AFFECTIVE/MOOD AND PERSONALITY DISORDERS

AFFECTIVE/MOOD AND AFFECTIVE/MOOD AND PERSONALITY DISORDERSPERSONALITY DISORDERS

Stefan Da SilvaStefan Da Silva20062006

(with a little help from Moritz and (with a little help from Moritz and Dave)Dave)

OverviewOverview• Approach to Psych PtApproach to Psych Pt• Affective DisorderAffective Disorder

– aka mood disorderaka mood disorder• Major depressive Major depressive • BipolarBipolar

• Personality DisordersPersonality Disorders– Cluster “A” (mad)Cluster “A” (mad)– Cluster “B” (bad)Cluster “B” (bad)– Cluster “C” (sad)Cluster “C” (sad)

• QuizQuiz

Approach to Psych Pt’sApproach to Psych Pt’s• Safety, safety, safety.Safety, safety, safety.

– Security, stand between pt and door, keep door open if Security, stand between pt and door, keep door open if requiredrequired

• InterviewInterview– Focus on trying to delineate between medical and Focus on trying to delineate between medical and

mentalmental– Focus on trying to determine dispositionFocus on trying to determine disposition

• ie. Does pt need to be “formed”ie. Does pt need to be “formed” Psychosis, suicidal, homicidalPsychosis, suicidal, homicidal

– Collateral HxCollateral Hx• Parents, spouse, police etcParents, spouse, police etc

– OLD CHARTS!!!!!OLD CHARTS!!!!!– Family HxFamily Hx– General Medical ConditionsGeneral Medical Conditions– Medical Clearance (we’ll talk more about this later)Medical Clearance (we’ll talk more about this later)– Our job: more of a risk assessment and disposition Our job: more of a risk assessment and disposition

issue rather than a DSM-IV diagnosis issue rather than a DSM-IV diagnosis

Medical ClearanceMedical Clearance• What is medical clearance?What is medical clearance?

– ““Evaluation and treatment of organic causes of Evaluation and treatment of organic causes of presenting psychiatric complaints, and any presenting psychiatric complaints, and any existing medical comorbidities prior to transfer of existing medical comorbidities prior to transfer of care to the psychiatric service.”care to the psychiatric service.”EmergMedClin. 18(2):185-198. 2000EmergMedClin. 18(2):185-198. 2000

• What constitutes a “medically clear” patient?What constitutes a “medically clear” patient?– No physical illness identifiedNo physical illness identified– Known co morbid illness but not thought causativeKnown co morbid illness but not thought causative– Adequately treated medical conditionAdequately treated medical condition

Medical ClearanceMedical Clearance• Functional vs. OrganicFunctional vs. Organic

– HistoryHistory•WHY NOW?WHY NOW?•Precipitating events and chronologyPrecipitating events and chronology•baseline mental / physical statusbaseline mental / physical status•prior psychiatric history / family psych hxprior psychiatric history / family psych hx•past medical historypast medical history•Meds / drugs of abuseMeds / drugs of abuse•collateral hx (friends, family, EMS, old collateral hx (friends, family, EMS, old

charts)charts)•MSEMSE

Medical ClearanceMedical Clearance• OrganicOrganic

– Age <12 or >40 yoAge <12 or >40 yo– Sudden onset (hrs-Sudden onset (hrs-

days)days)– Fluctuating courseFluctuating course– DisorientationDisorientation– Dec’d LOCDec’d LOC– Visual hallucinationsVisual hallucinations– No psychiatric HxNo psychiatric Hx– Emotional labilityEmotional lability– Abnormal vitals / examAbnormal vitals / exam– Hx of substance Hx of substance

abuse / toxinsabuse / toxins

• FunctionalFunctional– Age 13 – 40 yoAge 13 – 40 yo– Gradual onset (wks-Gradual onset (wks-

mo’s)mo’s)– Continuous courseContinuous course– Scattered thoughtsScattered thoughts– Awake and alertAwake and alert– Auditory hallucinationsAuditory hallucinations– Past psychiatric HxPast psychiatric Hx– Flat affectFlat affect– Normal physical exam / Normal physical exam /

vitalsvitals– No evidence of drug No evidence of drug

useuseEmergMedClin. 18(2):185-198. 2000

Psych InterviewPsych Interview• Safety FirstSafety First• Open ended questionsOpen ended questions• Mental Status ExamMental Status Exam

