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/clinical- memoranda.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 Manic
Ecstatic
Hypomanic Optimistic, cheerful Hyperthymic “Glass half full”
Euthymia ( not pathologic) Even mood, stable, content
Pessimistic Dysthymic “Glass half empty”
Depressed Hopeless, worthless suicidal
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 Bipolar Disorders
Predominant mood is Has elevations/ mania depression, no and depressions
elevations/ mania Bipolar disorder, manic
Major Depression, Bipolar disorder, single episode depressed
Major Depression, Bipolar disorder, mixed
recurrent Cyclothymic disorder
Dysthymic Disorder Bipolar disorder, not Depressive Disorder, otherwise specified 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 the 9*
Irritability and anger
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