Mood and Personality Disorder

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Mood and Personality Disorder

• David Peterson
• March 4 2004
• Emergency Medicine

2
Summary

• Mood disorders
• Major depressive disorder
• Bipolar I and II disorders
• Dysthymia
• Cyclothymia
• Mood disorder due to a general medical condition
• Substance-induced mood disorder

3
Summary

• Personality Disorders
• Cluster A
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Cluster B
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Antisocial Personality Disorder
• Borderline Personality Disorder

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Summary

• Personality Disorders
• Cluster C
• Avoidant Personality Disorder
• Dependent Personality Disorder
• OCD Personality Disorder

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Mood Disorders

• Major Depressive Disorder
• Etiology
• Family Studies
• 50 have 1st relative with mood disorder
• Concordance for identical twins is 50
• Concordance for siblings is 15
• Adoption studies
• Support genetic etiology
• Linkage studies
• Chromosome 18 implicated in some studies
• Difficult
• Searching for genetic pattern of particular mood
  disorder vs spectrum of disease

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Major Depressive Disorder

• Etiology
• Neurochemical factors
• NE
• Based on variety of findings
• Many effective Antidepressant medication block
• Eg Nortriptyline
• NE reuptake and down regulate ß-receptors
• Speculated adrenergic function may be abnormal
• Measurement of NE or its metabolites in CSF,
  plasma and urine show variable results

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Major Depressive Disorder

• Etiology
• Neurochemical factors
• 5-HT
• SSRIs proved to be effective antidepressants
• Serotonin and metabolites found in low levels in
  depressed patients
• Serotonin depleted by tryptophan depleted diets
  can worsen depression
• Dopamine
• Less solidly linked to depression
• Bupropion effective antidepressant purely
  dopaminergic in action
• Parkinsons disease which involves dopaminergic
  dysfunction oftens leads to depressive symptoms
• Other neurotransmitters
• GABA

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Major Depressive Disorder

• Etiology
• Other biological factors
• Neuroendocrine regulation
• Hypothalamic-pituitary-adrenal axis disrupted
• Dexamethasone suppression test
• Normally administration of Dexamethasone
  suppresses HPA axis and cortisol level drops
• Depressed patients show Nonsuppression
• - Cortisol remains elevated
• Not specific or sensitive for clinical use
• Hypothyroidism may mimic depression
• Subset of depressed patients have low TSH after
  being give TRH (thyrotropin-releasing hormone)

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Major Depressive Disorder

• Etiology
• Other biological factors
• Sleep and circadian rhythm
• Common in mood disorders
• Have have insomnia or hypersomnia
• Polysomnography
• Shows shortened REM latency period
• Other abnormalities found
• Sleep deprivation is an effective tx for
  depression
• Depression returns after next nights sleep
• Kindling
• Subthreshold stimulation of the brain results in
  seizure activity
• Anticonvulsant drugs are effectiv for Bipolar II
  disorder

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Major Depressive Disorder

• Etiology
• Psychological and social factors
• Stress
• Can precipitate brain changes
• Makes individual more vulnerable to future mood
  episodes
• Loss of parent before age 11
• Psychodynamic theorist
• Propose depression represents anger turned inward
• Animal studies
• Lead to model of depression as learned
  helplessness
• Cognitive therapy
• Depressed individuals express inaccurate negative
  cognitions
• Cognitive therapy aims at changing these
  conditions

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Major Depressive Disorder

• Epidemiology
• Risk and prevalence
• Lifetime risk 15
• Prevalence in woman roughly twice that of men
• Similar across different countries and races
• Age of onset
• Range from childhood to old age
• Mean 40 years
• Recurrence
• 50 will have more than one MDE

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Major Depressive Disorder

• DSM-IV Diagnostic Criteria for Major Depressive
  Episode
• A
• 5 of following symptoms present during same 2
  week period and represents change from previous
  functioning
• Depressed mood most of the day
• Markedly diminished interest in pleasure
• Significant weight changes
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss or energy
• Feelings of worthless or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death
• Recurrent SI
• Suicide attempt
• Pneumonic SIGECAPS

