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

Feb 19, 2016

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AFFECTIVE/MOOD AND PERSONALITY DISORDERS. Stefan Da Silva 2006 (with a little help from Moritz and Dave). 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. - PowerPoint PPT Presentation
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  • AFFECTIVE/MOOD AND PERSONALITY DISORDERS

    Stefan Da Silva2006(with a little help from Moritz and Dave)

  • OverviewApproach to Psych PtAffective Disorderaka mood disorderMajor depressive BipolarPersonality DisordersCluster A (mad)Cluster B (bad)Cluster C (sad)Quiz

  • Approach to Psych PtsSafety, safety, safety.Security, stand between pt and door, keep door open if requiredInterviewFocus on trying to delineate between medical and mentalFocus on trying to determine dispositionie. Does pt need to be formedPsychosis, suicidal, homicidalCollateral HxParents, spouse, police etcOLD CHARTS!!!!!Family HxGeneral Medical ConditionsMedical Clearance (well talk more about this later)Our job: more of a risk assessment and disposition issue rather than a DSM-IV diagnosis

  • Medical ClearanceWhat 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. 2000What constitutes a medically clear patient?No physical illness identifiedKnown co morbid illness but not thought causativeAdequately treated medical condition

  • Medical ClearanceFunctional vs. OrganicHistoryWHY NOW?Precipitating events and chronologybaseline mental / physical statusprior psychiatric history / family psych hxpast medical historyMeds / drugs of abusecollateral hx (friends, family, EMS, old charts)MSE

  • Medical ClearanceOrganicAge 40 yoSudden onset (hrs-days)Fluctuating courseDisorientationDecd LOCVisual hallucinationsNo psychiatric HxEmotional labilityAbnormal vitals / examHx of substance abuse / toxinsFunctionalAge 13 40 yoGradual onset (wks-mos)Continuous courseScattered thoughtsAwake and alertAuditory hallucinationsPast psychiatric HxFlat affectNormal physical exam / vitalsNo evidence of drug useEmergMedClin. 18(2):185-198. 2000

  • Psych InterviewSafety FirstOpen ended questionsMental Status ExamGeneral DescriptionMood and AffectSpeechPerceptual DisturbancesThoughtCognitionImpulse ControlJudgement and InsightReliability

  • General Tidbits and Useless Information20 40% of homeless people in US have major mental illness23% of psych patients will have mood disorder of some sortApprox 5.4% of all ED visits are psych relatedLifetime risk for suicide in pts with untreated depressive illness is 15%Mood = enduring emotional orientation that colors the persons psychology

  • Mood/Affective DisordersApprox 23% of psychFemales > MalesDisturbances in 4 major areasMoodPsychomotor ActivityCognitionVegetative FunctioningCan be episodicCan have some features of schizophreniaie. Hallucinations, delusions, etc.

  • EtiologyBiologicalNeurotransmitterBiological amines eg. Serotonin, norepi, dopamineDecreased amounts seemed to correlate with decreased moodBrainLocus cerulus prolonged stress decreases neuronal activity responsible for alertness, appetite etcMedian Forebrain bundle prolonged stress decreases norepi decrease energy and interestDorsal Raphe decreased serotonin affects sleep, libido, appetiteTuberoinfundibular system pleasure, emotion, learning

    GeneticFamily studies 50% have 1st degree relativeIdentical twins 50%Siblings 15%Psychosocial FactorsStress learned helplessnessTraumatic experience ie. loss of parent

  • Major Depressive DisorderLifetime prevalance of 15%Mean onset 40 yrs Decreased mood, suicidalAnhedonia inability to experience pleasure or interest in formerly pleasurable or satisfying activitiesPsychomotor: retardation, agitation, vegetativeSometimes psychosisIn SAD CAGESInterest, sleep, appetite, depressed mood, concentration, activity, guilt, energy, suicide

  • Major Depressive DisorderDifferential DiagnosisOther psychiatric conditionsSubstance induced mood disordersMood disorder due to GMCNormal bereavementComorbid medical conditions must be identified and ruled outMay present atypically ie. Vague physical symptoms weakness, pain, fatigue, heavy users of medical care.

  • Major Depressive DisorderDSM-IV Criteria

  • Major Depressive DisorderDisturbances in MoodSad, gloomy, dejected, unhappy, discouragedChanges in Psychomotor ActivityRetardationSlowing of thought processes and physical activityAgitationFidgety, pacing, unable to sit still Cognitive ChangesUnable to think or concentrate properlyFeelings of overwhelming guiltVegetative ChangesChanges in sleep, appetite, and sexual function

  • Major Depressive DisorderTreatment OptionsUsually not started in ERAside from anxiolytics or antipsychoticsSSRIs, MAOIs, TCAs (usually takes 4 to 6 weeks)ECT (severe depression with malnutrition, psychosis, suicide risk)CBT (community based support groups etc.)Rapid Tranquilization (Rosens) Haldol 5mg IM plus Ativan 2mg IM repeated q30 -45mins until resolution of target symptoms

  • Other Depressive DisordersSADSeasonal affective disorderphototherapyPostpartum65% of mothers report some depressed mood after childbirthMore severe in mothers with pre-existing mood disorderDsythymicChronic decreased mood for most of a day for most days for at least 2 yrs

  • General Medical Condition and DepressionLOTS!ParkinsonsMSPancreatic CAThyroidMIESRDLupusSubstance Abuse

  • Bipolar Disordersepisodic exacerbation of symptoms and deterioration of function characterized by extreme mood swingsMania 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.