– General DescriptionGeneral Description– Mood and AffectMood and Affect– SpeechSpeech– Perceptual DisturbancesPerceptual Disturbances– ThoughtThought– CognitionCognition– Impulse ControlImpulse Control– Judgement and InsightJudgement and Insight– ReliabilityReliability

General Tidbits and Useless General Tidbits and Useless InformationInformation• 20 – 40% of homeless people in US have 20 – 40% of homeless people in US have

major mental illnessmajor mental illness• 23% of psych patients will have mood 23% of psych patients will have mood

disorder of some sortdisorder of some sort• Approx 5.4% of all ED visits are psych Approx 5.4% of all ED visits are psych

relatedrelated• Lifetime risk for suicide in pt’s with Lifetime risk for suicide in pt’s with

untreated depressive illness is 15%untreated depressive illness is 15%• Mood = “enduring emotional orientation that Mood = “enduring emotional orientation that

colors the person’s psychology”colors the person’s psychology”

Mood/Affective DisordersMood/Affective Disorders• Approx 23% of psychApprox 23% of psych• Females > MalesFemales > Males• Disturbances in 4 major areasDisturbances in 4 major areas

– MoodMood– Psychomotor ActivityPsychomotor Activity– CognitionCognition– Vegetative FunctioningVegetative Functioning

• Can be episodicCan be episodic• Can have some features of schizophreniaCan have some features of schizophrenia

– ie. Hallucinations, delusions, etc.ie. Hallucinations, delusions, etc.

EtiologyEtiology• BiologicalBiological

– NeurotransmitterNeurotransmitter• Biological amines eg. Serotonin, norepi, dopamineBiological amines eg. Serotonin, norepi, dopamine

– Decreased amounts seemed to correlate with decreased moodDecreased amounts seemed to correlate with decreased mood– BrainBrain

• Locus cerulus Locus cerulus prolonged stress decreases neuronal activity responsible prolonged stress decreases neuronal activity responsible for alertness, appetite etcfor alertness, appetite etc

• Median Forebrain bundle Median Forebrain bundle prolonged stress decreases norepi prolonged stress decreases norepi decrease decrease energy and interestenergy and interest

• Dorsal Raphe Dorsal Raphe decreased serotonin decreased serotonin affects sleep, libido, appetite affects sleep, libido, appetite• Tuberoinfundibular system Tuberoinfundibular system pleasure, emotion, learning pleasure, emotion, learning

• GeneticGenetic– Family studies Family studies

• 50% have 150% have 1stst degree relative degree relative• Identical twins 50%Identical twins 50%• Siblings 15%Siblings 15%

• Psychosocial FactorsPsychosocial Factors– Stress Stress – learned helplessnesslearned helplessness– Traumatic experience ie. loss of parent Traumatic experience ie. loss of parent

Major Depressive DisorderMajor Depressive Disorder• Lifetime prevalance of 15%Lifetime prevalance of 15%• Mean onset 40 yrs Mean onset 40 yrs • Decreased mood, suicidalDecreased mood, suicidal• Anhedonia Anhedonia inability to experience pleasure or inability to experience pleasure or

interest in formerly pleasurable or satisfying interest in formerly pleasurable or satisfying activitiesactivities

• Psychomotor: retardation, agitation, vegetativePsychomotor: retardation, agitation, vegetative• Sometimes psychosisSometimes psychosis• In SAD CAGESIn SAD CAGES

– Interest, sleep, appetite, depressed mood, concentration, Interest, sleep, appetite, depressed mood, concentration, activity, guilt, energy, suicideactivity, guilt, energy, suicide

Major Depressive DisorderMajor Depressive Disorder• Differential DiagnosisDifferential Diagnosis

– Other psychiatric conditionsOther psychiatric conditions– Substance induced mood disordersSubstance induced mood disorders– Mood disorder due to GMCMood disorder due to GMC– Normal bereavementNormal bereavement– Comorbid medical conditions must be Comorbid medical conditions must be

identified and ruled outidentified and ruled out– May present atypically May present atypically

• ie. Vague physical symptoms weakness, pain, ie. Vague physical symptoms weakness, pain, fatigue, heavy users of medical care.fatigue, heavy users of medical care.

