AFFECTIVE/MOOD AND PERSONALITY DISORDERS

1. AFFECTIVE/MOOD AND PERSONALITY DISORDERS Stefan Da Silva 2006 (with a little help from Moritz and Dave)

2. Overview • Approach to Psych Pt • Affective Disorder • aka mood disorder • Major depressive • Bipolar • Personality Disorders • Cluster “A” (mad) • Cluster “B” (bad) • Cluster “C” (sad) • Quiz

3. Approach to Psych Pt’s • Safety, safety, safety. • Security, stand between pt and door, keep door open if required • Interview • Focus on trying to delineate between medical and mental • Focus on trying to determine disposition • ie. Does pt need to be “formed” • Psychosis, suicidal, homicidal • Collateral Hx • Parents, spouse, police etc • OLD CHARTS!!!!! • Family Hx • General Medical Conditions • Medical Clearance (we’ll talk more about this later) • Our job: more of a risk assessment and disposition issue rather than a DSM-IV diagnosis

4. Medical Clearance • What is medical clearance? • “Evaluation and treatment of organic causes of presenting psychiatric complaints, and any existing medical comorbidities prior to transfer of care to the psychiatric service.”EmergMedClin. 18(2):185-198. 2000 • What constitutes a “medically clear” patient? • No physical illness identified • Known co morbid illness but not thought causative • Adequately treated medical condition

5. Medical Clearance • Functional vs. Organic • History • WHY NOW? • Precipitating events and chronology • baseline mental / physical status • prior psychiatric history / family psych hx • past medical history • Meds / drugs of abuse • collateral hx (friends, family, EMS, old charts) • MSE

6. Organic Age <12 or >40 yo Sudden onset (hrs-days) Fluctuating course Disorientation Dec’d LOC Visual hallucinations No psychiatric Hx Emotional lability Abnormal vitals / exam Hx of substance abuse / toxins Functional Age 13 – 40 yo Gradual onset (wks-mo’s) Continuous course Scattered thoughts Awake and alert Auditory hallucinations Past psychiatric Hx Flat affect Normal physical exam / vitals No evidence of drug use Medical Clearance EmergMedClin. 18(2):185-198. 2000

7. Psych Interview • Safety First • Open ended questions • Mental Status Exam • General Description • Mood and Affect • Speech • Perceptual Disturbances • Thought • Cognition • Impulse Control • Judgement and Insight • Reliability

8. General Tidbits and Useless Information • 20 – 40% of homeless people in US have major mental illness • 23% of psych patients will have mood disorder of some sort • Approx 5.4% of all ED visits are psych related • Lifetime risk for suicide in pt’s with untreated depressive illness is 15% • Mood = “enduring emotional orientation that colors the person’s psychology”

9. Mood/Affective Disorders • Approx 23% of psych • Females > Males • Disturbances in 4 major areas • Mood • Psychomotor Activity • Cognition • Vegetative Functioning • Can be episodic • Can have some features of schizophrenia • ie. Hallucinations, delusions, etc.

10. Etiology • Biological • Neurotransmitter • Biological amines eg. Serotonin, norepi, dopamine • Decreased amounts seemed to correlate with decreased mood • Brain • Locus cerulus  prolonged stress decreases neuronal activity responsible for alertness, appetite etc • Median Forebrain bundle  prolonged stress decreases norepi  decrease energy and interest • Dorsal Raphe  decreased serotonin  affects sleep, libido, appetite • Tuberoinfundibular system  pleasure, emotion, learning • Genetic • Family studies • 50% have 1st degree relative • Identical twins 50% • Siblings 15% • Psychosocial Factors • Stress • learned helplessness • Traumatic experience ie. loss of parent

11. Major Depressive Disorder • Lifetime prevalance of 15% • Mean onset 40 yrs • Decreased mood, suicidal • Anhedonia  inability to experience pleasure or interest in formerly pleasurable or satisfying activities • Psychomotor: retardation, agitation, vegetative • Sometimes psychosis • In SAD CAGES • Interest, sleep, appetite, depressed mood, concentration, activity, guilt, energy, suicide

12. Major Depressive Disorder • Differential Diagnosis • Other psychiatric conditions • Substance induced mood disorders • Mood disorder due to GMC • Normal bereavement • Comorbid medical conditions must be identified and ruled out • May present atypically • ie. Vague physical symptoms weakness, pain, fatigue, heavy users of medical care.

