % self harmed o 1/8 came to medical attention  Commonest method = self poisoning especially females  1000 times more than suicide  Teenagers F:M=2:1Under 12 M=F  UK 15-16 year olds o 22% suicidal ideation over last 12/12 o 7 % self harmed o 1/8 came to medical attention  Commonest method = self poisoning especially females

15. Associated Factors  Lack of supportive family relationship;parental conflict  Family member with  disorder and alcohol abuse especially in fathers  Current/recent history of  disorder (depression/anxiety/conduct disorder/substance misuse)  History of physical/sexual abuse  School/work problems  Models of self harm:contagion in inpatient units  10-20% made previous attempt  Impulsive:acted on when immediate access to medications  Lack of supportive family relationship;parental conflict  Family member with  disorder and alcohol abuse especially in fathers  Current/recent history of  disorder (depression/anxiety/conduct disorder/substance misuse)  History of physical/sexual abuse  School/work problems  Models of self harm:contagion in inpatient units  10-20% made previous attempt  Impulsive:acted on when immediate access to medications

16. Assessment Case history A 14 year old girl was admitted to the paediatric ward overnight after an overdose of paracetamol. She did not require medical treatment.  How would you assess this girl for depression?  How would you do a mental state examination?  How would you do a risk assessment? A 14 year old girl was admitted to the paediatric ward overnight after an overdose of paracetamol. She did not require medical treatment.  How would you assess this girl for depression?  How would you do a mental state examination?  How would you do a risk assessment?

17. Assessment  You Must assess Circumstances of self harm and Degree of suicidal intent & markers of serious intent  Carried out in ISOLATION  TIMED so intervention unlikely  Precautions to AVOID DISCOVERY  Preparation in ANTICIPATIONN OF DEATH  Others informed before of intent  Extensive PREMEDITATION  Suicide NOTE  Failure to ALERT OTHERS  You Must assess Circumstances of self harm and Degree of suicidal intent & markers of serious intent  Carried out in ISOLATION  TIMED so intervention unlikely  Precautions to AVOID DISCOVERY  Preparation in ANTICIPATIONN OF DEATH  Others informed before of intent  Extensive PREMEDITATION  Suicide NOTE  Failure to ALERT OTHERS

18. Assessment  Precipitating factors  Predisposing factors  History and mental state examination  Was SH a maladaptive coping strategy?  Attitude to help-both patient and family  Precipitating factors  Predisposing factors  History and mental state examination  Was SH a maladaptive coping strategy?  Attitude to help-both patient and family

19. Management  First episode-admit overnight for “cooling off period” even if no need for medical treatment  Harm minimisation-lock away medicines  At least 1 follow up appointment  Treat underlying  problem  CBT/family work/problem solving  Group work-ASSIST trial  First episode-admit overnight for “cooling off period” even if no need for medical treatment  Harm minimisation-lock away medicines  At least 1 follow up appointment  Treat underlying  problem  CBT/family work/problem solving  Group work-ASSIST trial

20. Prognosis  10% repeat in next year  Risk factors for repetition: male sex >1 episode, extensive family psychopathology, poor social adjustment,  disorder  1% kills themselves in the next 2 years  Risk factors for eventual suicide: male, older adolescents,  disorder, active means used (hanging etc)  10% repeat in next year  Risk factors for repetition: male sex >1 episode, extensive family psychopathology, poor social adjustment,  disorder  1% kills themselves in the next 2 years  Risk factors for eventual suicide: male, older adolescents,  disorder, active means used (hanging etc)