Download Mood Disorders Workshop - The University of Auckland

Mood Disorders Workshop
2010
Dr Andrew Howie / Dr Tony Fernando
Psychological Medicine
Faculty of Medical and Health Sciences
University of Auckland
Goals
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To learn about the clinical presentation of mood
disorders
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Signs and symptoms
Mental status reporting
How to ask questions
To be able to differentiate the various types of
pathological mood states
Outline of treatment
To understand how it is to have a mood disorder
from a person who experiences it
Not included in today’s workshop
but student has to know…
Etiology and Pathophysiology
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Genetics
Social/ Developmental and Environmental
factors
Details of variant forms
Neurobiology
Abnormalities in neurotransmission
 Neuroimaging
 Neuroendocrine functioning
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Useful resources
(for further reading)
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American Psychiatric Association guidelines:
http://www.psych.org/MainMenu/PsychiatricPrac
tice/PracticeGuidelines_1.aspx
NICE Guidelines: http://www.nice.org.uk/
RANZCP Guidelines:
http://www.ranzcp.org/resources/clinicalmemoranda.html
Concept of Mood Spectrum
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Euphoric
Ecstatic
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Optimistic, cheerful
“Glass half full”
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Even mood, stable, content
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Pessimistic
“Glass half empty”
Hopeless, worthless
suicidal
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Individualized
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Set point/ range
Reactivity to situations/ thoughts
Neutral
 Positive
 Negative
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Despite fluctuations, the individual still is able
to function socially, vocationally
Modifiable?
Pathologic equivalents
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Euphoric
Ecstatic
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Manic
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Hypomanic
Hyperthymic
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Optimistic, cheerful
“Glass half full”
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Even mood, stable, content
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Euthymia ( not pathologic)
Pessimistic
“Glass half empty”
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Dysthymic
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Depressed
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Hopeless, worthless
suicidal
Pathologic Changes
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Resetting of “set point”
Sustained, unshifting mood state
Change in reactivity to situations/
thoughts
Impaired functionality- socially, work
Change in sense of self
Mood Disorders
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Depressive Disorders
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Predominant mood is
depression, no
elevations/ mania
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Major Depression,
single episode
Major Depression,
recurrent
Dysthymic Disorder
Depressive Disorder,
not otherwise specified
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Bipolar Disorders
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Has elevations/ mania
and depressions
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Bipolar disorder, manic
Bipolar disorder,
depressed
Bipolar disorder, mixed
Cyclothymic disorder
Bipolar disorder, not
otherwise specified
Specific Mood Disorders
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Depressive Disorders
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Major Depression, single episode
Major Depression, recurrent
Dysthymic Disorder
Depressive Disorder, not otherwise specified
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Other Variants:
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Atypical depression, Postpartum depression, Seasonal
Affective Disorder, Depression with psychosis
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Depressive Disorders
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Must exclude:
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Mixed Episode
Secondary to General Medical Condition
Secondary to Substance Abuse
Bereavement- Duration and Severity
Specific Mood Disorders
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Bipolar Disorders
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Bipolar disorder, manic
Bipolar disorder, depressed
Bipolar disorder, mixed
Cyclothymic disorder
Bipolar disorder, not otherwise specified
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Other Variants: Bipolar I and II, rapid cycling, ultra
rapid cycling
Major Depressive Disorder
DSM IV
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5 or more of the following
with at least one being depressed mood or anhedonia
for at least two weeks and
with change in function
1. Depressed mood
2. Loss of interest / pleasure or Anhedonia
3. Weight loss change
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness /guilt
8. Decreased ability to think /concentrate
9. Suicidality or thoughts of death
Major Depressive Disorder
Mnemonic
 Depressed Mood
 S
Sleep disturbance* ↕
 I
Interest
↓
 G
Guilt levels 
 E
Energy* ↓
 C
Concentration* ↓
 A
Appetite* ↕
 P
Psychomotor disturbances
 S
Suicidal thoughts
* neurovegetative symptoms- sleep, energy, concentration,
appetite, libido
Dysthymia/ Dysthymic Disorder
DSM IV
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Depressed mood for most of the day more days than not at least 2yrs
( children and adolescents 1yr)
Chronic, low grade depression
2 or more ( not 5)
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self esteem
5. Poor concentration / difficulties making decisions
6. Feelings of hopelessness
Never without symptoms for more than two months
No MDE for first two years (one year) of the disturbance
Dysthymia Mnemonic
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A – Appetite changes
C – Concentration difficulties
H – Hopelessness
E - (Self) esteem low
W – Worthlessness
S – Sleep disturbances.
Dysthymia rule of 2’s
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At least 2 symptoms
Minimum 2 years
Never without symptoms for more than 2
months
Other Depressive symptoms not in
the 9*
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Irritability and anger
Unexplained physical complaints
(somatizers)
In some severe depressions, can have
delusions and hallucinations
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9 DSM IV symptoms DSIGECAPS
Interview of patient with
depression
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observe interview process, how to ask
questions
document Mental Status Examination (use
template)
MSE in Depression (Some possible
findings)
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Appearance, attitude, activity: Sometimes
dishevelled, markers of self harm/suicide
attempts, may be very cooperative or apathetic,
psychomotor agitated or retarded.
