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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 – – – – 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: – – – – 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: – – – – – 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 – – – – – 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 – – – – 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: – – – – – – – • 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 – – – – 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 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