Major Depressive DisorderMajor Depressive Disorder• DSM-IV CriteriaDSM-IV Criteria

Major Depressive DisorderMajor Depressive Disorder• Disturbances in MoodDisturbances in Mood

– Sad, gloomy, dejected, unhappy, discouragedSad, gloomy, dejected, unhappy, discouraged• Changes in Psychomotor ActivityChanges in Psychomotor Activity

– RetardationRetardation• Slowing of thought processes and physical activitySlowing of thought processes and physical activity

– AgitationAgitation• Fidgety, pacing, unable to sit still Fidgety, pacing, unable to sit still

• Cognitive ChangesCognitive Changes– Unable to think or concentrate properlyUnable to think or concentrate properly– Feelings of overwhelming guiltFeelings of overwhelming guilt

• Vegetative ChangesVegetative Changes– Changes in sleep, appetite, and sexual functionChanges in sleep, appetite, and sexual function

Major Depressive DisorderMajor Depressive Disorder• Treatment OptionsTreatment Options

– Usually not started in ERUsually not started in ER• Aside from anxiolytics or antipsychoticsAside from anxiolytics or antipsychotics

– SSRI’s, MAOI’s, TCA’s (usually takes 4 to 6 weeks)SSRI’s, MAOI’s, TCA’s (usually takes 4 to 6 weeks)– ECT (severe depression with malnutrition, ECT (severe depression with malnutrition,

psychosis, suicide risk)psychosis, suicide risk)– CBT (community based support groups etc.)CBT (community based support groups etc.)

• ““Rapid Tranquilization” (Rosen’s) Rapid Tranquilization” (Rosen’s) – Haldol 5mg IM plus Ativan 2mg IM repeated q30 -Haldol 5mg IM plus Ativan 2mg IM repeated q30 -

45mins until resolution of “target” symptoms45mins until resolution of “target” symptoms

Other Depressive DisordersOther Depressive Disorders• SADSAD

– Seasonal affective disorderSeasonal affective disorder– phototherapyphototherapy

• PostpartumPostpartum– 65% of mothers report some depressed mood 65% of mothers report some depressed mood

after childbirthafter childbirth– More severe in mothers with pre-existing mood More severe in mothers with pre-existing mood

disorderdisorder• DsythymicDsythymic

– Chronic decreased mood for most of a day for Chronic decreased mood for most of a day for most days for at least 2 yrsmost days for at least 2 yrs

General Medical Condition and General Medical Condition and DepressionDepression• LOTS!LOTS!

– Parkinson’sParkinson’s– MSMS– Pancreatic CAPancreatic CA– ThyroidThyroid– MIMI– ESRDESRD– LupusLupus– Substance AbuseSubstance Abuse

Bipolar DisordersBipolar Disorders• ““episodic exacerbation of symptoms and episodic exacerbation of symptoms and

deterioration of function characterized by deterioration of function characterized by extreme mood swings”extreme mood swings”

• ““Mania” Mania” “revved up”, may need “revved up”, may need restraining, pressured speech, grandiosity, restraining, pressured speech, grandiosity, decreased need for sleep, promiscuity.decreased need for sleep, promiscuity.

• Disturbance must be severe enough to cause Disturbance must be severe enough to cause pyschosis, the need for hospitalization, or pyschosis, the need for hospitalization, or marked impairment in functioning.marked impairment in functioning.

