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Lockdown during the pandemic has had significant impacts on public mental health. Previous studies suggest an increase in self-harm and suicide in children and adolescents. There has been little research on the roles of stringent lockdown.
To investigate the mediating and predictive roles of lockdown policy stringency measures in self-harm and emergency psychiatric presentations.
This was a retrospective cohort study. We analysed data of 2073 psychiatric emergency presentations of children and adolescents from 23 hospital catchment areas in ten countries, in March to April 2019 and 2020.
Lockdown measure stringency mediated the reduction in psychiatric emergency presentations (incidence rate ratio of the natural indirect effect [IRRNIE] = 0.41, 95% CI [0.35, 0.48]) and self-harm presentations (IRRNIE = 0.49, 95% CI [0.39, 0.60]) in 2020 compared with 2019. Self-harm presentations among male and looked after children were likely to increase in parallel with lockdown stringency. Self-harm presentations precipitated by social isolation increased with stringency, whereas school pressure and rows with a friend became less likely precipitants. Children from more deprived neighbourhoods were less likely to present to emergency departments when lockdown became more stringent,
Lockdown may produce differential effects among children and adolescents who self-harm. Development in community or remote mental health services is crucial to offset potential barriers to access to emergency psychiatric care, especially for the most deprived youths. Governments should aim to reduce unnecessary fear of help-seeking and keep lockdown as short as possible. Underlying mediation mechanisms of stringent measures and potential psychosocial inequalities warrant further research.
This study aimed to examine factors that may have contributed to community disaster resilience following Hurricane Maria in Puerto Rico.
In April 2018, qualitative interviews (n = 22) were conducted with stakeholders in 7 Puerto Rican municipalities (9% of total). Transcripts were deductively and inductively coded and analyzed to identify salient topics and themes, then examined according to strategic themes from the Federal Emergency Management Association’s (FEMA) Whole Community Approach.
Municipal preparedness efforts were coordinated, community-based, leveraged community assets, and prioritized vulnerable populations. Strategies included (1) multi-sectoral coordination and strategic personnel allocation; (2) neighborhood leader designation as support contacts; (3) leveraging of community leader expertise and social networks to protect vulnerable residents; (4) Censuses of at-risk groups, health professionals, and first responders; and (5) outreach for risk communication and locally tailored protective measures. In the context of collapsed telecommunications, communities implemented post-disaster strategies to facilitate communication with the Puerto Rican Government, between local first responders, and to keep residents informed, including the use of: (1) police radios; (2) vehicles with loudspeakers; (3) direct interpersonal communication; and (4) solar-powered Internet radio stations.
Adaptive capacities and actions of Puerto Rican communities exemplify the importance of local solutions in disasters. Expanded research is recommended to better understand contributors to disaster resilience.
An emerging picture has seen increasing numbers of young people with mental health crisis attend paediatric emergency departments in Ireland. Following paediatric review, many are referred to in-house paediatric liaison psychiatry (PLP) services. This pilot study describes referral patterns and practice over a 1-month period across three Dublin centres.
Case notes of all referrals to PLP were reviewed to extract relevant clinical and administrative data. For those admitted, costs associated with length of stay were estimated. Clinical profile, management and intra-hospital pathway differences were explored.
Fifty-nine young people under 16 years presented to one of the three EDs with an acute MH presentation. The sample consisted of 39 females (66%) with a mean age of 13.7 years. The majority (n = 34, 58%) presented out of hours. A substantial portion of youths presenting (n = 37, 63%) were admitted, and had a mean duration of stay of 4.51 days. There were differences between hospitals in terms of frequency of presentation with self-harm, admission rates and length of stay.
Different PLP service configuration, staffing and funding streams may explain some of the differences observed across centres, although the findings should be interpreted with caution given the limited sample size. Standardisation of service provision and management is needed for PLP services. Additional community CAMHS resourcing is needed to support the development of alternative pathways for youth in need of urgent MH review.
Catatonia is a psychomotor dysregulation syndrome of diverse aetiology, increasingly recognised as a prominent feature of N-methyl-d-aspartate receptor antibody encephalitis (NMDARE) in adults. No study to date has systematically assessed the prevalence and symptomatology of catatonia in children with NMDARE. We analysed 57 paediatric patients with NMDARE from the literature using the Bush-Francis Catatonia Rating Scale. Catatonia was common (occurring in 86% of patients), manifesting as complex clusters of positive and negative features within individual patients. It was both underrecognised and undertreated. Immunotherapy was the only effective intervention, highlighting the importance of prompt recognition and treatment of the underlying cause of catatonia.
The coronavirus crisis occurs at a time when many clinicians have already experienced burnout. One in three Irish doctors were suffering from burnout in the 2019 National Study of Wellbeing of Hospital Doctors in Ireland; rates are also high in Irish Psychiatry. We present a perspective on the use of narrative in medicine and recognise that storytelling, and the patient history are very much at the heart of medicine. Clinician storytelling, such as Schwartz Rounds and Balint group work, has very much come to the fore in Irish Psychiatry and in training. Projects such as MindReading have explored overlaps between clinicians, humanities experts and experts by experience. We give an overview of some approaches from the movement around narrative in medicine to bolster this. We explore why clinicians write as ways to support identification, catharsis and a way to process experiences. Clinicians and patients may also use literature and poetry to promote coping. The historical context and practical strategies are highlighted, particularly with reference to poetry use during the current crisis.
