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/ , no and depressions

elevations/ mania  , 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 / or Anhedonia 3. Weight loss change 4. Insomnia or hypersomnia 5. or retardation 6. Fatigue or loss of energy 7. of worthlessness / 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*

and

 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).  : 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 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

( 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:

( 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