Bipolar DisorderBipolar Disorder• DSM-IV Criteria for ManiaDSM-IV Criteria for Mania

• A) A distinct period of abnormally and persistently elevated, expansive or irritable mood, 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)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 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:persisted (four if the mood is only irritable) and have been present to a significant degree:1) inflated self-esteem or grandiosity1) inflated self-esteem or grandiosity2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) more talkative than usual or pressure to keep talking3) more talkative than usual or pressure to keep talking4) flight of ideas or subjective experience that thoughts are racing4) flight of ideas or subjective experience that thoughts are racing5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external 5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)stimuli)6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor 6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitationagitation7) excessive involvement in pleasurable activities that have a high potential for painful 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)business investments)C) The symptoms do not meet criteria for a Mixed EpisodeC) The symptoms do not meet criteria for a Mixed EpisodeD) The mood disturbance is sufficiently severe to cause marked impairment in occupational D) 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 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.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 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., of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)hyperthyroidism)

Bipolar DisorderBipolar Disorder• ManiaMania

– DIGFASTDIGFAST• DistractibilityDistractibility• Indiscretion (“excessive involvment in pleasurable Indiscretion (“excessive involvment in pleasurable

activities)activities)• GrandiosityGrandiosity• Flight of IdeasFlight of Ideas• Activity IncreaseActivity Increase• Sleep DeficitSleep Deficit• Talkativeness (pressured speech)Talkativeness (pressured speech)

Bipolar DisorderBipolar Disorder• EpidemiologyEpidemiology

– Lifetime risk ~1%Lifetime risk ~1%– Similar in men and women and across racesSimilar in men and women and across races– Mean age of onset 21 yearsMean age of onset 21 years– More than 90% of people who have manic episode will have additional More than 90% of people who have manic episode will have additional

episodes of mania or major depressionepisodes of mania or major depression• Genetic studiesGenetic studies

– 90% bipolar patients have first degree relative with mood disorder 90% bipolar patients have first degree relative with mood disorder – Adoption studies support genetic etiologyAdoption studies support genetic etiology– Linkage studiesLinkage studies

• X-linkedX-linked• Chromosome 11Chromosome 11

• DiagnosisDiagnosis– Bipolar I Disorder: 1 or more manic or mixed episodesBipolar I Disorder: 1 or more manic or mixed episodes– Mixed episodes: 1 week period were patient meets criteria for both Mixed episodes: 1 week period were patient meets criteria for both

manic episodes and MDEmanic episodes and MDE

Bipolar DisorderBipolar Disorder– Patient usually brought to ED by someone elsePatient usually brought to ED by someone else– Volatile moodsVolatile moods– Often try to leave ASAPOften try to leave ASAP– May need to be restrainedMay need to be restrained– Pressured speech, grandiosity, massive undertakingsPressured speech, grandiosity, massive undertakings– Decreased need for sleepDecreased need for sleep– Disregard for consequences of actionsDisregard for consequences of actions– May present as trauma patients (injured by action May present as trauma patients (injured by action

reflected by grandiosity, impulsivity, or belligerence)reflected by grandiosity, impulsivity, or belligerence)

Bipolar IBipolar I• Bipolar IBipolar I

– Lifetime prevalance of 1%Lifetime prevalance of 1%– Mean age 30 yrs oldMean age 30 yrs old– Needs “single manic episode” Needs “single manic episode” psychosis, impairment in psychosis, impairment in

function, hospitalizationfunction, hospitalization– Depression cycling with maniaDepression cycling with mania– Suicide attempt common for both bipolar I and II disordersSuicide attempt common for both bipolar I and II disorders– Comorbid medical problems can deteriorate because of poor Comorbid medical problems can deteriorate because of poor

compliancecompliance– Reckless behaviors can increase risk of STD and injuryReckless behaviors can increase risk of STD and injury– ETOH and drug abuse frequently complicate manic episodesETOH and drug abuse frequently complicate manic episodes– Eating disordersEating disorders– Anxiety disordersAnxiety disorders– ADHDADHD