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Major Depressive Disorder

• B
• Symptoms cause clinically significant distress or
  impair functioning
• C
• Symptoms not due to direct effects of a substance
• Drugs, medications or GMC
• D
• Symptoms not better accounted for by bereavement
• Persisting longer than 2 months after death

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Major Depressive Disorder

• Differential diagnosis
• Other psychiatric conditions
• Substance induced mood disorders
• Mood disorder due to GMC
• Normal bereavement
• Some symptoms not normal
• Hallucinations
• Varies among cultutres
• Diagnostic evaluation
• Comorbid medical conditions must be identified
  and ruled out
• Assessment of safety
• Treat to self or others
• Voluntary vs involutary hospitalization

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Major Depressive Disorder

• Treatment
• Combination of medication and psychotherapy
• Medications
• TCAs
• Tertiary tricyclics (imipramine, amitriptyline)
• Oldest
• Use limited by SE profile including prominent
  sedative and anticholinergic effects
• Secondary tricyclics (nortriptyline, desipramine)
• Tend to be less anticholinergic and sedating
• Less likely to cause orthostatic hypotension
• MAOIs
• Not popular because hypertensive crisis can be
  precipitated
• RIMA
• Reversible inhibitors of monoamine oxidase A
• Much safer and as effective as MAOIs

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Major Depressive Disorder

• SSRIs
• First line therapy
• Once daily dosing
• Wide therapeutic index
• SE profile
• N/V
• Insomnia
• Anxiety
• Sexual dysfunction
• Drug interactions
• Serotonin syndrome
• Bupropion
• Aminoketone that blocks reuptake of dopamine
• Narrow therapeutic index
• Dose related tendency to cause seizes
• Venlafaxine
• Selective 5-HT-NE reuptake inhibitor
• Wide therapeutic index
• Twice a day dosing

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Major Depressive Disorder

• Treatment
• ECT
• Safe and effective
• Limited use because bias remaining from years ago
  when much cruder procedure
• Usually reserved for psychotic depression or
  failed medical therapy
• Common complications include confusion and memory
  loss which usually resolves within 6 months
• No evidence causes permanent brain damage

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Major Depressive Disorder

• Psychotherapy
• Psychodynamic
• Psychoanalytic
• Cognitive therapy
• Interpersonal therapy

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Bipolar I Disorder

• Epidemiology
• 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

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Bipolar I Disorder

• DSM-IV criteria for manic episode
• A
• Period of abnormally and persistently elevated,
  expansive or irritable mood lasting at least 1
  week
• B
• During this period at least 3 of the following
• Grandiosity
• Insomnia
• Flight of ideas
• Distractibility
• Increased goal directed activity
• Reckless activities
• Sex
• Spending
• ETOH
• drugs

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Bipolar I Disorder

• C
• Symptoms do not meet criteria for a mixed episode
• D
• Mood disturbance severe enough to cause marked
  functioning
• E
• Symptoms not substance induced or due to GMC

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Bipolar I Disorder

• Associated clinical features
• Psychotic features
• Delusions
• Hallucinations
• Disorganization
• Often mood congruent
• Morbidity and mortality
• 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

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Bipolar I Disorder

• Psychiatric comorbidity
• ETOH and drug abuse frequently complicate manic
  episodes
• Eating disorders
• Anxiety disorders
• ADHD
• Differential diagnosis
• Other psychiatric disorders
• Similar symptoms seen in bipolar II disorder and
  cyclothymia
• With psychiatric symptoms difficult to
  differentiate bipolar I from schizophrenia or
  schizoaffective disorder
• If delusion and hallucinations for at least in
  absence of mania or major depression then
  psychotic disorder must be diagnosed
• Rather than mood disorder with psychotic features
• Narcissistic personality disorder also has
  overlapping features

