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/PsychiatricPractice/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

Ecstatic

Optimistic, cheerful

“Glass half full”

Even mood, stable, content

Pessimistic

“Glass half empty”

Hopeless, worthless

suicidal

Manic

Hypomanic Hyperthymic

Euthymia ( not pathologic)

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 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/loadPracQuickRefPdf.aspx?file=Bipolar_QRG

Accessed 28 January 2010