  • Bipolar DisorderDSM-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 grandiosity 2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking 4) flight of ideas or subjective experience that thoughts are racing 5) 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 agitation 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 business investments) C) The symptoms do not meet criteria for a Mixed Episode 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 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)

  • Bipolar DisorderManiaDIGFASTDistractibilityIndiscretion (excessive involvment in pleasurable activities)GrandiosityFlight of IdeasActivity IncreaseSleep DeficitTalkativeness (pressured speech)

  • Bipolar DisorderEpidemiologyLifetime risk ~1%Similar in men and women and across racesMean age of onset 21 yearsMore than 90% of people who have manic episode will have additional episodes of mania or major depressionGenetic studies90% bipolar patients have first degree relative with mood disorder Adoption studies support genetic etiologyLinkage studiesX-linkedChromosome 11DiagnosisBipolar I Disorder: 1 or more manic or mixed episodesMixed episodes: 1 week period were patient meets criteria for both manic episodes and MDE

  • Bipolar DisorderPatient usually brought to ED by someone elseVolatile moodsOften try to leave ASAPMay need to be restrainedPressured speech, grandiosity, massive undertakingsDecreased need for sleepDisregard for consequences of actionsMay present as trauma patients (injured by action reflected by grandiosity, impulsivity, or belligerence)

  • Bipolar IBipolar ILifetime prevalance of 1%Mean age 30 yrs oldNeeds single manic episode psychosis, impairment in function, hospitalizationDepression cycling with maniaSuicide attempt common for both bipolar I and II disordersComorbid medical problems can deteriorate because of poor complianceReckless behaviors can increase risk of STD and injuryETOH and drug abuse frequently complicate manic episodesEating disordersAnxiety disordersADHD

  • Bipolar IIMDE with cycling of hypomanic episodeDSM IV CriteriaA) 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 grandiosity 2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3) more talkative than usual or pressure to keep talking 4) flight of ideas or subjective experience that thoughts are racing 5) 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 agitation 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 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)

  • Bipolar DisordersMood stabilizing drugsLithium, Valproate, CarbamazepineUsually takes > 3 weeksPsychotherapyEspecially for family support

  • Personality DisordersWhen personality traits cause impairment it leads to personality disorderCluster A madParanoidSchizoidSchizotypalCluster B badAntisocialBorderlineNarcissisticHistrionicCluster C sadAvoidantDependantObsessive-Compulsive

  • Personality DisordersDSM-IV Criteria for most EtiologyGeneticTempermental ie. Nature vs nuturegoodness of fit ie child may be hyperactive if kept in small closed apartment but not in a large house and yard.BiologicalImpulsivity linked to increased levels of hormones in animals

  • Personality DisordersParanoidSuspiciousness, mistrust of peopleMay seem hostile, irritable, and angry during exam0.5 2.5% of personality d/oMale > femaleTx: various anxiolytics and antipsychotics

  • Personality DisorderSchizoidLifelong pattern of social withdrawalBland constricted affectCan be seen in up to 7.5% of general populationMay have poor eye contact and seem cold and aloof during examSolitary jobsTx: antipsychotics, antidepressants, psychostimulants

  • Personality DisordersSchizotypalODD!!!magical thinking, peculiar ideas, odd speech and thought processesUp to 3% of general populationTx: antipsychotics

  • Personality DisordersAntisocialInability to conform to social normsContinous antisocial/criminal acts7.5% of prison populationLow socioeconomic statusstress interviewConfront patient with inconsistencies in their story may reveal underlying disorderLack of remorseBegins in adolescenceAlways in trouble TX: careful pharmacotherapy due to tendancy to drug abuse

  • Personality DisorderBorderline border b/w neurosis and psychosisUnstable affect, mood, behavior1 2 % of pop.Seemingly always in state of crisisself-mutilationNeed for companionshipTx: psychotherapy plus pharmacotherapy (anticonvulsants)

  • Personality DisordersHistrionicColorful, dramatic, extroverted behaviorCenter of attentionUnable to maintain deep relationshipsEAGER to give incredibly detailed hx!Need for reassuranceTx: pharmacotherapy for symptomatic relief

  • Personality DisorderNarcissitic2 16% of pop.Grandiose sense of self-importanceBelief that he/she is specialRequires excessive admirationDIVA-likeTx: not much

  • Personality DisorderAvoidantExtreme sensitivity to rejection1 10%Poor self-esteemAnxious during interviewTx: occ. B-blockers to manage nervous hyperactivity

  • Personality DisordersDependantSubordinate their own needs to those of othersNeed for compansionship2.5% of all personality d/oSubmissive behaviourUsually in abusive relationship and will tolerateTx: various pharmacotherapies

  • Personality DisordersObessive-CompulsivePervasive pattern of perfectionism and inflexabilityConstricted affectPreoccupied with rules, regulations, orderliness, neatness, and achievement of perfectionAnxious when routine threatenedActually have o.k insight re: their problems and will seek medical treatment.

  • So what the rip does this all mean????Our Jobr/o general medical condition and medically clear patientDetermine who needs possible hospital admissionCriteria (Rosens)Suicidal and homicidal riskLacks capacity to co-operate with outpt txInadequate psychosocial support for safe outpatient tx and complianceComorbid condition or complication that makes outpatient tx unsafe (ie. Bizarre behaviour, acute psychosis)Stabilize acute episodes and ensure patient and staff safety