psych- mood disorders

7/27/2019 Psych- Mood Disorders

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The IT Expert: a case-based discussion on

mood disordersNoreen Marie GarciaChristopher Alec Maquiling

ASMPH 2015


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Identifying Data

MO, 29 year old, Filipino, Roman Catholic, married, ITspecialist, from Mandaluyong who was admitted for the firsttime at The Medical City on June 16, 2013.

Informant: Patient, with fair reliability

Chief Complaint: I went cuckoo


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History of Present Illness

Timeline Event

2 weeks PTA Involved in a sideline (regular work in Globe) business

transaction which the px claims to have a very huge socio-economic implication for the country. He believes that he can

save the country if this business deal prospers.

Since his involvement in this business, he reports that he

cannot stop thinking about it especially because he thinks he

can fix a lot of things about the business proposal (My

thoughts are racing, I was thinking and thinking and thinkingabout it) often taking up most of his time throughout the day

He has an elevated mood most of the time, and has

progressively lacked sleep in the succeeding days (average of

1-2 hours of sleep per day)


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Timeline Event

1 day PTA Patient called up a family meeting to discuss about"what he discovered about himself." During themeeting, he would discuss business matters mixedwith Einstein theories, numbers, "doing the greatergood for mankind" and releasing the universe. Thepatient's family could not comprehend what thepatient was saying and advised him to take a rest,possibly attributing the rambling to fatigue and

stress.


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Timeline Event

Hours PTA Claimed to have a full blown panic attack andrealized that someone is out there to kill me (hedescribed this as an AHA moment, and he deniedhearing any voices)

He then became very agitated, and told his familyto get out of the house, and bring weapons. Heknocked on the doors of his neighbors in theirapartment telling them about his belief about an

attempt to claim his life. Persistence of behavioral changes prompted his

admission in this institution.


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Review of Systems

General: (-) weight changes, (-) fever, (-) fatigue

Skin: (-) rashes,(-) sores, (-) itching, (-) dryness, (-) jaundice and (-)

discolorations

HEENT: Head: (-) headache, (-) blurring of vision. (-) deafness, (-) frequent

colds, (-) bleeding gums, (-) sore throat

Respiratory: (-) cough, (-) hemoptysis, (-) dyspnea, (-) wheezing

Cardiovascular: (-) palpitations, (-) chest pains, (-) syncope

GI: (-) dysphagia, (-) nausea/vomiting

Urinary: (-) frequency, (-) nocturia, (-) urgency, (-) hematuria and (-) dysuriaEndocrine: (-) polyuria, (-) excessive thirst

Musculoskeletal: (-) arthritis and weakness

Neurologic: (-) seizures, tremors


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Anamnesis

He was born full term to a G1P1 (1001) mother after anunplanned but wanted pregnancy, via NSD. Nofetomaternal complications noted.

Primary caregiver was the mother. He claims to have a

loving relationship with his mother. Patient is the eldest among 4 siblings (2 younger

sisters, and a brother who is the youngest). He claims tohave a normal relationship with them throughout hislife.

His father was the disciplinarian in the family.


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Anamnesis

As a young kid and throughout his teenage years, hewas very interested in science fiction and digital mediaart.

He claims to have a close set of friends, although not

many. In school, he claims to have an average performance all

throughout (grade school to college) In high school, he realized that he was gifted and had

superior level of intelligence. However, he opted not toapply this and purposely tried to lower his gradesbecause he claims to be lazy.


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Anamnesis

He took up ECE in DLSU. After graduation, he washired as an IT specialist in Globe Telecom, where hehas been working for 6 years. He claims to enjoy hiswork there, although he is frustrated with the many

number of people who tries to get in his way wheneverhe wants to fix stuff in his department.

He has 2 kids (both females) aged 6 and 8 years old,and another one due on September this year. He saysthat his children and his wife are his number one priorityin his life. He said he wanted to provide all the wantsand the needs of my family


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Sexual History

Coitus: 20 years old with his wife.

During the first few years of their marriage, he claims thatthere were instances when they did it in the car, finally

ending when a police officer caught them and reprimandedthem. He also claims that he watches porn andmasturbates all the time, which he does everyday, once ortwice twice a day.


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Personal/Social History

Substance History: non-smoker, non-alcoholic beveragedrinker; no known use of illicit substances.

Patient lives with his wife and 2 children in an Apartmentthat they own. They have regular supply of electricity andclean water source. Regular garbage collection.

Primary Financier: Patient

Primary Decision-maker: PatientPrimary Caregiver: Wife


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Physical Examination

Vital Signs:BP 140/80, T 36.1, HR 80, RR 20, VAS 0/10

The rest of the PE was unremarkable.


