CASE PRESENTATION (Mood Disorder)

PBL 12CASE PRESENTATION(Mood Disorder) HISTORY TAKINGA) IDENTIFICATION DATAName: Rasida Akma OthmanAge : 32 year-oldAddress : Pasir Puteh, KelantanMarital status: SingleSex & Race : Female, MalayOccupation : Former restaurant worker Religion : IslamStatus : In-patientDate of admission : 3rd November 2010Date of clerking : 27th November 2010Informant : Patient herselfReliability : Reliable

B) Chief Complaint

Patient self-admitted to HUSM complaining of uncompleted tasks and unable to sleep 1 day prior to admission.

2010History started back in 1996 when the patient was diagnosed to have bipolar disorder and being warded. Starting from that, she was frequently being admitted due to similar problems. On 3rd November 2010, the patient admitted to HUSM with complaint of unfinished tasks and inability to sleep 1 day prior to admission. She worked as a restaurant worker since 1 month ago. Patient claimed that her job was so stressful that her working hour was 18 hours per day. She had to wake up at 4am everyday and the job finished at about 10pm. She felt not enough sleep during that period of working.C) History of Presenting IllnessShe also claimed that her workload was too heavy for her that she had to do all the jobs in the restaurant except for mopping the floor. The stressful job caused her difficult to sleep. She did not find any relieving factor for her stress.She did not take her medication regularly because she was too busy with her work. Patient claimed that this cause her unease. 1 day prior to admission, patient unable to sleep for the whole night and she also noticed uncompleted house chores. For example she could not finish folding her clothes completely.

She request to be admitted to HUSM(5th time) as she felt that the dose of medication was not enough for her symptoms at that time.

During further questioning, she also claimed that Shahir, one of the chef in Hotel Mania(tv drama) who is her current boyfriend is falling in love with her and ask her to marry him. Current Condition She sang at the top of her voice, screaming and talking something that didnt make sense. She claimed that she liked to wear bright clothes especially red when she wanted to sing. On further questioning, she mentioned that she liked to wear expensive branded clothing such as Adidas, Nike and so on. She denied hearing voices, seeing shadows, being suspicious to others and having anxiety symptoms; palpitations and sweating.

1996History started in 1996 (18 year-old), when she had high grade fever for 3 months and some episodes of seizure. She was not fully conscious and bedridden.She believed that she developed rotten teeth as complication of high grade fever and seizure. D) Past psychiatric History 9Her family doctor came to treat her at home and medication was given to her.

Besides, during fever, patient was depressed for about 3 days because her elder sister got married to her ex-boyfriends brother . She could not attend the wedding ceremony and she kept crying at her room. However, she claimed that her mood became normal few days after the ceremony.In addition, she felt more depressed when she knew most of her friends were able to further study in matriculation and university while she couldnt. She claimed that she didnt feel jealous but feel sad because she had to re-sit her SPM.

2000She worked as a factory worker in Selangor-1 day at Sumida factory, 7 days at Hitachi factory. (Quarelling with other workers and felt irritated. She claimed that other workers bully her because she was new there.)Later, she returned to Kelantan because she was unable to cope with her stress and felt depressed. Due to this problem, she attended general practitioner and was diagnosed with bipolar disorder and prescribed with medication. She claimed that she developed limbs stiffness and drooling of saliva because of the medication given. So, she went to HUSM and being admitted to the psychiatry ward for the first time.She believed that her illness was due to drug overdose.2004She said that she submitted her photo to magazine(pen-pal). She claimed that many guys want to know her. She mentioned that she was creative and was a Malay literature experts. She claimed that there was a magazine publisher(Datos) asking her to write a poem. So, she produced a poem and submitted to the Dato but the Dato did not respond. She got depressed because of that and being admitted to HUSM again (2nd time).During admission(a day after Tsunami), she claimed that she saw the effects of Tsunami destruction in Kubang Kerian. She said that all the buildings in front of HUSM were ruined by Tsunami. In addition, she felt sympathy to the victims. 2006She worked as a Neutrimetics(beauty product) direct seller.She claimed that she felt depressed during her works because some of her customers did not pay their debts. Because of that, she had to pay on behalf of her customers by using her own money to the company .She claimed that she did not take her medication regularly because of her stressful job.During her depressive mood, she wrote poems in order to relieve her stress.She went to HUSM for 3rd admission due to her stressful life and not compliance to the medication.2008She worked as a AVON direct seller which was one of multilevel marketing company.She had similar problems as in 2006She went to HUSM for 4th admission because of her stressful job and she did not compliance to her medication

E) SYSTEMIC REVIEWCardiovascular SystemNo shortness of breathNo chest painNo ankle swellingNo palpationNo syncopeNo intermittent claudication.

