mood and personality disorders joe maclellan pgy-3 july 28, 2011
Post on 28-Dec-2015
216 Views
Preview:
TRANSCRIPT
Outline
• Mood Disorders– Depressed mood– Elevated Mood
• Personality Disorders– Cluster A, B, and C
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?
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
Adolescents– Misdiagnosed as
ADD– Boredom*– Substance
use/criminal activity– Mood can be irritable
Geriatrics– Cognitive changes
(dementia)
Specifiers
• Seasonal Affective
• Postpartum
• With other features: psychotic, atypical, melancholic
Treatment
Moderate-Severe:• Anti-depressants• Psychotherapy• ECT
Mild:• Exercise, self-help books• Counseling
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?
“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.”
Manic Episode
• Elevated mood lasting 1 week
• 3 or more of DIGFAST*
• Not mixed, substance-induced, GMC
• Causes impairment
How would you control an aggressive Manic patient
• Initially:– Single room, offering medications
• If necessary:– Haldol/lorazepam– restraints
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
“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”
Cluster A
• Schizoid Personality Disorder
• Schizotypal Personality Disorder
• Paranoid Personality Disorder
Cluster C
• Dependant Personality Disorder
• Avoidant Personality Disorder
• Obsessive-compulsive Personality Disorder
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
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
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 self-image
• Appeal to their narcissism
ASPD in the ED
• Facing charges and is now “suicidal”
• Facing charges, now “acting bizarrely”
• Assault
• Intoxicated
• Demanding abusable substances
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.
top related