Mood and Personality Disorders

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Mood and Personality Disorders

• Joe MacLellan
• PGY-3
• July 28, 2011

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Thank you

• Dr. Colleen Carey
• Colleen Weir

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Outline

• Mood Disorders
• Depressed mood
• Elevated Mood
• Personality Disorders
• Cluster A, B, and C

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Mood Disorders

• Bipolar disorder I
• Bipolar disorder II
• Cyclothymia

• MDE/MDD
• Dysthymia

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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?

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How do depressed patients present to the ED?
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• 1) Suicidal Ideation
• 2) Depressed
• 3) Vague complaints
• 4) Anxiety

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Major Depressive Episode
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MDE Criteria

• At least 5 of SIGECAPS
• Causes impairment, for gt2 weeks
• Not a mixed episode, not substance-induced or
  caused by a GMC, not bereavement

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How do adolescents and elderly differ in their
presentation?
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• Adolescents
• Misdiagnosed as ADD
• Boredom
• Substance use/criminal activity
• Mood can be irritable

• Geriatrics
• Cognitive changes (dementia)

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Should we be prescribing anti-depressant
medication in the ED?
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What disorders mimic Major Depression?
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Mimics

• Medical Conditions
• Medications
• Substance Abuse/Withdrawal

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How does Dysthymia differ?
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Dysthymia

• Chronic, low-grade depression
• Responsive to anti-depressants
• Increase risk of MDD

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Specifiers

• Seasonal Affective
• Postpartum
• With other features psychotic, atypical,
  melancholic

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Treatment

• Moderate-Severe
• Anti-depressants
• Psychotherapy
• ECT
• Mild
• Exercise, self-help books
• Counseling

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Who needs to be admitted?
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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?

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Resources

• We will come back to this

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All the kids are doing it
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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
  thats me.

Did you get out of control? Well yeah! I dont
have another gear!
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(No Transcript)
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How do manic patients typically present to the ED?
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Mania presents as

• Dangerous activity
• Trauma
• Gambling
• Binge Drinking

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Manic Episode

• Elevated mood lasting 1 week
• 3 or more of DIGFAST
• Not mixed, substance-induced, GMC
• Causes impairment

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Mimics

• Substance abuse/withdrawal
• Medications
• Delirium
• Hyperthyroid

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How would you control an aggressive Manic patient

• Initially
• Single room, offering medications
• If necessary
• Haldol/lorazepam
• restraints

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How does Hypomania differ?
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Hypomania

• Elevated/irritable for 4 days
• 3 or more of DIGFAST
• BUT
• Not signicant enough to cause marked impairment
  or to necessitate hospitalization

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Bipolar disorder

• Bipolar I
• Episode of mania, /- MDE /-, hypomania
• Bipolar II
• Hypomanic and MDE episodes
• NO manic or mixed episodes

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Cyclothymia

• 2 years of episodes of hypomania and depressive
  symptoms
• Not meeting criteria for MDE, mania, or mixed
  episoder
• Not substance-induced, GMC, schizophreniform

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Treatment

• Acute depression
• SSRIs
• Acute mania
• Lithium
• /- antipsychotics, benzodiazepines
• Maintenance
• lithium
• Educational and psychosocial support

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Disposition

• Who needs admission?
• Who can be discharged?

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Resources

• We will come back to this

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Personality Disorders
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• 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

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Is this a Personality Disorder?
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• Is this?

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2 people in this room have a PD
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• Cluster A
• Cluster B
• Cluster C

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Conscientiousness
Extraversion
Neuroticism
Openness
Agreeableness
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Cluster A

• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Paranoid Personality Disorder

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Cluster C

• Dependant Personality Disorder
• Avoidant Personality Disorder
• Obsessive-compulsive Personality Disorder

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Personality Disorder Party
Jason
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The Guest List
Amber
Kim
Crystle
Jason
Tyler
Skye
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Cheat Sheet

• Harold - Schizoid
• Kim - Paranoid
• Skye - Dependant
• Tyler - Schizotypal
• Amber - OCPD
• Crystle - Avoidant

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A

• These patients rarely seek treatment.
• Treatment largely psychotherapy
• Use clear explanations, establish trust

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C

• Typically present with another symptom
• Pharmacotherapy for symptom relief but mainstay
  is psychotherapy
• Be supportive but set limits

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Cluster B
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• Borderline
• PD

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How does Borderline PD present to the ED?
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BPD in the ED

Biological Sequelae of self-harm Sequelae of reckless behaviour
Psychological Depression (mood instability) Suicidal ideation Intense anger, agitation in the community Stress-related psychosis
Social Therapist is unavailable Caregiver is unavailable Housing crisis Financial crisis (day before AISH cheque) Seeking admission
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What is the approach to the Borderline patient
in the ED?
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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
4. Ask the patient what would be helpful
5. Nicorette, warm blanket, food
6. Recognize and reinforce healthy choices
7. Watch your own countertransference (helplessness
   anger)
8. Take responsibility for the patients treatment,
   but not the patients behaviours.

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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

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Narcissistic PD

• Be careful of overlap with manic grandiosity
• Illness disrupts their self-image
• Appeal to their narcissism

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How does Antisocial PD present to the ED?
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ASPD in the ED

• Facing charges and is now suicidal
• Facing charges, now acting bizarrely
• Assault
• Intoxicated
• Demanding abusable substances

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What is the approach to the Antisocial patient
in the ED?
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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
4. Ask the patient what would be helpful
5. Nicorette, warm blanket, food
6. Recognize and reinforce healthy choices
7. Watch your own countertransference (helplessness
   anger)
8. Take responsibility for the patients treatment,
   but not the patients behaviours.

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Tips for working with ASPD

• Be Objective
• Provide a thorough, non-authoritarian approach to
  investigation
• Set clear approach/plan with patient

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Histrionic PD

• Vague/loosely connected sx.
• Often under/over investigate
• Sensitive to emotional concerns while avoiding
  closeness

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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.

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Resources

• Private (Fee)
• Inner solutions
• Bridging the gap
• Calgary counseling

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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