Mood and Personality Disorders
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Transcript of Mood and Personality Disorders
Mood and Personality Disorders
Joe MacLellanPGY-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/MDDDysthymia
Bipolar disorder IBipolar 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 substance-induced or caused by a GMC, not bereavement
How do adolescents and elderly differ in their
presentation?
Adolescents– Misdiagnosed as
ADD– Boredom*– Substance
use/criminal activity– Mood can be irritableGeriatrics
– Cognitive changes (dementia)
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…
“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!”
“I feel more alive. I feel more focused. I feel more energetic. My workouts are really intense.”
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
Openness
Agreeableness
ExtraversionConscientiousness
Neuroticism
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
CrystleKimTylerSkye
JasonAmber
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
BorderlinePD
How does Borderline PD present to the ED?
BPD in the ED
Biological 1. Sequelae of self-harm2. Sequelae of reckless behaviour
Psychological 1. “Depression” (mood instability)2. Suicidal ideation3. Intense anger, agitation in the community4. Stress-related “psychosis”
Social 1. Therapist is unavailable2. Caregiver is unavailable3. Housing crisis4. 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 interventions1. Ask the patient what would be helpful2. Nicorette, warm blanket, food3. Recognize and reinforce healthy choices4. 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 self-image
• 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 interventions1. Ask the patient what would be helpful2. Nicorette, warm blanket, food3. Recognize and reinforce healthy choices4. 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