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Bipolar I Disorder

• Substance-induced mood disorder
• Intoxication with stimulants like cocaine or
  amphetamines can mimic mania
• Medications
• Steroids
• Dopamine agonists
• Anticholinergic
• Cimetidine
• Mood disorder due to GMC
• Manic symptoms can be seen with
• Infectious diseases eg AIDS
• Endocrinopathies eg Cushings disease,
  Hyperthyroid
• SLE
• Variety of neurological disorders eg Epilepsy,
  MS, Wilsons disease

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Bipolar II Disorder

• Officially recognized for the first time in
  DSM-IV
• Epidemiology
• Lifetime risk 0.5
• Women gt men
• No racial differences
• Diagnosis
• At least one MDE and one hypomanic episode
• Hypomanic episode
• Similar to manic episode but less severe
• Episode need only last 4 days
• Episode must not lead to hospitalization
• Episode must not include psychotic features
• Episode must not cause severe impairment in
  functioning
• Differential diagnosis
• Similar to Bipolar I disorder

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Bipolar Disorders

• Treament
• Containment of manic behavior
• Can prevent disastrous consequences
• Compliance often an issue
• Combination of medications and psychotherapy
• Medications
• Lithium first line tx
• During acute mania 80 respond to lithium within
  1-2 wks
• Coadministration of antipsychotics during initial
  periods to control behavior and psychosis
• Reduces relapse rate by 50
• Renally excreted
• Narrow therapeutic index
• SE include
• Seizure
• Confusion
• Coma
• Cardiac dysrythmias

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Bipolar Disorders

• Medications
• Valproate
• Recently found to be as effective as lithium
• Plays a role particularly in rapid cycling
  patients
• SE include
• N/V
• Tremor
• Sedation
• Hair loss
• Rarely can cause hepatic failure, pancreatitis
  and agranulocytosis
• Wide therapeutic index
• Can be fatal in OD

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Bipolar Disorders

• Medications
• Carbamazepine
• Effective in acute mania
• Prophylaxis reduces frequency and severity of
  manic and depressive episodes
• SE include
• Dose related
• Blurred vision
• Ataxia
• N/V
• Fatigue
• Rarely Steven-Johnsons syndrome, liver failure
  and agranulocytosis
• Hepatically metabolized
• Toxic at high doses
• Monitor levels
• OD can be fatal

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Bipolar Disorders

• Medications
• Antipsychotics
• Commonly used during acute phase
• Provides symptomatic relief while mood
  stabilizers are taking effect
• Not used as maintenance tx because risk of
  tardive dyskinesia
• Benzodiazepines
• Particularly clonazepam
• Sedation and full nights sleep can markedly
  improve symptoms
• Antidepressants
• Frequently used in Bipolar II
• Alone or with lithium

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Dysthymic Disorder

• Diagnosis
• 2 years chronic depression but not severe enough
  to met criteria for MDE
• Presence while depressed of at least 2 of the
  following
• Poor appetite or over eating
• Insomnia or hypersomnia
• Fatigue
• Low self esteem
• Poor concentration
• Feeling of hopelessness
• Never without depressed mood for more than 2
  months at a time
• No evidence of past MDE, manic, mixed or
  hypomanic episodes
• Epidemiology
• Lifetime risk 5
• Prevalence in women twice that of men
• If develops before age 21 more likely to develop
  MDD later

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Dysthymic Disorder

• Differential diagnosis
• Similar to MDD
• Associated clinical features
• Social impairment
• Health problems
• ETOH and drug abuse
• MDD
• Coexistence of dysthymia and major depression
  referred to as double depression
• Treatment
• Traditionally tx with psychotherapy
• May respond to SSRIs and MAOIs
• Of psychotherapies cognitive and behavioral
  therapy have best data to support use

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Cyclothymia

• Diagnosis
• Presence of numerous periods of hypomanic and
  depressive symptoms
• Not meeting criteria for MDE
• For at least 2 years
• Never without symptoms for gt 2 months
• No MDE, manic or mixed episodes
• No evidence of psychosis
• Treatment
• Mood stabilizing drugs
• Antidepressants frequently precipitate manic
  symptoms
• Supportive psychotherapy also important