Central Nervous SystemNo numbness or increasing sensation, No blurring of visionNo hearing problemNo muscle weaknessNo symptom of sphincter disturbance No loss of consciousness

Musculoskeletal SystemNo pain, stiffness or swelling of the jointNo muscle wastingNo limb weakness.Respiratory SystemNo coughNo purulent sputumNo haemoptysisNo night sweat.

Genitourinary SystemNo pain and difficulty in passing urine No abnormal changes in urine color No urinary incontinenceNo frequency

Endocrine SystemNo swelling in the neck.Hematological SystemNo bruises No lumps under the arms, neck or groin.Prenatal historyPatient was delivered via spontaneous vaginal delivery.

Early childhood (through age 3)According to the patient, there was no abnormalities in the development.

Middle childhood (age 3-11)She went to primary school and was one of the 5 top students.She was an active students and took part in many competitions.She did not have any problems making friends.

F) PERSONAL HISTORYAdolesenceShe was active in debate competition.Her social life at school was normal and she was able to make friends.She started having relationship with her boyfriend when she was13years old but it lasted for 4 months only. She claimed that she got depressed and became tearfulness for about 2-3 days only, then she recovers.

Early AdulthoodShe kept changing her jobs as she was unable to cope with the stress at work.

G) PAST MEDICAL/ SURGICAL HISTORYShe had prolonged fever for about 3 months on year 1996. She had home-visit treatment due to her bed-ridden condition. There was no previous surgical history.

H) Pre-morbid PersonalityShe claimed that she is a cheerful, energetic and positive thinking person. She claimed that she is responsible to her work and family.Intellectually intact.She claimed that she is talented in Malay literature. She joined various competitions and won most of the time.

I) FAMILY HISTORYShe is the 6th among her sibling (total of 9). She claimed that she does not have any past major illnesses (eg. hypertension, diabetes mellitus, heart disease etc)There was no known medical and psychiatric illness run in her family.PatientFemale 32 y/oShe is the 6th amongst her 9 siblings.Sex and age of her sibling was not askedJ) Social HistoryShe lives with her parents in Pasir Puteh, Kelantan. She claimed that she is the apple in his fathers eye.She is financially supported by her father and siblings.She write poems in her free time. She enjoys Malay literature. She claimed that she is friendly to everyone and she prefer to befriend with male compare to female friend.She claimed that she is not a drug abuser nor alcoholic. K) Drug HistoryShe was prescribed with Epilim Chrono (sodium valproate),1000mg and Seroquel (quetiapine-atypical antipsychotic), which has been increased the dose from 600mg to 800mg.She admitted that previously, she was careless with her medication intake because she was too busy with her works. She also mentioned of gaining weight since she started to consume the medicine.She claimed that she had no allergy towards any known medication.

SUMMARYMy patient, a 32 year old Malay lady, complained of uncompleted task and unable to sleep 1 day prior to admission. She had depressed mood, easily irritated and tearfulness. Despite that, she also had manic symptoms like insomnia, grandiose delusion and engaged in buying sprees. She presented with some psychotic symptoms as well such as visual hallucination and amorous delusion.Mental Status ExaminationsContentAppearance and Behaviour SpeechMood and AffectPerceptualThoughtCognitiveAbstract ReasoningJudgementInsightAppearance and Behaviour My patient was overweight, appearing at her age, sitting comfortable on a chair. She dressed well with a green scarf and green baju kurung. She claimed that she liked to wear colour-matched clothes. She had rotten teeth on her left anterior maxillary teeth. She had an overall neat appearance and adequate hygiene. She was being over-friendly and approached us on the day of interview. She was polite and had appropriate manners. She looked cheerful and was cooperative throughout the interview. However, she was easily distracted by noises and movements. She remained good eye contact and rapport was easily established. SpeechShe spoke in Malay language fluently. Her speech was normal in tone, volume and speed but increased in quantity/ amount. The speech was coherent and relevant. Patient reaction time towards the question asked was normal.Emotional ExpressionMood = Normal

