Mood disorder


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  • Unhyeginiec – urine smell/split his sputum on the floor
  • Flight of ideas – Taman medan Taman DesaRia  Bangunan tinggi2
  • Investigation?????????
  • Secondary mania closed head injury, and relatively frequent occurrence of irritability, aggression and hypersexuality has important implications for management of these patients. The major neuroanatomic correlate of mania after TBI is the presence of anterior temporal lesions (Robinson et al., 2000). Infectious processes, including HIV infection, may also be an important risk factor for the development of secondary mania, and it has been suggested that mania occurring late in HIV infection is likely the result of HIV effects on the CNS, while mania that occurs early in asymptomatic HIV seropositive patients may be more etiologically related to genetic predisposition (Evans et al., 1995).
  • Mood disorder

    1. 1. NG<br />BOON KEAT<br />MOHD<br />HANAFI<br />PSYCHOLOGICAL<br />MEDICINE<br />CONFERENCE<br />
    2. 2. MR. S<br />55-year-old | Security Guard <br />Married | 3 children<br />Progressively worsened disturbed behaviourfor 4 days<br />
    3. 3. HISTORY OF PRESENT ILLNESS<br />Brought by the son to the accident and emergency due to bizarre behaviours:<br />Appeared to be irritable and aggressive<br />Shouting with vulgar words<br />No physical damages to self or other people<br />Known case of psychiatric illness, under UMMC follow-up<br />
    4. 4. WITHIN 3 DAYS<br />Decrease need for sleep <br />Increase activities<br />Wandering around the house non-stop<br />Pacing faster than normal<br />Talkative<br />Described as talking non-sense<br />Impaired functions<br />Cannot do daily activities properly<br />Getting complains from working colleagues<br />Mood is happy without reason<br />
    5. 5. FURTHER CURRENT HISTORY<br />No psychotic symptoms<br />No depressive symptoms<br />Clear history of past depressive episodes<br />
    6. 6. WHAT<br />DO YOU<br />THINK?????<br />
    7. 7. PAST PSYCHIATRIC HISTORY<br />Since 2002  Multiple admission due to inappropriate behavior with depression.<br />Treated with:<br />Lorazepam| anxiolytic<br />Chlopromazine | antipsychotic<br />Perphenazine | antipsychotic<br />Carbamazepine | anxiolytic<br />Poor compliance to medication<br />
    8. 8. PAST PSYCHIATRIC HISTORY<br />8/02<br />Sm: Abnormal behaviour & Epilepsy<br />SurgDx: AVM<br />1/06, 7/06, 12/06<br />Multiple admission on Epilepsy<br />10/09<br />Motor Vehicle accident: cross the highway |polytrauma[contusion, haemothorax, SDH, AVM <br />Current Admission<br /> 2005 2006 2007 2008 2009 2010<br />12/05<br />Sm: ↓ need of sleep, aggressive [shouting]<br />19/8 – 21/9<br />Stressor: stolen motor,<br />Fired from job<br />Sm: shouting to family, aggitated<br />10/09<br />After operation: ruptured diagphragm with right upper limb fracture<br />
    9. 9. PAST MEDICAL HISTORY<br />Known case of epilepsy since young.<br />Patient was seeking psychiatric service in UMMC in 2002 and was referred to surgical team the same year.<br />
    10. 10. Diagnosed to have arteriovenous malformation.<br />Healthy without other medical conditions.<br />No previous history of ECT:<br />AVM<br />Epilepsy<br />
    11. 11. Follow-up in neuro-surgical and neuro-medicalclinic.<br />Relatively “stable”<br />
    12. 12. FAMILY HISTORY<br />d. | unknown cause<br />70 | housewife | no medical illness<br />No psychiatric, suicide history in the family<br />No history of epilepsy, neurological disease in the family.<br />Family relationships are good.<br />
    13. 13. PERSONAL HISTORY: EARLY CHILDHOOD<br />13/4/1955 | AlorStar<br />uncomplicated FTSVD | village midwife.<br />No health problems| Nodevelopmental delay<br />
    14. 14. PERSONAL HISTORY: SCHOOL PERFORMANCE<br />SRK Kancut| SMK Syed Omar<br />Moderate achievement in primary school<br />Drop-out of school after SRP due to poor performance<br />No disciplinary problem<br />Socialize with friends<br />