13. Major Depressive Disorder • DSM-IV Criteria

14. Major Depressive Disorder • Disturbances in Mood • Sad, gloomy, dejected, unhappy, discouraged • Changes in Psychomotor Activity • Retardation • Slowing of thought processes and physical activity • Agitation • Fidgety, pacing, unable to sit still • Cognitive Changes • Unable to think or concentrate properly • Feelings of overwhelming guilt • Vegetative Changes • Changes in sleep, appetite, and sexual function

15. Major Depressive Disorder • Treatment Options • Usually not started in ER • Aside from anxiolytics or antipsychotics • SSRI’s, MAOI’s, TCA’s (usually takes 4 to 6 weeks) • ECT (severe depression with malnutrition, psychosis, suicide risk) • CBT (community based support groups etc.) • “Rapid Tranquilization” (Rosen’s) • Haldol 5mg IM plus Ativan 2mg IM repeated q30 -45mins until resolution of “target” symptoms

16. Other Depressive Disorders • SAD • Seasonal affective disorder • phototherapy • Postpartum • 65% of mothers report some depressed mood after childbirth • More severe in mothers with pre-existing mood disorder • Dsythymic • Chronic decreased mood for most of a day for most days for at least 2 yrs

17. General Medical Condition and Depression • LOTS! • Parkinson’s • MS • Pancreatic CA • Thyroid • MI • ESRD • Lupus • Substance Abuse

18. Bipolar Disorders • “episodic exacerbation of symptoms and deterioration of function characterized by extreme mood swings” • “Mania”  “revved up”, may need restraining, pressured speech, grandiosity, decreased need for sleep, promiscuity. • Disturbance must be severe enough to cause pyschosis, the need for hospitalization, or marked impairment in functioning.

19. Bipolar Disorder • DSM-IV Criteria for Mania • A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary)B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:1) inflated self-esteem or grandiosity2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) more talkative than usual or pressure to keep talking4) flight of ideas or subjective experience that thoughts are racing5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)C) The symptoms do not meet criteria for a Mixed EpisodeD) The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.E) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)

20. Bipolar Disorder • Mania • DIGFAST • Distractibility • Indiscretion (“excessive involvment in pleasurable activities) • Grandiosity • Flight of Ideas • Activity Increase • Sleep Deficit • Talkativeness (pressured speech)

21. Bipolar Disorder • Epidemiology • Lifetime risk ~1% • Similar in men and women and across races • Mean age of onset 21 years • More than 90% of people who have manic episode will have additional episodes of mania or major depression • Genetic studies • 90% bipolar patients have first degree relative with mood disorder • Adoption studies support genetic etiology • Linkage studies • X-linked • Chromosome 11 • Diagnosis • Bipolar I Disorder: 1 or more manic or mixed episodes • Mixed episodes: 1 week period were patient meets criteria for both manic episodes and MDE

22. Bipolar Disorder • Patient usually brought to ED by someone else • Volatile moods • Often try to leave ASAP • May need to be restrained • Pressured speech, grandiosity, massive undertakings • Decreased need for sleep • Disregard for consequences of actions • May present as trauma patients (injured by action reflected by grandiosity, impulsivity, or belligerence)

23. Bipolar I • Bipolar I • Lifetime prevalance of 1% • Mean age 30 yrs old • Needs “single manic episode”  psychosis, impairment in function, hospitalization • Depression cycling with mania • Suicide attempt common for both bipolar I and II disorders • Comorbid medical problems can deteriorate because of poor compliance • Reckless behaviors can increase risk of STD and injury • ETOH and drug abuse frequently complicate manic episodes • Eating disorders • Anxiety disorders • ADHD