Affect Nature = HappyAppropriateness = NormalRange= NormalDepth= NormalLability= Sudden unexpected emotional outburst PerceptionNo illusionPresence of functional hallucination

*Functional hallucination = Normal perception of a stimulus and a hallucination in the same modality are experienced simultaneously.Thinking Form/ Structural

Stream/ Flow

CircumstantialityFlight of ideasTangentialityPressure of speechContent

Possesion

GrandiosityAmorous delusion

No thought insertion, thought withdrawal and thought broadcasting

Orientation

Attention/ ConcentrationCognitivePatient awared and orientated to time, place and person. Patient was not co-operative and refused to answer.Memorya) Immediate

b) Short term

c) Remote

Patient was not co-operative and refused to answer.IntactIntactInformation and IntelligentComprehensionGeneral knowledge IntactVocabulary

* Calculation

Patient was not co-operative and refused to answer.Abstract ReasoningSimilarity and Difference Testing

ProverbShe was able to answer the meanings of the proverbs that were given to her. Eg. Bagai aur dengan tebing Bagai isi dengan kukuPatient was not co-operative and refused to answer.JudgementSocial judgementTest judgement

Personal judgement Q= Apakah rancangan kamu selepas keluar dari sini?A= Saya nak kahwin.Patient was not co-operative and refused to answer.InsightGood insightConclusionOn MSE, her appearance, behavior, speech, mood & affect, and cognition were good, except perceptual disturbance= Hallucination (Once only)thinking = Grandiosity= Amorous delusion

Moderate Mental Status.

PhysicalExaminationGeneral ExaminationMy patient was sitting comfortably on a chair. She looked well and not in pain. She was not in respiratory distress. Her hydrational and nutritional statuses were clinically adequate. No abnormal movements and no attachments were noted.Vital SignsTemperature= 37 CPulse rate= 78 b.p.mRespiratory rate= 18 b.p.m.Blood pressure= 120/ 70 mm HgHand Her hands were warm, moist and pink. There is no peripheral cyanosis and clubbing. Capillary refilling time was normal.

Eye There was no yellow discolouration on the sclera and the conjunctiva was pink.

Nose and EarsNo discharge was noted.MouthThe tongue was not coated. There was no central cyanosis and the oral hygiene was poor.

LegAbsence of pitting oedema. Peripheral pulses was detected.Specific ExaminationNervous SystemAll 12 cranial nerves were intact.DISCUSSIONMood is defined as pervasive emotional tone That profoundly influences ones outlook and perception of self, others and the environment.Mood Disorder

DSM categories of Mood Disorders

A. Depressive Disorders1.Major Depressive Disorder, MDD2.DysthymicDisorder3.Depressive Disorder Not Otherwise Specified

B. Bipolar Disorders1.Bipolar I Disorder2.Bipolar II Disorder3.CyclothymicDisorder4.Bipolar Disorder NOS

C. Other Mood Disorders1.Mood Disorder d/tGMC2.Substance induced Mood Disorder3.Mood Disorder NOS

Other causes of Depresive and Manic Symptomss1.Schizoaffective Disorder2.Cognitive Disorder with Depressed mood3.Adjustment Disorder with depressed mood4.Personality Disorder Borderline, Avoidant, Dependent, and Histrionic PD5.Bereavement-sadness at the death of relative or friend6.Other Disorders schizophrenia, eating Disorders, Sexual Dis, Gender Identity DisandAnxiety DisordersBipolar DisorderAlso known as Bipolar affective disorderManic depressive disorderDiagnostic Overview (DSM-IV-TR)

DSM-IV-TR 2000: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. 2000. Bipolar IBipolar IICyclothymicBipolar NOS1. At least onemanicor mixed episode. 2. Major depressive orhypomanicepisode may occur1. At least one major depressive episode.2. At least one hypomanicepisode, NOmanic episode1.At least one hypomanic episode2.Mood states do not meet full criteria for depressive, manic, or mixed episode.A disorder with bipolar features, but does not meet specific criteria for any specific bipolar disorder

Epidemiology

Bipolar disorder affects both sexes equallyUsually first occurs between the ages of 20 and 30, starting with a manic episodeDSM-IV-TR FOR MANIC EPISODE