Bipolar IIBipolar II• MDE with cycling of hypomanic episodeMDE with cycling of hypomanic episode• DSM IV CriteriaDSM IV Criteria• A) A distinct period of persistently elevated, expansive or irritable mood, lasting throughout 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.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 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:persisted (four if the mood is only irritable) and have been present to a significant degree:1) inflated self-esteem or grandiosity1) inflated self-esteem or grandiosity2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)3) more talkative than usual or pressure to keep talking3) more talkative than usual or pressure to keep talking4) flight of ideas or subjective experience that thoughts are racing4) flight of ideas or subjective experience that thoughts are racing5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external 5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)stimuli)6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor 6) increase in goal-directed activity (at work, at school, or sexually) or psychomotor agitationagitation7) excessive involvement in pleasurable activities that have a high potential for painful 7) excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)business investments)C) The episode is associated with an unequivocal change in functioning that is C) The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.uncharacteristic of the person when not symptomatic.D) The disturbance in mood and the change in functioning are observable by others.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 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 occupational functioning, or to necessitate hospitalization, and there are no psychotic features.features.F) The symptoms are not due to the direct physiological effects of a substance (e.g., a drug 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., of abuse, a medication or other treatment) or a general medical condition (e.g., hyperthyroidism)hyperthyroidism)

Bipolar DisordersBipolar Disorders• Mood stabilizing drugsMood stabilizing drugs

– Lithium, Valproate, CarbamazepineLithium, Valproate, Carbamazepine– Usually takes > 3 weeksUsually takes > 3 weeks

• PsychotherapyPsychotherapy– Especially for family supportEspecially for family support

Personality DisordersPersonality Disorders• When personality traits cause impairment it leads to When personality traits cause impairment it leads to

personality disorderpersonality disorder• Cluster A Cluster A mad mad

– ParanoidParanoid– SchizoidSchizoid– SchizotypalSchizotypal

• Cluster B Cluster B bad bad– AntisocialAntisocial– BorderlineBorderline– NarcissisticNarcissistic– HistrionicHistrionic

• Cluster C Cluster C sad sad– AvoidantAvoidant– DependantDependant– Obsessive-CompulsiveObsessive-Compulsive

Personality DisordersPersonality Disorders• DSM-IV Criteria for most DSM-IV Criteria for most • EtiologyEtiology

– GeneticGenetic– Tempermental Tempermental

• ie. Nature vs nutureie. Nature vs nuture– ““goodness of fit” ie child may be hyperactive if kept in goodness of fit” ie child may be hyperactive if kept in

small closed apartment but not in a large house and yard.small closed apartment but not in a large house and yard.– BiologicalBiological

• Impulsivity linked to increased levels of hormones in Impulsivity linked to increased levels of hormones in animalsanimals

Personality DisordersPersonality Disorders• ParanoidParanoid

– Suspiciousness, mistrust of peopleSuspiciousness, mistrust of people– May seem hostile, irritable, and angry May seem hostile, irritable, and angry

during examduring exam– 0.5 – 2.5% of personality d/o0.5 – 2.5% of personality d/o– Male > femaleMale > female– Tx: various anxiolytics and Tx: various anxiolytics and

antipsychoticsantipsychotics

Personality DisorderPersonality Disorder• SchizoidSchizoid

– Lifelong pattern of social withdrawalLifelong pattern of social withdrawal– Bland constricted affectBland constricted affect– Can be seen in up to 7.5% of general populationCan be seen in up to 7.5% of general population– May have poor eye contact and seem cold and May have poor eye contact and seem cold and

aloof during examaloof during exam– Solitary jobsSolitary jobs– Tx: antipsychotics, antidepressants, Tx: antipsychotics, antidepressants,

psychostimulantspsychostimulants

Personality DisordersPersonality Disorders• SchizotypalSchizotypal

– ODD!!!ODD!!!– ““magical thinking”, peculiar ideas, odd magical thinking”, peculiar ideas, odd

speech and thought processesspeech and thought processes– Up to 3% of general populationUp to 3% of general population– Tx: antipsychoticsTx: antipsychotics

Personality DisordersPersonality Disorders• AntisocialAntisocial

– Inability to conform to social normsInability to conform to social norms– Continous antisocial/criminal actsContinous antisocial/criminal acts– 7.5% of prison population7.5% of prison population– Low socioeconomic statusLow socioeconomic status– ““stress interview”stress interview”

• Confront patient with inconsistencies in their story may reveal Confront patient with inconsistencies in their story may reveal underlying disorderunderlying disorder

