Transcript Affective and Personality Disorders

Mood and Personality
Disorders
Joe MacLellan
PGY-3
July 28, 2011
Thank you
• Dr. Colleen Carey
• Colleen Weir
Outline
• Mood Disorders
– Depressed mood
– Elevated Mood
• Personality Disorders
– Cluster A, B, and C
Mood Disorders
MDE/MDD
Dysthymia
Bipolar disorder I
Bipolar disorder II
Cyclothymia
Case 1
45 single F, presents to the ED c/o fatigue and
abdominal pain.
• Vitals Normal
• Bloodwork is Normal
• Abdominal exam is benign
Next step?
How do depressed patients
present to the ED?
1) Suicidal Ideation
2) Depressed
3) Vague complaints
4) Anxiety
Major
Depressive
Episode
MDE Criteria
• At least 5 of SIGECAPS*
• Causes impairment, for >2 weeks
• Not a mixed episode, not substanceinduced or caused by a GMC, not
bereavement
How do adolescents and
elderly differ in their
presentation?
Adolescents
Geriatrics
– Cognitive changes
(dementia)
– Misdiagnosed as
ADD
– Boredom*
– Substance
use/criminal activity
– Mood can be irritable
Should we be
prescribing
anti-depressant
medication in the
ED?
What disorders mimic Major
Depression?
Mimics
• Medical Conditions
• Medications
• Substance Abuse/Withdrawal
How does Dysthymia differ?
Dysthymia
• Chronic, low-grade depression
• Responsive to anti-depressants
• Increase risk of MDD
Specifiers
• Seasonal Affective
• Postpartum
• With other features: psychotic, atypical,
melancholic
Treatment
Moderate-Severe:
• Anti-depressants
• Psychotherapy
• ECT
Mild:
• Exercise, self-help books
• Counseling
Who needs to be admitted?
Disposition
• Who needs admission?
– Risk of suicide/homicide
– Lacks capacity to cooperate with treatment
– Inadequate psychosocial support
– Co-morbid condition requiring admission
• Who can be discharged?
Resources
We will come back to this…
All the kids are doing it…
“I feel more alive. I feel more focused. I
feel more energetic. My workouts are
really intense.”
“Every great movement begins with one
man, and that’s me.”
[Did you get out of control?] “Well yeah! I
don’t have another gear!”
How do manic patients
typically present to the ED?
Mania presents as
• Dangerous activity
• Trauma
• Gambling
• Binge Drinking
Manic Episode
• Elevated mood lasting 1 week
• 3 or more of DIGFAST*
• Not mixed, substance-induced, GMC
• Causes impairment
Mimics
• Substance abuse/withdrawal
• Medications
• Delirium
• Hyperthyroid
How would you control an
aggressive Manic patient
• Initially:
– Single room, offering medications
• If necessary:
– Haldol/lorazepam
– restraints
How does Hypomania differ?
Hypomania
• Elevated/irritable for 4+ days
• 3 or more of DIGFAST
• BUT…
– Not signicant enough to cause marked
impairment or to necessitate hospitalization
Bipolar disorder
• Bipolar I
– Episode of mania, +/- MDE +/-, hypomania
• Bipolar II
– Hypomanic and MDE episodes
– NO manic or mixed episodes
Cyclothymia
• 2 years of episodes of hypomania and
depressive symptoms
• Not meeting criteria for MDE, mania, or
mixed episoder
• Not substance-induced, GMC,
schizophreniform
Treatment
• Acute depression:
– SSRI’s
• Acute mania:
– Lithium
– +/- antipsychotics, benzodiazepines
• Maintenance:
– lithium
– Educational and psychosocial support
Disposition
• Who needs admission?
• Who can be discharged?
Resources
We will come back to this…
Personality Disorders
“an enduring pattern of inner experience
and behavior that deviates markedly
from the expectations of the individual's
culture, is pervasive and inflexible, has
an onset in adolescence or early
adulthood, is stable over time, and
leads to distress or impairment”
Is this a
Personality
Disorder?
