Culminating Case Discussion

General Information

• Fernando Genodepa• 35/M• Iglesia ni Cristo• From Muntinlupa• Vendor

• Informant: patient, mother• Reliability: fair

VIOLENT BEHAVIORChief Complaint

History of Present Illness

3 days PTC: Noted change in behavior• Violent behavior– Throwing objects, breaking things

• Hurting mother• Markedly decreased appetite• Crying often

History of Present Illness

According to the mother:Patient became very friendly and fell in love with his neighbor (married woman with 7 children, husband is working as a seaman)

When said woman left, patient felt very sad and would often cry and shout the woman’s name.

(+) Sleeping disturbances (~1 hour of sleep)(+) Anhedonia

Review of Systems

• (+) weight loss, not quantified• (+) insomnia• (+) poor appetite• (+) feelings of hopelessness

Past Medical History(+) Earlier 2011 Major Depressive Disorder

– meds: lamotrigine, risperidone, sertraline(+) April 2011 Major Depressive Disorder

– lamotrigine (50mg/tab x 6 months)– risperidone (50mg/tab x 6 months)– sertraline (50mg/tab x 6 months)

(+) 2007 hosital admissions– Electrolyte imbalance, hypokalemia, diagnosed w/ epilepsy (allegedly)– No maintenance medications

(+) Bronchial asthma– No maintenance medications

(-) HPN/DM/heart disease/PTB

Family Medical History

(+) Psychiatric disorder (?) – father(-) HPN/DM/PTB/BA/heart disease

Anamnesis – Pregnancy and Perinatal

• Born to a then 42 year-old primigravid via SVD at home attended by a midwife.

• No fetomaternal complications were noted at that time

• No congenital deformities were noted.• Wanted pregnancy– No maternal illness, no vices– Regular prenatal checkups c/o local health center

Anamnesis - Childhood

• The patient was cared for by his mother and his aunt.

• He had no playmates, he is an only child, and the patient was usually left to play in his crib.

• Developmental milestones were at par with age, as claimed.

Anamnesis - Education

• Started schooling at the age of seven, an average student.

• In the first grade, there was one incident when the mother was called by the principal because there was a complaint that the patient hurt his classmate.

• The patient finished high school and took a vocational course in electronics.

Anamnesis - Relationships

• Described by mother as someone who always wants to get what he wants.– Gets angry, shouts, throws away things if he does not

get his way• Fell in love with a woman named Daisy as

previously mentioned.– Persuaded by the mother not to pursue the woman– Patient would not listen and would simply ignore her– Mother would advice the patient, and he either accepts

it or gets mad, depending on his mood.

Anamnesis - Religion

• Devout member of Iglesia ni Cristo, like his mother and father.

• Used to regularly attend prayer meetings and hear masses frequently

• Raised with firm belief and faith.

Anamnesis - Occupation

• Used to work as an electrician• Used to work in a family owned junkshop

Anamnesis – Family

• Father passed away in 2008– noted to have depressed mood for most of the day– would visit father’s grave often (at least once a

month, every month)– started losing drive to work and to practice his

faith– persistent, frequent crying episodes following

father’s death.– patient ceased working and attending church

activities since

Physical ExaminationAwake, ambulatory, not in cardiorespiratory distress

BP: 120/80 HR: 86 RR: 18 Temperature: afebrile

pink conjunctivae, anicteric sclerae, (-) tonsopharyngeal congestion/ neck vein engorgement/anterior neck mass, (-)cervical lymphadenopathy

Equal chest expansion, clear breath sounds, (-) retractions/rales/wheezes

Adynamic precordium, distinct heart sounds, normal rate, regular rhythm, apex beat at 5th ICS LMCL, (-) murmurs

Firm, flat, non-tender abdomen, (-)hepatosplenomegaly, (-) masses

Full, strong equal pulses, pink nailbeds, (-) edema, no limits on ROM

Neurologic Exam

Coherent, awake, oriented to 3 spheresCranial Nerves:

CN Findings CN Findings

I no anosmia VIII Intact gross hearing

II 2/2mm BRTL, (-) RAPD

IX Midline uvula

III, IV, VI Full and equal EOMS

X Intact gag reflex

V Brisk corneal reflex

XI Good shoulder shrug

VII No facialy asymmetry

XII Normal tongue bulk

Neurologic Exam

Normotonic extremities,(-) muscle atrophy, fasciculations and fibrillations

Sensory: 100% all extremitiesMotor: 100% all extremitiesDTR: normoreflexive, all extremities

(-) Babinski, clonus(-) dysdiadochokinesia(-) Nuchal rigidity

Mental Status ExamPatent was seen poorly kempt, clad in denim pants and short-sleeved shirt. He was initially asleep but arousable.There are no mannerisms, and no abnormal behaviors noted. Patient was initially answering questions with few words in a low volume but was eventually conversing with normal volume and tone, slow speech.There was depressed mood and constricted affect.There are no thought process disturbances; he was answering questions with direct answers. Patient denies presence of hallucinations and delusions. There was suicidal ideation, but no manner of execution was reported.Patient is oriented to place, person, and time. Concentration was poor.Immediate, recent and remote memory are intact. Good fund of knowledge, fair abstract thinking, poor insight and judgment.