– Lack of remorseLack of remorse– Begins in adolescenceBegins in adolescence– ““Always in trouble” Always in trouble” – TX: careful pharmacotherapy due to tendancy to drug TX: careful pharmacotherapy due to tendancy to drug

abuseabuse

Personality DisorderPersonality Disorder• Borderline Borderline

– ““border” b/w neurosis and psychosisborder” b/w neurosis and psychosis– Unstable affect, mood, behaviorUnstable affect, mood, behavior– 1 – 2 % of pop.1 – 2 % of pop.– Seemingly always in state of “crisis”Seemingly always in state of “crisis”– ““self-mutilation”self-mutilation”– Need for companionshipNeed for companionship– Tx: psychotherapy plus pharmacotherapy Tx: psychotherapy plus pharmacotherapy

(anticonvulsants)(anticonvulsants)

Personality DisordersPersonality Disorders• HistrionicHistrionic

– Colorful, dramatic, extroverted behaviorColorful, dramatic, extroverted behavior– Center of attentionCenter of attention– Unable to maintain deep relationshipsUnable to maintain deep relationships– EAGER to give incredibly detailed hx!EAGER to give incredibly detailed hx!– Need for reassuranceNeed for reassurance– Tx: pharmacotherapy for symptomatic Tx: pharmacotherapy for symptomatic

reliefrelief

Personality DisorderPersonality Disorder• NarcissiticNarcissitic

– 2 – 16% of pop.2 – 16% of pop.– Grandiose sense of self-importanceGrandiose sense of self-importance– Belief that he/she is “special”Belief that he/she is “special”– Requires excessive admirationRequires excessive admiration– ““DIVA-like”DIVA-like”– Tx: not muchTx: not much

Personality DisorderPersonality Disorder• AvoidantAvoidant

– Extreme sensitivity to rejectionExtreme sensitivity to rejection– 1 – 10%1 – 10%– Poor self-esteemPoor self-esteem– Anxious during interviewAnxious during interview– Tx: occ. B-blockers to manage nervous Tx: occ. B-blockers to manage nervous

hyperactivityhyperactivity

Personality DisordersPersonality Disorders• DependantDependant

– Subordinate their own needs to those of othersSubordinate their own needs to those of others– Need for compansionshipNeed for compansionship– 2.5% of all personality d/o2.5% of all personality d/o– Submissive behaviourSubmissive behaviour– Usually in abusive relationship and will tolerateUsually in abusive relationship and will tolerate– Tx: various pharmacotherapiesTx: various pharmacotherapies

Personality DisordersPersonality Disorders• Obessive-CompulsiveObessive-Compulsive

– Pervasive pattern of perfectionism and Pervasive pattern of perfectionism and inflexabilityinflexability

– Constricted affectConstricted affect– Preoccupied with rules, regulations, Preoccupied with rules, regulations,

orderliness, neatness, and achievement of orderliness, neatness, and achievement of perfectionperfection

– Anxious when routine threatenedAnxious when routine threatened– Actually have o.k insight re: their Actually have o.k insight re: their

problems and will seek medical treatment.problems and will seek medical treatment.

So what the rip does this all So what the rip does this all mean????mean????• Our JobOur Job

– r/o general medical condition and medically clear r/o general medical condition and medically clear patientpatient

– Determine who needs possible hospital admissionDetermine who needs possible hospital admission• Criteria (Rosen’s)Criteria (Rosen’s)

– Suicidal and homicidal riskSuicidal and homicidal risk– Lacks capacity to co-operate with outpt txLacks capacity to co-operate with outpt tx– Inadequate psychosocial support for safe outpatient tx and Inadequate psychosocial support for safe outpatient tx and

compliancecompliance– Comorbid condition or complication that makes outpatient Comorbid condition or complication that makes outpatient

tx unsafe (ie. Bizarre behaviour, acute psychosis)tx unsafe (ie. Bizarre behaviour, acute psychosis)– Stabilize acute episodes and ensure patient and Stabilize acute episodes and ensure patient and

staff safetystaff safety