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Personality Disorders

• Clinical picture
• Have trouble in work setting
• Social relationships are disrupted or absent
• May seek help from concurrent medical or surgical
  problems or primary emotional distress
• Biology
• Twin and adoption studies show strong genetic
  component to personality traits
• Familial association for Axis I disorders

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Personality Disorders

• Clusters of Personality Disorders
• Cluster A
• Odd or eccentric group
• Paranoid Personality Disorder
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Use defense mechanisms of projection and fantasy
• Vulnerable to cognitive disorganization when
  stressed

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Personality Disorders

• Clusters of Personality Disorders
• Cluster B
• Dramatic, emotional and erratic group
• Histrionic Personality Disorder
• Narcissistic Personality Disorder
• Antisocial Personality Disorder
• Borderline Personality Disorder
• Use defense mechanism such as dissociation,
  denial and acting out
• Mood disorders common
• Somatization disorder associated with histrionic
  personality disorder

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Personality Disorders

• Clusters of Personality Disorders
• Cluster C
• Anxious and fearful group
• Avoidant Personality Disorder
• Dependent Personality Disorder
• Obsessive-Compulsive Personality Disorder
• Use defense mechanism of isolation, passive
  aggressive and hypochondriasis
• Twin studies suggest some genetic factors

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Cluster A Personality Disorders

• Schizoid Personality Disorder
• Diagnosis
• Does not desire close relationships
• Chooses solitary activities
• Little experience in sexual experiences
• Takes pleasure in few activities
• No close friends except first degree relatives
• Excessive social anxiety
• Prevalence unknown
• Medical-surgical setting
• Illness brings patients close to caregivers
• Sees as threat to equilibrium
• Treatment
• Usually dont seek tx
• Individual pyschotherapy

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Cluster A Personality Disorders

• Paranoid Personality Disorder
• Diagnosis
• Suspect others of exploiting, harming or
  deceiving him/her
• Doubts trustworthiness of others
• Interprets benign remarks as demeaning
• Bears grudges
• Quick to react angrily
• Repeatedly questions fidelity of partner
• Prevalence unknown
• Medical-surgical setting
• Illness exacerbates personality style
• Tends to be more guarded and suspicious
• Treatment
• Difficult
• Attempt to establish trust
• Antipsychotic medications in small doses

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Cluster A Personality Disorders

• Schizotypal Personality disorder
• Diagnosis
• Ideas of reference
• Odd beliefs or magical thinking
• Usual perceptual experiences
• Odd thinking or speech
• Paranoid ideation
• Inappropriate affect
• Odd or eccentric behavior
• No close friends except first degree relatives
• Excessive social anxiety
• Prevalence 3
• Medical-surgical setting
• Tend to put off caregivers
• Illness threatens isolation
• Treatment
• Psychotherapy
• Cognitive behavioral therapy

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Cluster B Personality Disorders

• Antisocial Personality Disorder
• Diagnosis
• Repeated unlawful activity
• Deceitfulness
• Impulsivity
• Irritability and aggressiveness
• Reckless disregard for safety of others
• Consistent irresponsibility
• Lack of remorse
• Symptoms of conduct disorder before age 15
• Prevalence 3 in men and 1 in women

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Cluster B Personality Disorders

• Etiology
• Both environmental and genetic
• Precipitated by brain damage secondary to head
  injury of encephalitis
• Inconsistent and impulsive parenting
• Treatment
• Control drug and ETOH abuse
• Control behavior
• Set limits
• Group therapy
• Medications
• SSRIs
• ß-blockers
• bupropion

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Cluster B Personality Disorders

• Borderline personality disorder
• Gem of ED and psychiatry
• Best friends one minute, worst enemies the next
• Diagnosis
• Frantic effort to avoid real or imagined
  abandonment
• Unstable and intense relationships
• Impulsive
• Affective instability
• Chronic feelings of emptiness
• Difficulty controlling anger
• Transient dissociative symptoms
• Prevalence 1-2
• Women twice that of men
• 90 have another psychiatric diagnosis
• 40 have two other psychiatric diagnosis
• Etiology
• Severe abuse in childhood
• Decreased levels of serotonin

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Cluster B Personality Disorders