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Mental Status Examination

Patient was seen on the couch but opted to stand whenbeing interviewed. He was wearing green shorts and anorange collared shirt. His hair is disheveled. He is ofaverage stature and medium build, looking appropriate for

chronological age. He appears anxious, but cooperativeand with good eye contact.

Speech is hyperproductive and spontaneous.

Mood is elated with appropriate affect


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Mental Status Examination

He is preoccupied with having no extra underwear, thefixtures needing repair, the lights not having the samedesign and the medical staff being mostly female. He isalso preoccupied with having writing materials to write

down ideas for his business.

He denies perceptual disturbances. He is oriented to threespheres, with poor insight, judgment, and impulse control.


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Initial Impression

Axis I: Bipolar I Mood Disorder MRE Manic w/PsychoticFeatures

Axis II: t/c Narcissistic Personality Disorder

Axis III: Hyperuricemia

Axis IV: Social and Work-related stress

Axis V: GAF 21-30


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DSM IV TR Criteria forBipolarDisorder I

At least one manic or mixed episode

No need fora prior depressive episode

Episodes of substance-induced mood disorder or of mooddisorder due to a general medical condition need to beexcluded.

In addition, the episodes must not be better accounted forby schizoaffective disorder or superimposed onschizophrenia,schizophreniform disorder, delusionaldisorder, or a psychotic disorder not otherwise specified.
http://en.wikipedia.org/wiki/Schizophreniahttp://en.wikipedia.org/wiki/Schizophreniform_disorderhttp://en.wikipedia.org/wiki/Schizophreniahttp://en.wikipedia.org/wiki/Schizophreniform_disorderhttp://en.wikipedia.org/wiki/Delusional_disorderhttp://en.wikipedia.org/wiki/Psychotic_disorderhttp://en.wikipedia.org/wiki/Delusional_disorderhttp://en.wikipedia.org/wiki/Delusional_disorderhttp://en.wikipedia.org/wiki/Schizophreniform_disorderhttp://en.wikipedia.org/wiki/Schizophreniahttp://en.wikipedia.org/wiki/Schizoaffective_disorder


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Criteria for a Manic Episode

Elevated (or irritable) mood for >1 week (check)Three or more of following (four if mood irritable):

1. Grandiosity (check)2. Decreased need for sleep (check)3. Pressured speech (check)4. Flight of ideas, racing thoughts (check)5. Distractibility

6. Increased goal-directed activity (check)7. Excessive involvement in pleasurable activities with highrisk (check)

6 out of 7: strongly consider a manic episode for this

patient.


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Differential Diagnosis

1. Mood Disorder secondary to GMC

What is it? Episodes are judged to be a consequence of a

medical condition such as multiple sclerosis, stroke orhyperthyroidism. Onset or exacerbation of mood coincideswith that of medical condition

Rule out: Patient denies any medical conditions besides

hyperuricemia. Review of systems were all negative.

Further laboratory tests/imaging studies are needed


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2. Substance-induced mood disorder

Episodes are judged to be a consequence of a substance

such as an illicit drug, a medication (stimulants, steroids, L-dopa, antidepressants), or toxin exposure.Episodes may be related to intoxication or withdrawal

Rule out: Patient denies history of taking any substances.Needs toxicology/drug screening.


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3. Psychotic disorders (schizoaffectivedisorder, schizophrenia, brief psychotic disorder, delusionaldisorder)

Rule in: Paranoid delusion. Delusion of grandeur. Disorganized behavior. Social/occupational

dysfunction.

Rule out:Schizoaffective: because delusions did not occur in absence of mood symptoms for at least 2 weeksBrief psychotic disorder: chronology of the symptoms is a ruling in factor (more than 1 day but lessthan 1 month), less than 1 month, but a return to a social functioning should be noted. Moreover,symptoms of the patient fit more of a manic episode.Schizophreniform: Psychotic ssymptoms occurred for less than the prescribed criteria (1 month to less

than 6 months)Schizophrenia: psychotic symptoms occurred for less than 6 months.Delusional disorder: msot recent delusion cannot be considered non-bizaare; social and occupationalfunctioning was significantly impaired


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4. Bipolar II Disorder

1. The presence of a hypomanic or major depressive

episode.

2. If currently in major depressive episode, history of a

hypomanic episode. If currently in a hypomanic episode,

history of a major depressive episode. No history of amanic episode.

3. Significant stress or impairment in social, occupational,

or other important areas of functioning


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Does the patient have amajor depressive episode?

