Download Affective and Personality Disorder

Mood and Personality
Disorder
David Peterson
March 4 2004
Emergency Medicine
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
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
Summary
• Personality Disorders
– Cluster C
• Avoidant Personality Disorder
• Dependent Personality Disorder
• OCD Personality Disorder
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
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
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
• Parkinson’s disease which involves dopaminergic dysfunction
oftens leads to depressive symptoms
– Other neurotransmitters
• GABA
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)
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 night’s sleep
– Kindling
• Subthreshold stimulation of the brain results in seizure
activity
• Anticonvulsant drugs are effectiv for Bipolar II disorder
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
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
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
1.
2.
3.
4.
5.
6.
7.
8.
9.
–
–
•
Recurrent SI
Suicide attempt
Pneumonic: SIGECAPS
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
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
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
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
SE similar to SSRIs
• Dose dependent
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
Major Depressive Disorder
• Psychotherapy:
– Psychodynamic
– Psychoanalytic
– Cognitive therapy
– Interpersonal therapy
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
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
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
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
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
Bipolar I Disorder
Substance-induced mood disorder
• Intoxication with stimulants like cocaine or
amphetamines can mimic mania
• Medications
–
–
–
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Steroids
Dopamine agonists
Anticholinergic
Cimetidine
Mood disorder due to GMC
• Manic symptoms can be seen with:
–
–
–
–
Infectious diseases eg AIDS
Endocrinopathies eg Cushing’s disease, Hyperthyroid
SLE
Variety of neurological disorders eg Epilepsy, MS, Wilson’s
disease
Bipolar II Disorder
• Officially recognized for the first time in DSM-IV
• Epidemiology
– Lifetime risk ~0.5%
– Women > 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
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:
–
–
–
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Seizure
Confusion
Coma
Cardiac dysrythmias
Bipolar Disorders
• Medications:
– Valproate
• Recently found to be as effective as lithium
• Plays a role particularly in rapid cycling patients
• SE include:
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–
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–
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N/V
Tremor
Sedation
Hair loss
Rarely can cause hepatic failure, pancreatitis and
agranulocytosis
– Wide therapeutic index
» Can be fatal in OD
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-Johnson’s syndrome, liver failure and agranulocytosis
• Hepatically metabolized
• Toxic at high doses
– Monitor levels
– OD can be fatal
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
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
Dysthymic Disorder
• Differential diagnosis
– Similar to MDD
• Associated clinical features
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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
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 > 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
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
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
Personality Disorders
• Clusters of Personality Disorders
– Cluster B:
• Dramatic, emotional and erratic group
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–
–
–
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
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
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 don’t seek tx
• Individual pyschotherapy
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
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
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
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
Cluster B Personality Disorders
• Borderline personality disorder
– Gem of ED and psychiatry
– Best friends one minute, worst enemies the next
• Diagnosis:
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•
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
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
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
Cluster B Personality Disorders
• Medical-surgical setting
– Reacts to illness as threat to sense of selfperfection
• Treatment
– Individual psychotherapy tx of choice
• Stormy at first
– Group therapy
• Get feedback about effect on others
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
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
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
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
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
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
Cluster C Personality Disorders
• Associated features
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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
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Illness perceived as threat to control
Patient becomes more inflexible
May lead to multiple complaints about staff and hospital
Don’t fall into trap of argument with patient or be defensive
Control should be shared with patients
• Allow patient to be involved with decisions
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
The End