• Treatment
• Psychotherapy
• Medications
• MAOIs improve mood
• Does not change behavior
• SSRIs
• Help impulsivity and self-injury
• Carbamazepine
• Decreases behavioral dyscontrol
• Benzodiazepines
• contraindicated

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Cluster B Personality Disorders

• Narcissistic Personality Disorder
• Diagnosis
• Exaggerated sense of self importance
• Preoccupied with fantasies of unlimited power and
  success
• Believes he/she is special
• Requires excessive admiration
• Takes advantage of others
• Lacks empathy
• Often envious
• Arrogant attitude
• Prevalence unknown
• Associated features
• Depression common

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Cluster B Personality Disorders

• Medical-surgical setting
• Reacts to illness as threat to sense of
  self-perfection
• Treatment
• Individual psychotherapy tx of choice
• Stormy at first
• Group therapy
• Get feedback about effect on others

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Cluster B Personality Disorders

• Histrionic Personality Disorder
• Diagnosis
• Not comfortable unless centre of attention
• Inappropriately sexually seductive
• Uses appearance to attract attention
• Dramatic or exaggerated expression of emotion
• Easily influenced by other
• Considers relationship to be more intimate than
  they actually are
• Prevalence unknown
• Associated features
• Depression
• Somatization disorder

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Cluster B Personality Disorders

• Medical-surgical setting
• Illness threat to physical attraction
• Tx seen as threat of mutilation
• Men may behave sexually inappropriate with female
  nurses
• Treatment
• Psychotherapy tx of choice
• Become aware of real feelings
• Medications
• SSRIs
• MAOIs

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Cluster C Personality Disorders

• Avoidant Personality Disorder
• Diagnosis
• Avoids interpersonal contact due to fear of
  criticism or rejection
• Unwilling to get involved with people unless
  certain to be liked
• Preoccupied with being rejected in social
  situations
• Views as inferior to others
• Reluctant to engage in new activities for fear of
  embarrassment
• Prevalence unknown
• Associated features
• Social phobia
• Agoraphobia
• Medical-surgical setting
• Do well in hospital
• Undemanding and generally cooperative
• Treatment
• Psychotherapy
• Assertiveness training
• May give new social skills

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Cluster C Personality Disorders

• Dependent Personality Disorder
• Diagnosis
• Difficulty making everyday decision without
  excessive advice
• Needs other to assume responsibility
• Difficulty expressing disagreement
• Goes to excessive lengths to obtain support
• Uncomfortable when alone
• Urgently seeks another source of care when
  relationship ends
• Prevalence unknown
• Associated features
• Children with chronic illness at risk
• Children with extreme separation anxiety at risk

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Cluster C Personality Disorders

• Medical-surgical setting
• Illness may increase helplessness or fear of
  abandonment
• Physicians need to set limits
• Treatment
• Psychotherapy can be very useful
• Focus on current behaviors and consequences
• Behavioral therapies including assertiveness
  training can be helpful

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Cluster C Personality Disorders

• Obsessive-compulsive Personality Disorder
• Diagnosis
• Preoccupied with details so main goal of activity
  is lost
• Perfectionism interferes with task completion
• Excessively devoted to work
• Inflexible about morality
• Unable to discard worthless objects
• Reluctant to delegate tasks to others
• Rigidity and stubbornness
• Miserly spending
• Prevalence unknown
• More common in men

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Cluster C Personality Disorders

• Associated features
• Few friends
• Difficult to live with
• Tend to drive people away
• May do well in jobs that require precision with
  little social interaction
• Hypochondriasis may develop later
• Medical-surgical setting
• Illness perceived as threat to control
• Patient becomes more inflexible
• May lead to multiple complaints about staff and
  hospital
• Dont fall into trap of argument with patient or
  be defensive
• Control should be shared with patients
• Allow patient to be involved with decisions

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Cluster C Personality Disorders

• Treatment
• Difficult because patient uses defense of
  isolation
• Group therapy may be more useful
• Focus on current feelings and situations
• Struggles for control should be avoided
• Depression should be tx

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The End