MULTIAXIAL DIAGNOSIS

• Axis I: Major Depressive Disorder• Axis II: Borderline personality traits• Axis III: Defer pending laboratory results• Axis IV: Economic problems, Poor compliance

to medications, Poor primary support• Axis V: GAF 11-20

Differential DiagnosisRule in Rule out

Major Depressive Disorderwith borderline personality traits

(+)depressed mood(+) anhedonia(+) weight loss, not quantified(+) insomnia(+) poor appetite(+) feelings of hopelessness(+) suicidal ideation(+) violent behavior

Differential DiagnosisRule in Rule out

Dysthymic Disorder

• Depressed mood• Insomnia• Low energy and

fatigue• Feelings of

hopelessness

• Not present for 2 years• Has a history of depressive

episode in the last 2 years

Differential DiagnosisRule in Rule out

Adjustment Disorder

• Presence of stressor within the past 3 months

• Depressive mood after the stressor

• Marked distress that in excess of what would be expected

• Wastebasket diagnosis• May only be confirmed if disorder is

resolved after 6 months from the stressful event.

Major Depressive Disorder

• Presentation:– Low mood, anhedonia, somatic complaints,

irritability• Etiology:– Multifactorial– Genetic, environmental stressors, brain structural

abnormalities, neuroendocrine abnormalities

DSM-IV-TR Criteria for MDD

• 5 or more of the following, in the same 2-week period– Depressed mood*– Markedly diminished interest or pleasure*– Significant weight loss or weight gain, or decreased or increase in

appetite– Insomnia or hypersomnia– Psychomotor agitation or retardation– Fatigue or loss of energy– Feelings of worthlessness or inappropriate guilt– Diminished ability to think or to concentrate– Recurrent thoughts of death, recurrent suicidal ideation w/o a

specific plan, suicide attempt or specific plan for commiting suicide

DSM-IV-TR Criteria for MDD

• Symptoms:– Do not meet criteria for a mixed episode– Causes clinically significant distress or impairment

in social, occupational, or other important areas of functioning

– Not due to direct physiological effects of a substance or a GMC

– Not better accounted for by bereavement

Major Depressive Disorder

• Neurotransmitters implicated:– Serotonin 5-HT– Norepinephrine– Dopamine– Glutamate– Brain-derived neurotrophic factor

Management for MDD

• Management depends on the severity and the accompanying symptoms

• Because GAF = 11-20, patient can be classified as SEVERE

Severity Classification of MDDSeverity DSM-IV Description Suggested Line

of TherapyMild Few, if any, symptoms in excess of those required to make the

diagnosis. Symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

Medication or time-limited,

Depression-targeted psychotherapiesModerate Symptoms or functional impairment between mild and severe.

Severe w/o psychotic features

Several symptoms in excess of those required to make the diagnosis. Symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

Medications are essential. Consider ECT.

Severe with psychotic features

Delusions or hallucinations. If possible, specify whether the psychotic features are mood-congruent or mood-incongruent:

Antipsychotic + antidepressant medication, ECT.

Types of Therapies for MDD

• Psychopharmacology

• Psychotherapy

• Electroconvulsive Therapy

Psychopharmacologic Agents

• Different classes of anti-depressants have similar efficacy, speed of response and overall effectiveness

• Failure of one medication does not automatically mean failure for another drug

• 50% chance for the other drug to work

Categories of Anti-depressants

• NE reuptake inhibitors• 5-HT reuptake inhibitors• NE and 5HT reuptake inhibitors• Pre- and post- synaptic active agents• Dopamine reuptake inhibitor• Mixed action agents

Initial Treatment

• Consider using SSRIs or SNRIs as first line of therapy easy to adjust and have low adverse effect profiles

• Consider using atypical antidepressants if for harder to treat depression that will require combination therapy

• Consider the adverse effect profiles when using TCAs and MAO Inhibitors

Second Treatment

• Psychopharmacologic Options– Adjust dose

• Side effects• Prior history of rapid drug metabolism• Low therapeutic blood levels• Partial benefit

– Extend use of drug• Initial trial < 6 weeks• 25% response in 6 weeks• Prior medications trials have been unsuccessfu

– Change drug

Psychotherapy

• Objectives– Symptoms remission– Psychosocial restoration– Prevention, relapse and recurrence

• Additional benefits when combined with current medications

• Discuss the psychosocial consequences arising from the disorder

• Can improve adherence to medications

Electroconvulsive Therapy

• Highly effective treatment for depression• Onset of action faster than medications• Lasts for 12 sessions, benefits seen already after 1 week• Indications

– Failure of drug therapies– History of good response to ECT– Patient’s preference– High risk of suicide– High risk of medical morbidity and mortality

• Side effects are related to general anesthesia, post-ictal confusion and rarely memory loss

Management of Borderline Personality

• Dialectic Behavior Therapy – the only data supported treatment for BPD

• Teaches 4 skills– Mindfulness– Interpersonal effectiveness– Emotional regulation– Distress tolerance without impulsivity

• May also give SSRIs but may have only a placebo effect• Benzodiapenes are contraindicated reduces

inhibitions and will increase impulsivity