MONDAY 3RD NOVEMBER: A PAEDSOC + PSYCHSOC JOINT EVENT
A record turn-out of MedSoc members, homemade cakes, bottomless wine glasses and a fantastic professional husband and wife team made for a magnificent MedSoc Monday event. Last week, the UCL Harrie Massey Lecture Theatre was taken over by a host of enthusiastic medical students of all ages and stages in training. The speakers – Dr Rory Conn a child and adolescent psychiatrist and Dr Chloe Bulwer, a paediatrician both currently working at ICH and Great Ormond Street provided an inspiring and engaging discussion of the overlap between the two specialties. Four cases were discussed.
Case one – constipation in a 7 year old boy with an anxious mother. Key points of interest included the impact of missing school at this age, and the distinction between functional and medical causes of constipation. Defaecating can undeniably become a psychological challenge particularly when previous fissures lead to an association with discomfort or pain of with parental obsession or despair when toilet training causes sensitisation to an essential daily task. This case also highlighted, however, that paediatricians can deal with some psychological issues themselves. Interventions such as star charts, laxatives, exercise and normalising of toileting behaviour are possible without psychiatric input.
Case two – ‘fitting’ for a psychiatrist – explored the fascinating case of a young child having what appeared to be seizures. The child would frequently fall to the floor with no prior warning. These unexpected attacks would happen utterly randomly, whilst the child was mid-sentence or, even, whilst on the stairs. Interestingly, though, the child never sustained any injuries during these ‘seizures’ and would recover relatively quickly. It was these factors, combined with the impact upon the child’s life who was now frequently missing school, which led to the transfer of the case to the psychiatry team. After several meetings it transpired that the child had been feeling severely anxious about his transition to high school. Whilst this move was still 18 months away the child was feeling the pressure. Having aired these anxieties and learnt to deal with them the child’s ‘seizures’ stopped and he was able to return to a less stressful school life. Having touched upon the topic of seizures the case then allowed us to explore the varied nomenclature of seizures and the proposed stigma behind the label ‘pseudo-seizure.’
Case three – highlighted the importance of family trees in both paediatrics and psychiatry. A lot of medical problems can be traced back directly, or indirectly, to other family health issues. This strategy of showing natural linkage can help children to engage in and understand more the ‘why me?’ aspect of coping with a medical condition at a young age. This case described a 15 year old girl with type 1 diabetes. Her mother and sister, unusually, also had the condition and managed to keep their blood sugars under good control. The 15 year old however had poor control with medically unexplained hypoglycaemic attacks and seizures. Finding additional used insulin on the girl’s person prompted some handover from paediatrics to psychiatry. Was this girl purposefully injecting insulin as an attempt at weight control, self-harm or attention seeking? Although paediatricians are essential to ensure good management of this chronic condition, this would be imposssible without compliance from the patient. Psychiatrics therefore become indispensible in investigating a patient’s coping mechanisms and attitude towards their diagnosis alongside illiciting a complete psychiatric history and management plan. Drs Conn and Bulwer discussed the difficulties of helping this girl who denied inflicting any problems on herself and the possibility or dissociative amnesia or genuine lack of awareness of her actions. The case also highlighted the importance of family meetings and rapid response to potentially life-threatening scenarios.
Case four – raised some questions about handover into adult services. In Australia, there are specialist psychiatrists for the age range 16-25 due to the complex and clear psychological challenges and changes at this time. Potentially a very influential sub-specialty as 1 in 4 adolescents will attempt self-harm of some sort and, at this age, suicide, particularly male, is the commonest cause of death. We discussed a 20 year old gentleman with an expansive pituitary tumour. He was treated with Cabergoline, a commonly used dopamine agonist in Parkinson’s disease. This massively reduced his production of prolactin and along with hormone treatment the boy completed puberty and reached his full height potential. Physically, the endocrinologists were very pleased with this treatment response and, with the tumour location and spread, felt that surgery or radiotherapy were not desirable management options. The paediatricians faced a new challenge when the boy experienced extreme, unanticipated side effects of the Cabergoline and decided to ask the psychiatrists for help. The boy was experiencing what he perceived to be undesirable and uncharacteristic sexual impulses. It is well-documented that some Parkinson’s patients can become impulsive with treatment for example beginning to gamble and shop excessively. The boy was becoming distressed by his ‘need’ to masturbate, impulse to watch porn and potential attraction to males around him. In this case, as the medication had to be continued, psychological input was essential to ensure that this highly functioning university student could keep the impulses under control so as not to jeopardize his social life, education or even future employment. A hard balance to make but a nice example of multi-disciplinary teams weighing up the cost and benefit of a particular treatment ensuring the psychological impact is minimised.
With anonymous questions literally pulled from a hat between case studies we were able to facilitate discussion of taboo and difficult topics students may not have wished to have shouted out themselves. These included how to pursue an interest in Psychiatry when faced by the stigma against the specialty from other professionals and even parents, which specialty creates the best dinner party stories and the variation in on-call rotas and responsibilities (don’t chose paediatrics if you want to sleep at weekends!). Audience participation was relaxed and general atmosphere one of enthusiasm and enjoyment. As psychsoc and paedsoc presidents we were thrilled to see so much interest in the two specialities and honoured to have such a generous and honest perspective from a couple of highly-experienced professionals.
To more events!
Elspeth and Rosie