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 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 irritable

Geriatrics– 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

Borderline

PD

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 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

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