    15. 15. PERSONAL HISTORY: WORK RECORDS<br />Move to Kuala Lumpur | 18-year-old<br />Work | security guard since then.<br />Never change his job.<br />Income | around RM1000<br />
    16. 16. PERSONAL HISTORY: SEXUAL ATTITUDE AND PRACTICE<br />Nosexual experience | before marriage<br />1st intercourse |age of 30<br />No history of child abuse<br />
    17. 17. PERSONAL HISTORY: MARRIAGE<br />Arrangedby parents<br />His wife: 53 year old | Freelance teacher| Had been supportive to the husband despite his condition<br />
    18. 18. HIS CHILDREN<br />55 | retired security<br />53 | housewife | freelance teacher<br />36 | factory worker<br />d.18 | MVA<br />38 | despatch<br />37 | despatch<br />
    19. 19. PERSONAL HISTORY: SOCIO-CULTURAL BACKGROUND<br />RM5000 family income per month??<br />Socialize with friends?<br />No criminal records<br />$<br />
    20. 20. PERSONAL HISTORY: SUBSTANCE USE<br />Smoking| 74 pack years<br />No alcohol consumption |<br />No substance abuse<br />
    21. 21. PERSONAL HISTORY: PRE-MORBID PERSONALITY<br />Proper social | relationships<br />Stable mood |but depress occasionally<br />Personality trait??<br />Weak faith | religion<br />Favouritepast time | sports<br />Coping skill | sports<br />
    22. 22. MENTAL STATE: GENERAL APPEARANCE<br />Alert | conscious | cooperative<br />Easily make rapport | poor eye contact<br />Hospital attire | unhygienic<br />Anxious | frowning of the forehead<br />
    23. 23. MENTAL STATE: SPEECH & THOUGHT<br />↑ amount | ↑ tone | ↑ rate<br />Pressured speech<br />Malay-spoken | coherence but irrelevance<br />thought blocking | flight of ideas<br />NO<br />Loose/clang association | circumstantialities | neologism | obsession/phobua | delusions<br />Suicidal thought<br />
    24. 24. MENTAL STATE: MOOD & PERCEPTION<br />Sadin mood<br />Inappropriate affect | incongruent<br />NO<br />Hallucinations| Pseudohallucinations |Illusions| Derealization/Depersonalization| Flashback<br />
    25. 25. MENTAL STATE: COGNITIVE FUNCTION<br />Time, Place, Person | Orientated<br />Remote, Recent Memory | Good<br />[date of birth & breakfast]<br />5mins memory test | Remember only 1<br />Information/knowledge | Appropriate<br />Proverbs | Can answer <br />[Udang di sebalikbatu & sikit-sikit lama-lama jadibukit]<br />Similarities | Give 2<br />[apple & orange: tastes, eaten]<br />
    26. 26. MENTAL STATE: COGNITIVE FUNCTION 2<br />Attention | Easily distracted<br />Concentration | Cant do it<br />[serial 7 test, digit span, world backward]<br />Judgement | Cant assess<br />[patient started irritable and agitated]<br />Insight | Poor <br />[he and others do not realised his abnormality | not accept and do not need treatment]<br />
    27. 27. PHYSICAL EXAMINATION<br />Alert | conscious | not in respiratory distress. <br />37.5˚C | 92 beats pm | 20 bpm| 120/80. <br />Couldn’t assess<br />1st day | patient irritable and agitated<br />2nd day | patient physically restrained and chemically sedated<br />
    28. 28. IN SUMMARY<br />History| irritable, aggressive and shouting for 4 days, with maniac symptoms | no depressive symptoms within the current period<br />Previous History | psychiatric illness since 2002 | not complicant with medication | Complicated with AVM and MVA<br />Mental State | easilydistracted | mostly cannot assess| poorinsight<br />
    29. 29.
    30. 30.
    31. 31. WHAT<br />IS THE MOST<br />LIKELY<br />PROVISIONAL DIAGNOSIS?<br />
    32. 32. PROVISIONAL DIAGNOSIS<br />BIPOLAR I DISORDER<br />manic episode <br />The patient has had at least one previous major depressive episode, manic episode, or mixed episode <br />
    34. 34. WARD: Investigation done<br />Full Blood Count | Liver Function Test | Glucose Level | Renal Profile<br />Normal<br />CT Brain was ordered…..<br />
    35. 35.