Is this?
2 people
in this
room
have a
PD
• Cluster A
=
• Cluster B
• Cluster C
Conscientiousness
Extraversion
Neuroticism
Openness
Agreeableness
Cluster A
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Paranoid Personality Disorder
Cluster C
• Dependant Personality Disorder
• Avoidant Personality Disorder
• Obsessive-compulsive Personality
Disorder
Personality Disorder Party
Jason
The Guest List
Kim
Skye
Jason
Amber
Tyler
Crystle
Cheat Sheet
•
•
•
•
•
•
Harold - Schizoid
Kim - Paranoid
Skye - Dependant
Tyler - Schizotypal
Amber - OCPD
Crystle - Avoidant
A
• These patients rarely seek treatment.
• Treatment largely psychotherapy
• Use clear explanations, establish trust
C
• Typically present with another
symptom*
• Pharmacotherapy for symptom relief but
mainstay is psychotherapy
• Be supportive but set limits
Cluster B
Borderline
PD
How does Borderline PD
present to the ED?
BPD in the ED
Biological
1. Sequelae of self-harm
2. Sequelae of reckless behaviour
Psychological 1. “Depression” (mood instability)
2. Suicidal ideation
3. Intense anger, agitation in the community
4. Stress-related “psychosis”
Social
1. Therapist is unavailable
2. Caregiver is unavailable
3. Housing crisis
4. Financial crisis (day before AISH cheque)
5. Seeking admission
What is the approach to the
Borderline patient
in the ED?
1. Medical clearance – untold parasuicidal or suicidal
gestures
2. Mental state clearance – look for new features to this
presentation (is this “the same old same old”?)
3. Supportive interventions
1. Ask the patient what would be helpful
2. Nicorette, warm blanket, food
3. Recognize and reinforce healthy choices
4. Watch your own countertransference (helplessness;
anger)
4. Take responsibility for the patient’s treatment, but
not the patient’s behaviours.
Tips for Working with BPD
• Be truthful and keep it simple
• Beware of splitting, communicate clearly with
other staff
• Elicit expectations from patient
• Goal: have patient take ownership of solution
Narcissistic PD
• Be careful of overlap with
manic grandiosity
• Illness disrupts their selfimage
• Appeal to their narcissism
How does Antisocial PD
present to the ED?
ASPD in the ED
• Facing charges and is now “suicidal”
• Facing charges, now “acting bizarrely”
• Assault
• Intoxicated
• Demanding abusable substances
What is the approach to the
Antisocial patient
in the ED?
1. Medical clearance – untold parasuicidal or suicidal
gestures
2. Mental state clearance – look for new features to this
presentation (is this “the same old same old”?)
3. Supportive interventions
1. Ask the patient what would be helpful
2. Nicorette, warm blanket, food
3. Recognize and reinforce healthy choices
4. Watch your own countertransference (helplessness;
anger)
4. Take responsibility for the patient’s treatment, but
not the patient’s behaviours.
Tips for working with ASPD
• Be Objective
• Provide a thorough, non-authoritarian
approach to investigation
• Set clear approach/plan with patient
Histrionic PD
• Vague/loosely connected sx.
• Often under/over investigate
• Sensitive to emotional
concerns while avoiding
closeness
Cognitive Behavioural
Therapy
A psychotherapeutic treatment that helps
patients understand the thoughts and
feelings that influence behaviors
Patients learn how to identify and change
maladaptive thought patterns that have
a negative influence on behaviour.
Resources
• Private (Fee):
– Inner solutions
– Bridging the gap
– Calgary counseling
Resources
• Public Access:
– Admission, short stay, day program
– SCHC and SC
• walk in counseling
• Brief therapy
–
–
–
–
–
ERO
DBT program
Access Mental Health
Crisis Line
PAS