Speech: latent, slow, soft, loss of prosody (or
the opposite if agitated and upset).
Affect: dysphoric, loss of mobility, intensity
varies, range often restricted, reactivity may be
diminished, congruent with content of thought
(possibly not, if psychotic).
Mood: dysphoric, dysthymic, anxious.
MSE in Depression (Continued)
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Thought: stream slowed, form – loss of goal through
inattention, distractibility. Content: nihilistic themes,
loss, guilt/ helplessness/hopelessness/ worthlessness.
Nihilistic delusions (if psychotic).
Perception: Hallucinations if psychotic.
Memory and cognition: Decreased attention and
concentration (and consequent deficits in other
modalities). Pseudodementia.
Insight: Usually intact (but beware masked depressin
e.g. alexithymia).
Judgment : often impaired e.g self harm, not seeking
therapy.
Post Interview
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Discussion of Interview
Discussion of MSE
Bipolar Disorder
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2 poles
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Depression
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Similar to Major Depression but not quite
Mania
Bipolar Disorder
DSM IV
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Manic episode ( seen in Bipolar I)
A. A distinct pattern of abnormally and persistently elevated mood
at least one week or any duration if hospitalized
B. Three or Four present to a significant degree
1. Inflated self esteem or grandiosity
2. Decreased need for sleep
3. More talkative than usual
4. Flight of ideas or subjective experience that thoughts are racing
5. Distractibility
6. Increase in goal directed activity or psychomotor agitation
7. Excessive involvement in pleasurable activity that have high risk
of painful consequences
Mania Mnemonic
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D – Distractibility
I – Increased goal-directed energy
G – Grandiosity
F – Fast thinking
A – Activities (pleasurable with painful consequences)
S – Sleeplessness
T – Talkative
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Or diagram
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Bipolar Disorder
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Mania MYTH: always cheerful, enthusiastic,
happy, euphoric
 irritable, hostile, cutting
Inflated self esteem/ grandiosity
Neurovegetative symptoms
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A brain going on hyperdrive  can become psychotic
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Increased energy, not requiring sleep
Brain processing info faster than usual
Less need for food
Bipolar Disorder
DSM IV
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Exclusions
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Not due to general medical condition, substance abuse
Not a Mixed episode
Mania caused by treatment for depression should not count
towards a diagnosis of bipolar 1
Bipolar Disorder
DSM IV
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Hypomania ( less severe than mania)
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Criteria are as for mania but:
“The episode is not severe enough to cause
marked impairment in social or occupational
functioning or to necessitate hospitalization
and there are no psychotic features”
Seen in Bipolar II ( depressions and
hypomania)
Bipolar Disorder
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Depressed phase
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Longest, more frequent, undiagnosed, generally
untreated phase
Apart from usual depressive symptoms found in MDE,
can have:
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Anxiety ( non specific)
Hypersomnia
Psychomotor retardation
Poor response to antidepressants or can switch to mania
Risk issues that need to be
assessed
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Depression
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Suicide
Poor self cares
Unable to care for dependents
Suicide- Homicide ( ie postpartum)
Mania
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Rarely suicide
Impulsivity- anger, lashing out
Less inhibitions: driving; sexual; spending
Because of loud/ “in your face” behaviour, can be
assaulted
Co-morbidities of Mood disorders
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Anxiety disorders
Substance Abuse and Dependence /
Pathological Gambling
Significant Social Stress / Family
Dysfunction
Interview of manic patient
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observe interview process, how to ask
questions
document Mental Status Examination (use
template)
MSE in Mania (Possible findings)
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A / A / A: Dishevelled, dismissive, energetic,
agitated (pitfall – can hold things together for
interview of brief duration).
Speech diminished latency, rapid, pressured
(difficult to interrupt), loud, increased prosody.
Affect: elated / euphoric, irritable, very mobile,
intense, range may be restricted or increased,
reactivity may be increased, may be
incongruent.
Mood: elevated or irritable
MSE in Mania (Continued)
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Stream of thought: increased
Form of thought: tangential, circumstantial, flight of
ideas, loosening of associations (e.g. clang associations).
Content of thought: grandiose, persecutory themes
sometimes.
Memory and cognition: may be inattentive and
distractible, with associated impairment of other
findings.
Insight: Diminished
Judgment: sometimes severely impaired.
Post interview
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Discussion of Interview
Discussion of MSE
Some helpful interview questions
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Asking about mood
Asking about anhedonia
Asking about thoughts of suicide
Asking about hallucinations
Asking about mania
Asking about comorbidities (anxiety / trauma /
substance abuse and dependence)
See Mark Zimmerman’s Interview Guide for Evaluating
DSM IV Psychiatric Disorders and the MSE- available at
Philson
Management
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Safety / Status (Mental Health Act) / Situation
Further information – Collateral / Observation /
Investigations / Lab
Therapeutic Alliance / Engagement
Psychoeducation – Family focussed therapy
Specific Treatment Goals – Bio / Psycho / Social /
Cultural / Spiritual
Relapse Prevention
Rehabilitation Goals
Reference for management plan
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http://www.psychiatryonline.com/pracGuide/loa
dPracQuickRefPdf.aspx?file=Bipolar_QRG
Accessed 28 January 2010