    36. 36.
    38. 38. FINAL DIAGNOSIS: AXIS<br />
    39. 39. MANAGEMENT IN THE WARD<br />| Psychiatric View | <br />Psychotic medication not aim to cure the organic condition<br />ECT cancelled<br />Given Rozidal, Carbamazepine, Lorazepam, Chlorphomazine<br />
    40. 40. MANAGEMENT IN THE WARD<br />| Neurosurgical View | <br />CT Brain done  Cerebral oedema and complex AVM<br />No surgical management available (grade 5 AVM)<br />
    42. 42. FROM THE NEUROLOGICAL ASPECT<br />AVM<br />Mania and frontal lobe<br />
    43. 43. MANIA AND FRONTAL LOBE<br />Secondary mania can be resulted from frontal lobe lesion<br />Multiple case studies reported that most mania symptoms occurs in RIGHT frontal lobe lesion.<br />Can occur immediately or later in life after injury.<br />
    44. 44. PATHOPHYSIOLOGY<br />No clear mechanism<br />Postulation: <br />1. Brain asymmetry causing dis-inhibition syndrome.<br />2. Limbic system damage. <br />Psychosomatics 48:433-435, September-October 2007 doi: 10.1176/appi.psy.48.5.433 <br />
    45. 45. AVM: SHORT OVERVIEW<br />Patient has a right extensive fronto-temporo-occipital AVM<br />Not curable in this case<br />Causing the mood symptoms and epilepsy<br />
    46. 46. AVM: DEFINITION<br />Lesions of the cerebral vasculature<br />Blood flows from arterial to venous system<br />Without capillary system<br />Shunt<br />
    47. 47. AVM: CLINICAL PRESENTATION<br />Clinical presentations:<br />Haemorrhage(41-79%)<br />Seizure(11-33%)<br />Heache<br />Prognosis<br />Average rate of haemorrhage – 2.8-4.6%<br />
    48. 48. AVM: GRADING<br />
    49. 49. AVM: TREATMENT<br />Surgerynot a chance<br />Vascular surgery not a chance<br />Radiosurgery only chance for the patient(do in stages)<br />
    50. 50. DSM-IV criteria for mood disorder resulting from medical or neurologic condition, manic type (secondary mania)<br />Elation or irritability <br />Four of the following: <br />inflated self-esteem or grandiosity<br />decreased need for sleep<br />pressured speech<br />flight of ideas<br />Distractibility<br />increased goal-directed activity or psychomotor agitation<br />excessive involvement in pleasurable activities  <br />
    51. 51. ORGANIC MOOD DISORDER: CLASSIFICATION<br />ICD-10 specifies that the affective disorder must be judged not to represent an emotional response to the patient’s knowledge of having a concurrent brain disorder.<br />
    52. 52. MOOD DISORDER(DSM-IV & ICD 10)<br />
    53. 53. ORGANIC MOOD DISORDER: EPIDEMIOLOGY<br />Depression in the medically ill appears to be equally prevalent by sex, or possibly slightly higher in men <br />(Caine and Lyness, 2000).<br />Patients with secondary mania are more likely to have negative family and personal histories of mood disorder <br />(Evans et al., 1995)<br />
    54. 54. ORGANIC MOOD DISORDER: AETIOLOGY<br />cortical degenerations<br />extrapyramidal disorders<br />cerebrovascular diseases<br />cerebral neoplasms & trauma<br />CNS infections <br />endocrine disorders<br />inflammatory <br />(Cummings and Mega, 2003). <br />
    55. 55. ORGANIC MOOD DISORDER: MANAGEMENT<br />Poststroke Depression  Nortriptylineand trazodone. <br />(Lipsey et al., 1984; Reding et al., 1986). <br />Traumatic Brain Injury Depression Desipramineand sertraline <br />(Wroblewski et al., 1996; Fann et al., 2000).<br />Manic Lithium <br />(Evans et al., 1995). <br />SecondaryMania Clonidine, valproate, carbamazepine and antipsychotics<br />(Bakchine et al., 1989; Starkstein et al., 1991)<br />