Mood and Personality Disorder

1. Mood and Personality Disorder David Peterson March 4 2004 Emergency Medicine

2. 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

3. 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

4. Summary • Personality Disorders • Cluster C • Avoidant Personality Disorder • Dependent Personality Disorder • OCD Personality Disorder

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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

12. 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 • Recurrent SI • Suicide attempt • Pneumonic: SIGECAPS

13. 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

14. 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

15. 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

16. 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

17. 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

18. Major Depressive Disorder • Psychotherapy: • Psychodynamic • Psychoanalytic • Cognitive therapy • Interpersonal therapy

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. Cluster B Personality Disorders • Medical-surgical setting • Reacts to illness as threat to sense of self-perfection • Treatment • Individual psychotherapy tx of choice • Stormy at first • Group therapy • Get feedback about effect on others

46. 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

47. 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

48. 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

49. 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

50. 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