Criteria:

Five or more symptoms present for 2 weeks

1. Depressed mood- NO

2. Anhedonia- NO3. Decrease or increase in appetite OR significant weight loss or gain- NO4. Persistently increased or decreased sleep- YES5. Psychomotor agitation or retardation- YES6. Fatigue or low energy- NO7. Feelings of worthlessness or inappropriate guilt- NO

8. Decreased concentration or indecisiveness- YES9. Recurrent thoughts of death, suicidal ideation, or suicide attempt- NO

DOESN'T FULFILL THE CRITERIA


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Does the patient havehypomania?

Criteria:

Same symptoms as in manic episode, but with considerable differences:

1. Lasts at least 4 days- YES

2. No marked social or occupational dysfunction- NO3. Does not require hospitalization- NO4. No psychotic features- NO

DOESN'T FULFILL THE CRITERIA


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Rapid Cycling

Qualifier for either Bipolar I or Bipolar II disorder

Four or more mood episodes (any type) within any 1 yearperiod


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Axis II Diagnosis

Narcissistic Personality DisorderA pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy,

beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the

following:

(1) has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior withoutcommensurate achievements)- YES

(2) is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love- YES

(3) believes that he or she is "special" and unique and can only be understood by, or should associate with, other special or high-status

people (or institutions) - YES

(4) requires excessive admiration- yet to be elicited

(5) has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her

expectations- YES

(6) is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

(8) is often envious of others or believes that others are envious of him or her- YES
http://behavenet.com/grandiosity


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Other mood disorders

Major Depressive Disorder- Presence of a major depressive episode;Episode not better explained by another diagnosis; NO HISTORY ofmania, hypomania, or mixed episode (unless substance or medicalillness related)

Dysthymic Disorder- Depressed mood nearly every day for > 2 years;Associated with 2 of the following: decreased or increased appetite,decreased or increased sleep, low energy or fatigue, low self-esteem,poor concentration or indecisiveness, hopelessness, No more than 2months symptom free

Cyclothymic Disorder- Several hypomanic episodes; Several distinctperiods of depressive symptoms that do not meet criteria for a majordepressive episode; Hypomanic episodes and depressive symptomsalternate over at least 2 years; Symptom-free periods are < 2 monthsduration


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Clinical Course: Pathophysiology ofBipolar I Disorder (Manic Episode)

The pathophysiology of bipolar disorder has not been

determined.

However, twin, family, and adoption studies all indicate that

bipolar disorder has a genetic component.First-degree relatives of a person with bipolar disorder are

approximately 7 times more likely to develop bipolar

disorder than the rest of the population.

The genetic component of bipolar disorder appears to be

complex


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Pathophysiology

Structural and Functional Abnormalities: Volumetric in the prefrontal cortex andlimbic systems.

Neurotransmitter involvement: Deficiency in norepinephrine; Dopamineimplicated in the study of mania and psychotic symptoms; Serotonin levels

have also been implicated

Mitochondrial Dysfunction Abnormalities

Data from several lines of evidence is needed for a comprehensiveunderstanding of this illness, and studies examining the symptoms, genetics,

and treatment effects will all help to elucidate its pathophysiology.

P h d i F t i


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Psychodynamic Factors inMania

Most theories of mania view manic episodes as a defenseagainst underlying depression.

-May reflect an inability to tolerate a developmentaltragedy (e.g. loss of a parent)

-Defensive reaction to depression, using manicdefenses

such as omnipotence (e.g. delusions of grandeur)

May also result from a tyrannical superego, which producesan intolerable self-criticism that is then replaced byeuphoric satisfaction.


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Prevalence

Lifetime: .4-1.6%= in men and women

Men>manic episodes

Women>dep episodes

Women>rapid cycling

Ave. age onset = 20. Usually late adolescence or earlyadulthood. However some after age 50. Late onset is more commonly Type II.

Recurrent

60-70% of manic episodes occur before or after a depressive episode

Increased prevalence in upper socioeconomic classes


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Prognostic Indicators

SuicidalityPresence of a personality disorderQuality of family and social supportSubstance use

History of severity of prior episodesBipolar I type is most severeTreatment onset-the sooner the better

Age of onset-the younger the more severe


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Contextual Analysis

Patient is a male IT professional in his late 20's working in a mid-level job in amajor telecommunication company, and was currently very preoccupied in aparticular business venture that he believes has major socioeconomicimplications for this country, which is the primary psychosocial trigger for hisrecent behavioral changes.

Patient's insight is poor to fair. He said that his "going cuckoo" is only causedby his continuous lack of sleep. This will have implications in medicationcompliance and disease relapse/recurrence.