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week(any duration if hospitalization is necessary)

B. During the period of mood disturbance, 3 or more following symptoms persisted (4 if the mood is only irritable) and have been present to significant degree :Inflated self esteem or grandiosityReduced need for sleep (feel rested after only 3 hours of sleep)More talkative than usual/ pressure to keep talking Flight of ideas or subjective experience that thoughts are racingDistractibility ( attention to easily drawn to irrelevant external stimuli)Increased in goal directed activity (either socially, at work or school / sexually) or psychomotor agitationExcessive involvement in pleasurable activities that have high potential for painful consequence (eg: engaging in unrestrained buying sprees, sexual indiscretion/ foolish business investment)

C. The symptoms do not meet criteria for mixed episode

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

E. The symptoms are not due to the direct physiological effects of a substance(eg: drug abuse, medication or other treatment) / general medical condition: hyperthyroidismMajor Depression DisorderEpidemiology

Twice as common in females than in males. Symptoms must be present for at least 2 weeks and represent a change for previous functioning.DSM-IV-TR Criteria for Major Depressive Episode

A.Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depress mood or (2) loss of interest or pleasure.

NOTE: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations.

depress mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). NOTE: in children and adolescents, can be irritable mood.markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. NOTE: in children, consider failure to make expected weight gains.insomnia or hypersomnia nearly every day.

psychomotor agitation or retardation nearly every day (observable by other, not merely subjective feelings of restlessness or being slowed downfatigue or loss of energy nearly every day.feeling of worthlessness or excessive or inappropriate guilt (which may be delusion) nearly every day (not merely self-reproach or guilt about being sick).diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).recurrent though of death (not just fear of dying), recurrent suicidal ideation without specific plan, or a suicidal attempt or a specific plan for committing suicide.

B.The symptoms do not meet criteria for a mixed episode.C.The symptoms cause clinically significant distress or impairment in social, occupation, or other important areas of functioning.D.The symptoms are not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).E.The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.Dysthymic Disorder

is a long-term, mild depression that lasts for a minimum of two years.

There must be persistent depressed mood continuously for at least two years.

This disorder often begins in adolescence and crosses the lifespan.

By definition the symptoms are mild and not as severe as MDD, although those with Dysthymia are vulnerable to co-occurring episodes of MDD.

People who are diagnosed with Major depressive episodes and Dysthymic disorder are diagnosed with double depression.

Dysthymic disorder develops first and then one or more major depressive episodes happen later.SCHIZOAFFECTIVE DISORDER (SA)

SA is likely to be eitherA subtype of schizophreniaA subtype of affective disorderA heterogenousdisorder (intermediate between schizophrenia and affective disorder)-Continuum model (schizomanicand schizodepressivesubtype)Differential DiagnosisPositiveNegativeBipolarManic episodeDepressive episodeCyclothymicDepressive episodeManic episodeDysthymicDepressive episodeManic episode

SchizoaffectiveHallucinationDelusionMood disorderNo prominent perceptual and thought disturbanceSchizophreniaHallucinationDelusionNo prominent perceptual and thought disturbanceMood disorderManagement and TreatmentMOOD STABILIZERS : agents used to stabilise the mood swings of depression and maniaLithium (priadle or camcolit)Anticonvulsants: a) sodium valproate (epilim) b) carbamazepine (tegretol c) lamotrigine (lamictal)* For acute and prophylaxis

typical and atypical antipsychotics (eg; olanzapine and risperidone) used to treat the manic episodes

Antidepressants (eg; fluoxetine , venlafaxine and bupropion) sometimes used to treat depressive episodesPharmacology : Mood Stabilisers

PSYCHOSOCIAL TREATMENTSCognitive behavioral therapy Helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Psychoeducation Teach about the illness and its treatment and how to recognize signs of relapse so that any intervention can be sought before full-blown illness episodes occurFamily therapyTo reduce level of distress within the family that may either contribute to or result from the ill persons symptomsInterpersonal and social rhythm therapyImprove interpersonal relationships and regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes

OTHER TREATMENTSELECTROCONVULSIVE THERAPY may be considered when medication, psychosocial treatment and combination of these interventions were ineffective or work too slowly to relieve severe symptoms such as psychosis and suicidalityUsed when medications are too risky ( pregnancy)Highly effective treatment for severe depressive, manic or mixed episodes

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