Mood Disorders Workshop 2010 Dr Andrew Howie / Dr Tony Fernando Psychological Medicine Faculty of Medical and Health Sciences University of Auckland
Goals To learn about the clinical presentation of mood disorders 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 Genetics Social/ Developmental and Environmental factors Details of variant forms Neurobiology Abnormalities in neurotransmission Neuroimaging Neuroendocrine functioning
Useful resources (for further reading) 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 Euphoric Ecstatic Optimistic, cheerful Glass half full Even mood, stable, content Pessimistic Glass half empty Hopeless, worthless suicidal
Individualized Set point/ range Reactivity to situations/ thoughts Neutral Positive Negative Despite fluctuations, the individual still is able to function socially, vocationally Modifiable?
Pathologic equivalents Euphoric Ecstatic Optimistic, cheerful Glass half full Even mood, stable, content Manic Hypomanic Hyperthymic Euthymia ( not pathologic) Pessimistic Glass half empty Hopeless, worthless suicidal Dysthymic Depressed
Pathologic Changes 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 Depressive Disorders Predominant mood is depression, no elevations/ mania Major Depression, single episode Major Depression, recurrent Dysthymic Disorder Depressive Disorder, not otherwise specified Bipolar Disorders Has elevations/ mania and depressions Bipolar disorder, manic Bipolar disorder, depressed Bipolar disorder, mixed Cyclothymic disorder Bipolar disorder, not otherwise specified
Specific Mood Disorders Depressive Disorders Major Depression, single episode Major Depression, recurrent Dysthymic Disorder Depressive Disorder, not otherwise specified Other Variants: Atypical depression, Postpartum depression, Seasonal Affective Disorder, Depression with psychosis
Depressive Disorders Must exclude: Mixed Episode Secondary to General Medical Condition Secondary to Substance Abuse Bereavement- Duration and Severity
Specific Mood Disorders Bipolar Disorders Bipolar disorder, manic Bipolar disorder, depressed Bipolar disorder, mixed Cyclothymic disorder Bipolar disorder, not otherwise specified Other Variants: Bipolar I and II, rapid cycling, ultra rapid cycling
Major Depressive Disorder DSM IV 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 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 A Appetite changes C Concentration difficulties H Hopelessness E - (Self) esteem low W Worthlessness S Sleep disturbances.
Dysthymia rule of 2 s At least 2 symptoms Minimum 2 years Never without symptoms for more than 2 months
Other Depressive symptoms not in Irritability and anger the 9* Unexplained physical complaints (somatizers) In some severe depressions, can have delusions and hallucinations * 9 DSM IV symptoms DSIGECAPS
Interview of patient with depression observe interview process, how to ask questions document Mental Status Examination (use template)
MSE in Depression (Some possible findings) 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) 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 Discussion of Interview Discussion of MSE
Bipolar Disorder 2 poles Depression Similar to Major Depression but not quite Mania
Bipolar Disorder DSM IV 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 D Distractibility I Increased goal-directed energy G Grandiosity F Fast thinking A Activities (pleasurable with painful consequences) S Sleeplessness T Talkative Or diagram
Bipolar Disorder Mania MYTH: always cheerful, enthusiastic, happy, euphoric irritable, hostile, cutting Inflated self esteem/ grandiosity Neurovegetative symptoms A brain going on hyperdrive can become psychotic Increased energy, not requiring sleep Brain processing info faster than usual Less need for food
Bipolar Disorder DSM IV Exclusions 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 Hypomania ( less severe than mania) 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 Depressed phase Longest, more frequent, undiagnosed, generally untreated phase Apart from usual depressive symptoms found in MDE, can have: Anxiety ( non specific) Hypersomnia Psychomotor retardation Poor response to antidepressants or can switch to mania
Risk issues that need to be assessed Depression Suicide Poor self cares Unable to care for dependents Suicide- Homicide ( ie postpartum) Mania 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 Anxiety disorders Substance Abuse and Dependence / Pathological Gambling Significant Social Stress / Family Dysfunction
Interview of manic patient observe interview process, how to ask questions document Mental Status Examination (use template)
MSE in Mania (Possible findings) 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) 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 Discussion of Interview Discussion of MSE
Some helpful interview questions 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 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 http://www.psychiatryonline.com/pracguide/loa dpracquickrefpdf.aspx?file=bipolar_qrg Accessed 28 January 2010