Patient is the primary breadwinner of his own family. He also helps out in the

finances of his parents and siblings. So employment status particularly after hisconfinement in TMC is a major cause for concern for the patient.

The reaction of his family, particularly his kids, to his most recent episode ofmania and violence, should be processed, since the family has a major role inthe success of the interventions that will be done to the patient.


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Therapeutic

Just like long-term illnesses such as diabetes and heart disease,bipolar disorder is an illness that requires medication to improvequality of life

Not all medications work for every person

Severity of moods and side effects must be weighed

Medical management by a psychiatrist is best

A combination of medication and talk therapy is most effective,specifically cognitive behavior and family therapy

Long-term management of symptoms reduces risk of suicide


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Therapeutic

CANMAT and ISBD 2013 updated guideline

Lithium, valproate, and several atypical antipsychotic agents continueto be first-line treatments for acute mania. Monotherapy withasenapine, paliperidone extended release (ER), and divalproex ER, aswell as adjunctive asenapine, have been added as first-line options.

Bipolar depression: lithium, lamotrigine, and quetiapine monotherapy,as well as olanzapine plus selective serotonin reuptake inhibitor (SSRI),and lithium or divalproex plus SSRI/bupropion remain first-line options.

Lithium, lamotrigine, valproate, olanzapine, quetiapine, aripiprazole,risperidone long-acting injection, and adjunctive ziprasidone continue tobe first-line options for maintenance treatment of bipolar disorder.


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Pharmacologic

Lithium- first line therapy for the acute, continuation, and maintenancestages of bipolar disorder.

Potential side effects from lithium include gastrointestinal upset, tremor,sedation, excessive thirst, frequent urination, cognitiveproblems, impaired

motor coordination, hair loss, and acne.

Excessive levels of lithium can be harmful to the kidneys, and increase the riskof side effects in general. As a result, kidney function and blood levels of lithiumare monitored in patients being treated with lithium

Therapeutic plasma levels of lithium range of 0.51.5 mEq/L, with levels of 0.8or higher being desirable in acute mania.
http://en.wikipedia.org/wiki/Acute_maniahttp://en.wikipedia.org/wiki/Kidney_functionhttp://en.wikipedia.org/wiki/Blood_levelshttp://en.wikipedia.org/wiki/Motor_coordinationhttp://en.wikipedia.org/wiki/Hair_losshttp://en.wikipedia.org/wiki/Acnehttp://en.wikipedia.org/wiki/Acute_maniahttp://en.wikipedia.org/wiki/Blood_levelshttp://en.wikipedia.org/wiki/Kidney_functionhttp://en.wikipedia.org/wiki/Acnehttp://en.wikipedia.org/wiki/Hair_losshttp://en.wikipedia.org/wiki/Motor_coordinationhttp://en.wikipedia.org/wiki/Cognitivehttp://en.wikipedia.org/wiki/Excessive_thirsthttp://en.wikipedia.org/wiki/Sedationhttp://en.wikipedia.org/wiki/Tremorhttp://en.wikipedia.org/wiki/Gastrointestinalhttp://en.wikipedia.org/wiki/Lithium_(medication)


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Pharmacologic

Valproic acid is as effective as Lithium in mania prophylaxis but is notas effective in depression prophylaxis. Good for Bipolar Disorders withRapid Cycling, Mixed episodes, w/comborbid anxiety disorders.

Better tolerated than Lithium

Side Effects:

Thrombocytopenia and platelet dysfunctionNausea, vomiting, weight gainTransaminitis

Sedation, tremorIncreased risk of neural tube defect 1-2% vs 0.14-0.2% in general populationsecondary to reduction in folic acidHair loss


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Pharmacologic

Lamotrigine: bipolar depression (Stevens-Johnsonsyndrome)

Atypical Antipsychotics: Olanzapine, Quetiapine


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Psychosocial/Preventive

Psychosocial Therapies: Multifaceted services to educatethe patient and family about bipolar disorder, help themunderstand the pattern of the illness, and teach them tocope with the changes the illness brings about.

It also aims to help the patient repair any damage(emotional, social, family, occupational and financial) theillness may have caused.

Patient should be encouraged to set goals for treatment=does the patient want to return to life as before or to takeup a less demanding life or occupation?


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Psychosocial/Preventive

Stress patterns: Patient should draw up a formal life chart that shows theepisodes of acute illness on a time basis, together with major lifeevents/stressors. Precipitants should be avoided or minimized

Sleep patterns: establishing regular patterns of sleeping can make them feel

that other major aspects of life are falling into place.

psych- mood disorders

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