The experience of childhood trauma is linked to more severe symptoms and poorer functioning in severe mental disorders; however, the mechanisms behind this are poorly understood. We investigate the relationship between childhood trauma and sleep disturbances in severe mental disorders including the role of sleep disturbances in mediating the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.
In total, 766 participants with schizophrenia-spectrum (n = 418) or bipolar disorders (n = 348) were assessed with the Childhood Trauma Questionnaire. Sleep disturbances were assessed through the sleep items in the self-reported Inventory of Depressive Symptoms. Clinical symptoms and functioning were assessed with The Positive and Negative Syndrome Scale and the Global Assessment of Functioning Scale. Mediation analyses using ordinary least squares regression were conducted to test if sleep disturbances mediated the relationship between childhood trauma and the severity of clinical symptoms and poorer functioning.
Symptoms of insomnia, but not hypersomnia or delayed sleep phase, were significantly more frequent in participants with childhood trauma experiences compared to those without. Physical abuse, emotional abuse, and emotional neglect were significantly associated with insomnia symptoms. Insomnia symptoms partly mediate the relationship between childhood trauma and the severity of positive and depressive/anxiety symptoms, in addition to poorer functioning.
We found frequent co-occurrence of childhood trauma history and current insomnia in severe mental disorders. Insomnia partly mediated the relationship between childhood trauma and the severity of clinical symptoms and functional impairment.
Recently there has been a renewed interest in defining the boundaries and subdomains of the negative syndrome in schizophrenia and new scales have been asked for. Apathy is one of the symptoms in focus. The Apathy Evaluation Scale (AES) with its clinical version (AES-C) is one of the most used scales in an interdisciplinary context, but it has never previously been used in a population with first episode psychosis. The main aims of this study were to examine the psychometric properties of the AES-C and its relationship to the Positive and Negative Syndrome Scale (PANSS).
A total of 104 patients with first episode psychosis from the ongoing Thematic Organized Psychosis Research (TOP) study were included.
A factor analysis of the AES-C identified three subscales: Apathy, Insight and Social Contacts. Only the Apathy subscale showed satisfactory psychometric properties and showed acceptable convergent and discriminate properties by correlating strongly with the apathy-related items of the PANSS.
This study shows that the AES-C measures more than one dimension. The main factor, the Apathy subscale, can however be used to assess apathy in first episode psychosis patients in the ongoing work of refining the subdomains of the negative syndrome.
To examine adherence to a Mediterranean-like diet at age 9–10 years in relation to onset of breast development (thelarche) and first menstruation (menarche).
We evaluated the associations of adherence to a Mediterranean-like diet (measured by an adapted Mediterranean-like Diet Score, range 0–9) with thelarche at baseline, age at thelarche and time to menarche. Data were collected at baseline during a clinic visit, complemented with a mailed questionnaire and three 24 hour telephone dietary recalls, followed by annual follow-up questionnaires. Multivariable Poisson regression, linear regression and Cox proportional hazards regression were used to evaluate timing of pubertal development in relation to diet adherence.
New Jersey, USA.
Girls aged 9 or 10 years at baseline (2006–2014, n 202).
High Mediterranean-like diet adherence (score 6–9) was associated with a lower prevalence of thelarche at baseline compared with low adherence (score 0–3; prevalence ratio = 0·65, 95 % CI 0·48, 0·90). This may have been driven by consumption of fish and non-fat/low-fat dairy. Our models also suggested a later age at thelarche with higher Mediterranean-like diet adherence. Girls with higher Mediterranean-like diet adherence had significantly longer time to menarche (hazard ratio = 0·45, 95 % CI 0·28, 0·71 for high v. low adherence). Further analysis suggested this may have been driven by vegetable and non-fat/low-fat dairy consumption.
Consuming a Mediterranean-like diet may be associated with older age at thelarche and menarche. Further research is necessary to confirm our findings in other US paediatric populations and elucidate the mechanism through which Mediterranean-like diet may influence puberty timing.
The work of Aboriginal Education Workers (AEWs) in Australian schools is complex and multifaceted, and yet it is often misunderstood, or worse, devalued. Added to this, the conditions of employment for many AEWs is often insecure, with minimal pay, few opportunities for career progression or meaningful professional development. Despite this there continues to be, as there have been for decades, research findings, policies and reports attesting to the invaluable role of AEWs in schools and communities. The theoretical standpoint of Nakata's (2007) ‘cultural interface’ is used in this paper to critically (re) examine the role of AEWs in Australian schools. Drawing from relevant past and contemporary literature, this paper draws attention to past and contemporary theorising and policy concerning the roles of AEWs. It asserts that if the work of AEWs is to be better understood and valued then it must be reconsidered in a more transformative way that benefits both the students and schools which they support.
This article provides an overview of classification and outcome of eating disorders, before focusing on current evidence-based treatment for the two main disorders of anorexia nervosa and bulimia nervosa.
Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a form of encephalitis occurring primarily in women and associated with antibodies against NR1 or NR2 subunits of the NMDA receptor. As a potentially treatable differential for symptoms and signs seen in neurology and psychiatric clinics, clinicians practising across the lifespan should be aware of this form of encephalitis. Common clinical features include auditory and visual hallucinations, delusions, behavioural change (frequently with agitation), impaired consciousness, motor disturbance (ranging from dyskinesia to catatonia), seizures, and autonomic dysfunction. We present a review of the literature on the disorder, including its clinical presentation, differential diagnosis, epidemiology, treatment and prognosis.
This article reviews the recent changes to the DSM diagnostic classification of feeding and eating disorders with particular reference to children and adolescents. The common clinical presentations of the ‘atypical’ feeding and eating problems of middle childhood and early adolescence are reviewed using clinical case vignettes, and the limited evidence base regarding management is summarised. There are many gaps in the evidence base and this is likely to be an area of rapid development for the field subsequent on the new terminology outlined in DSM-5.
• Be able to describe the recent changes in terminology of DSM-5 for eating disorders in children and adolescents.
• Be able to provide information to young people and parents on the short- and long-term medical consequences of low weight in children.
• Be able to assess risk in children presenting with atypical eating disorders.
Dasha Nicholls, Honorary Senior Lecturer and Consultant Child and Adolescent Psychiatrist, Great Ormond Street Hospital, London, UK,
Elizabeth Barrett, Consultant in Child and Adolescent Liaison Psychiatry, Temple Street Hospital, Dublin, Ireland
This chapter provides an overview of classification and outcome of eating disorders, before focusing on current evidence-based treatment for the two main disorders of anorexia nervosa and bulimia nervosa. Eating disorders in childhood and adolescence present a serious threat to health and wellbeing, including medical consequences ranging from growth delay to life-threatening effects of starvation and refeeding (Nicholls et al, 2011a). Anorexia nervosa is frequently cited as the third most common chronic illness of adolescence (Lucas et al, 1991).
Setting the context: classification and epidemiology
Historically, the eating disorders (for which the majority of literature uses DSM terminology) comprise anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified (EDNOS), with separate classification of feeding disorders with onset before age 6. The point at which the responsibility for food intake changes from parent to child is complex, and includes factors such as the accurate recognition of hunger and satiety, knowledge of food hygiene and handling, sensory integration of texture and smell, as well as an understanding of nutritional needs. Eating disturbance is a common manifestation of emotional issues (anxiety, mood) and a medium through which autonomy and control are negotiated. There are therefore many potential mechanisms through which the feeding to eating transition can be deviated or delayed.
The revised classification of feeding and eating disorders in DSM-5 (American Psychiatric Association, 2013) and that proposed for ICD-11 recognises this continuous process. This will be an important conceptual shift. Key changes recommended for the classification of eating disorders (Uher & Rutter, 2012) can be summarised as follows.
• The merging of feeding and eating disorders into a single grouping with categories applicable across age groups.
• Diagnosis that can be made on the basis of behaviours (e.g. parental report of excessive exercise) that indicate fear of weight gain or other underlying fears or beliefs.
• Broadening the criteria for the diagnosis of anorexia nervosa and removing the requirement for amenorrhoea; extending the weight criterion to any significant underweight; and extending the cognitive criterion to include developmentally and culturally relevant presentations.
• Reducing the frequency requirement to meet diagnostic thresholds for binge eating and vomiting.
• Including binge eating disorder as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour.
Studies examining the association of dairy consumption with incident CHD have yielded inconsistent results. The current prospective study examined the association between dairy consumption and CHD in a population-based sample of older community-dwelling adults.
Baseline CHD risk factors were assessed and an FFQ was self-administered. Participants were followed for morbidity and mortality with periodic clinic visits and annual mailed questionnaires for an average of 16·2 years, with a 96 % follow-up rate for fatal and non-fatal CHD.
Participants were 751 men and 1008 women aged 50–93 years who attended a clinic visit in 1984–1987.
At baseline the mean age was 70·6 (sd 9·8) years for men and 70·1 (sd 9·3) years for women. Participants who developed CHD during follow-up were significantly older (P < 0·001), had higher BMI (P = 0·035) and higher total cholesterol (P = 0·050), and were more likely to be male (P < 0·001), diabetic (P = 0·011) and hypertensive (P < 0·001), than those who did not develop CHD. Multivariate regression analyses adjusting for age, BMI, diabetes, hypertension, LDL-cholesterol and oestrogen use (in women) indicated that women who consumed low-fat cheese ‘sometimes/often’ and women who consumed non-fat milk ‘sometimes/often’ had an increased risk of incident CHD (hazard ratio = 2·32; 95 % CI 1·57, 3·41) and CHD (hazard ratio = 1·48; 95 % CI 1·02, 2·16) compared with women who ‘never/rarely’ ate these dairy products.
Woman with higher intake of low-fat cheese and non-fat milk seem to have a higher risk of incident CHD. This needs further investigation considering recent evidence of cardiovascular benefits from certain dairy fat.