24. Bipolar II • MDE with cycling of hypomanic episode • DSM IV Criteria • A) A distinct period of persistently elevated, expansive or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.B) During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:1) inflated self-esteem or grandiosity2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) more talkative than usual or pressure to keep talking4) flight of ideas or subjective experience that thoughts are racing5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitation7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)C) The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.D) The disturbance in mood and the change in functioning are observable by others.E) The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.F) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)

25. Bipolar Disorders • Mood stabilizing drugs • Lithium, Valproate, Carbamazepine • Usually takes > 3 weeks • Psychotherapy • Especially for family support

26. Personality Disorders • When personality traits cause impairment it leads to personality disorder • Cluster A  mad • Paranoid • Schizoid • Schizotypal • Cluster B  bad • Antisocial • Borderline • Narcissistic • Histrionic • Cluster C  sad • Avoidant • Dependant • Obsessive-Compulsive

27. Personality Disorders • DSM-IV Criteria for most • Etiology • Genetic • Tempermental • ie. Nature vs nuture • “goodness of fit” ie child may be hyperactive if kept in small closed apartment but not in a large house and yard. • Biological • Impulsivity linked to increased levels of hormones in animals

28. Personality Disorders • Paranoid • Suspiciousness, mistrust of people • May seem hostile, irritable, and angry during exam • 0.5 – 2.5% of personality d/o • Male > female • Tx: various anxiolytics and antipsychotics

29. Personality Disorder • Schizoid • Lifelong pattern of social withdrawal • Bland constricted affect • Can be seen in up to 7.5% of general population • May have poor eye contact and seem cold and aloof during exam • Solitary jobs • Tx: antipsychotics, antidepressants, psychostimulants

30. Personality Disorders • Schizotypal • ODD!!! • “magical thinking”, peculiar ideas, odd speech and thought processes • Up to 3% of general population • Tx: antipsychotics

31. Personality Disorders • Antisocial • Inability to conform to social norms • Continous antisocial/criminal acts • 7.5% of prison population • Low socioeconomic status • “stress interview” • Confront patient with inconsistencies in their story may reveal underlying disorder • Lack of remorse • Begins in adolescence • “Always in trouble” • TX: careful pharmacotherapy due to tendancy to drug abuse

32. Personality Disorder • Borderline • “border” b/w neurosis and psychosis • Unstable affect, mood, behavior • 1 – 2 % of pop. • Seemingly always in state of “crisis” • “self-mutilation” • Need for companionship • Tx: psychotherapy plus pharmacotherapy (anticonvulsants)

33. Personality Disorders • Histrionic • Colorful, dramatic, extroverted behavior • Center of attention • Unable to maintain deep relationships • EAGER to give incredibly detailed hx! • Need for reassurance • Tx: pharmacotherapy for symptomatic relief

34. Personality Disorder • Narcissitic • 2 – 16% of pop. • Grandiose sense of self-importance • Belief that he/she is “special” • Requires excessive admiration • “DIVA-like” • Tx: not much

35. Personality Disorder • Avoidant • Extreme sensitivity to rejection • 1 – 10% • Poor self-esteem • Anxious during interview • Tx: occ. B-blockers to manage nervous hyperactivity

36. Personality Disorders • Dependant • Subordinate their own needs to those of others • Need for compansionship • 2.5% of all personality d/o • Submissive behaviour • Usually in abusive relationship and will tolerate • Tx: various pharmacotherapies

37. Personality Disorders • Obessive-Compulsive • Pervasive pattern of perfectionism and inflexability • Constricted affect • Preoccupied with rules, regulations, orderliness, neatness, and achievement of perfection • Anxious when routine threatened • Actually have o.k insight re: their problems and will seek medical treatment.

38. So what the rip does this all mean???? • Our Job • r/o general medical condition and medically clear patient • Determine who needs possible hospital admission • Criteria (Rosen’s) • Suicidal and homicidal risk • Lacks capacity to co-operate with outpt tx • Inadequate psychosocial support for safe outpatient tx and compliance • Comorbid condition or complication that makes outpatient tx unsafe (ie. Bizarre behaviour, acute psychosis) • Stabilize acute episodes and ensure patient and staff safety