Transcript 2006_08_31-DaSilva-Affective_and_personality_disorders

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
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”
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– Collateral Hx
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Psychosis, suicidal, homicidal
• 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
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
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
Medical Clearance
• Organic
– Age <12 or >40 yo
– Sudden onset (hrsdays)
– 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 (wksmo’s)
– Continuous course
– Scattered thoughts
– Awake and alert
– Auditory hallucinations
– Past psychiatric Hx
– Flat affect
– Normal physical exam /
vitals
– No evidence of drug
use EmergMedClin. 18(2):185-198. 2000
Psych Interview
• Safety First
• Open ended questions
• Mental Status Exam
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General Description
Mood and Affect
Speech
Perceptual Disturbances
Thought
Cognition
Impulse Control
Judgement and Insight
Reliability
General Tidbits and Useless
Information
• 20 – 40% of homeless people in US have major
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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”
Mood/Affective Disorders
• Approx 23% of psych
• Females > Males
• Disturbances in 4 major areas
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Mood
Psychomotor Activity
Cognition
Vegetative Functioning
• Can be episodic
• Can have some features of schizophrenia
– ie. Hallucinations, delusions, etc.
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
Major Depressive Disorder
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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
Major Depressive Disorder
• Differential Diagnosis
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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.
Major Depressive Disorder
• DSM-IV Criteria
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
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
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
General Medical Condition and
Depression
• LOTS!
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Parkinson’s
MS
Pancreatic CA
Thyroid
MI
ESRD
Lupus
Substance Abuse
Bipolar Disorders
• “episodic exacerbation of symptoms and
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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.
Bipolar Disorder
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DSM-IV Criteria for Mania
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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 Disorder
• Mania
– DIGFAST
• Distractibility
• Indiscretion (“excessive involvment in pleasurable activities)
• Grandiosity
• Flight of Ideas
• Activity Increase
• Sleep Deficit
• Talkativeness (pressured speech)
Bipolar Disorder
• Epidemiology
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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
Bipolar Disorder
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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)
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
Bipolar II
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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 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 Disorders
• Mood stabilizing drugs
– Lithium, Valproate, Carbamazepine
– Usually takes > 3 weeks
• Psychotherapy
– Especially for family support
Personality Disorders
• When personality traits cause impairment it leads to personality
disorder
• Cluster A  mad
– Paranoid
– Schizoid
– Schizotypal
• Cluster B  bad
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Antisocial
Borderline
Narcissistic
Histrionic
• Cluster C  sad
– Avoidant
– Dependant
– Obsessive-Compulsive
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
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
Personality Disorder
• Schizoid
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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
Personality Disorders
• Schizotypal
– ODD!!!
– “magical thinking”, peculiar ideas, odd speech
and thought processes
– Up to 3% of general population
– Tx: antipsychotics
Personality Disorders
• Antisocial
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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
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Lack of remorse
Begins in adolescence
“Always in trouble”
TX: careful pharmacotherapy due to tendancy to drug abuse
Personality Disorder
• Borderline
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“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)
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
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
Personality Disorder
• Avoidant
– Extreme sensitivity to rejection
– 1 – 10%
– Poor self-esteem
– Anxious during interview
– Tx: occ. B-blockers to manage nervous
hyperactivity
Personality Disorders
• Dependant
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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
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.
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