CASE PRESENTATION

(Mood Disorder)

PBL 12
HISTORY
TAKING
A) IDENTIFICATION DATA
Name : Rasida Akma Othman
Age : 32 year-old
Address : Pasir Puteh, Kelantan
Marital status : Single
Sex & Race : Female, Malay
Occupation : Former restaurant worker
Religion : Islam
Status : In-patient
Date of admission : 3rd November 2010
Date of clerking : 27th November 2010
Informant : Patient herself
Reliability : Reliable
B) Chief Complaint

Patient self-admitted to HUSM complaining of

uncompleted tasks and unable to sleep 1 day
prior to admission.
C) History of Presenting Illness

2010
History 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.
She 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 didn’t 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.
D) Past psychiatric History
1996
History 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.
Her 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-
boyfriend’s 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 couldn’t. She claimed that she
didn’t feel jealous but feel sad because
she had to re-sit her SPM.
2000
She 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.
2004
She 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(Dato’s) 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.
2006
She 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.
2008
She worked as a AVON direct seller which was one of
multilevel marketing company.
She had similar problems as in 2006
She went to HUSM for 4th admission because of her
stressful job and she did not compliance to her
medication
E) SYSTEMIC REVIEW
Cardiovascular System Respiratory System
 No shortness of breath No cough
No chest pain No purulent sputum
No ankle swelling No haemoptysis
No palpation No night sweat.
No syncope
No intermittent claudication. Genitourinary System
Central Nervous System No pain and difficulty in passing urine
 No numbness or increasing sensation, No abnormal changes in urine color
No blurring of vision No urinary incontinence
No hearing problem No frequency
No muscle weakness
No symptom of sphincter disturbance Endocrine System
No loss of consciousness No swelling in the neck.
 
Musculoskeletal System Hematological System
 No pain, stiffness or swelling of the No bruises
joint No lumps under the arms, neck or
No muscle wasting groin.
No limb weakness.
F) PERSONAL HISTORY
Prenatal history
Patient 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.
Adolesence
She 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 Adulthood
She kept changing her jobs as she was unable to cope
with the stress at work.
G) PAST MEDICAL/
SURGICAL HISTORY

She 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 Personality
She 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 HISTORY
She 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.
J) Social History
She lives with her parents in Pasir Puteh, Kelantan.
She claimed that she is the apple in his father’s 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 History
She 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.
SUMMARY
My 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 Examinations
Content
Appearance and Behaviour
Speech
Mood and Affect
Perceptual
Thought
Cognitive
Abstract Reasoning
Judgement
Insight
 Appearance 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.
Speech
She 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 Expression
Mood = Normal

Affect
Nature = Happy
Appropriateness = Normal
Range = Normal
Depth = Normal
Lability = Sudden unexpected emotional
outburst
Perception
No illusion
Presence of functional hallucination

*Functional hallucination
= Normal perception of a stimulus and a
hallucination in the same modality are
experienced simultaneously.
Thinking
Form/ Structural
Circumstantiality
Flight of ideas
Tangentiality

Stream/ Flow
Pressure of speech
Content
Grandiosity
Amorous
delusion
Possesion
No thought insertion, thought withdrawal
and thought broadcasting
Cognitive
 Orientation
Patient awared and orientated to time,
place and person.

 Attention/ Concentration
Patient was not co-operative and refused
to
answer.
Memory
a) Immediate
Patient was not co-operative and refused to
answer.
b) Short term
Intact

c) Remote
Intact
Information and Intelligent
Comprehension
General knowledge Intact
Vocabulary

* Calculation
Patient was not co-operative and refused to
answer.
Abstract Reasoning
Similarity and Difference Testing
Patient was not co-operative and refused to
answer.
Proverb
 She was able to answer the meanings of the proverbs that
were given to her.
 Eg. Bagai aur dengan tebing
Bagai isi dengan kuku
Judgement
Social judgement
Patient was not co-operative and refused
Test judgement to answer.

Personal judgement
Q = Apakah rancangan kamu selepas keluar dari sini?
A = Saya nak kahwin.

Insight
Good insight
Conclusion
On MSE, her appearance, behavior, speech, mood &
affect, and cognition were good, except
 perceptual disturbance = Hallucination (Once only)
 thinking = Grandiosity
= Amorous delusion

 Moderate Mental Status.

 Physical
Examination
General Examination
My 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 Signs
Temperature = 37 °C
Pulse rate = 78 b.p.m
Respiratory rate = 18 b.p.m.
Blood pressure = 120/ 70 mm Hg
Hand
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 Ears

No discharge was noted.
Mouth
The tongue was not coated. There was no central cyanosis
and the
oral hygiene was poor.

Leg
Absence of pitting oedema. Peripheral pulses was detected.
Specific Examination
Nervous System
 All 12 cranial nerves were intact.
DISCUSSION
Mood Disorder

Mood is defined as pervasive emotional tone

That profoundly influences one’s outlook and
perception of self, others and the environment.
DSM categories of Mood Disorders

A. Depressive Disorders
1.Major Depressive Disorder, MDD
2.DysthymicDisorder
3.Depressive Disorder Not Otherwise Specified

B. Bipolar Disorders
1.Bipolar I Disorder
2.Bipolar II Disorder
3.CyclothymicDisorder
4.Bipolar Disorder NOS

C. Other Mood Disorders

1.Mood Disorder d/tGMC
2.Substance induced Mood Disorder
3.Mood Disorder NOS

Other causes of Depresive and Manic Symptomss

1.Schizoaffective Disorder
2.Cognitive Disorder with Depressed mood
3.Adjustment Disorder with depressed mood
4.Personality Disorder –Borderline, Avoidant, Dependent, and Histrionic PD
5.Bereavement-sadness at the death of relative or friend
6.Other Disorders –schizophrenia, eating Disorders, Sexual Dis, Gender Identity DisandAnxiety
Disorders
Bipolar Disorder
Also known as
Bipolar affective disorder
Manic depressive disorder
Diagnostic Overview (DSM-IV-TR)
Bipolar I Bipolar II Cyclothymic Bipolar NOS
1. At least 1. At least one 1.At least one A disorder with
onemanicor major hypomanic bipolar features,
mixed episode. depressive episode but does not
2. Major episode. 2.Mood states meet specific
depressive 2. At least one do not meet full criteria for any
orhypomanicepi hypomanicepiso criteria for specific bipolar
sode may occur de, NOmanic depressive, disorder
episode manic, or mixed
episode.

DSM-IV-TR 2000: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.
Text Revision. 2000.
Epidemiology

•Bipolar disorder affects both sexes equally

•Usually first occurs between the ages of 20 and 30, starting with a manic
episode
DSM-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
:
i. Inflated self esteem or grandiosity
ii. Reduced need for sleep (feel rested after only 3 hours of sleep)
iii. More talkative than usual/ pressure to keep talking
iv. Flight of ideas or subjective experience that thoughts are racing
v. Distractibility ( attention to easily drawn to irrelevant external stimuli)
vi. Increased in goal directed activity (either socially, at work or school / sexually)
or psychomotor agitation
vii. Excessive 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: hyperthyroidism
Major Depression Disorder
Epidemiology

• 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.

i. 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.
ii. 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).
iii. 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.
iv. insomnia or hypersomnia nearly every day.
 v. psychomotor agitation or retardation nearly every day (observable by
other, not merely subjective feelings of restlessness or being slowed
down
vi. fatigue or loss of energy nearly every day.
vii. feeling of worthlessness or excessive or inappropriate guilt (which
may be delusion) nearly every day (not merely self-reproach or guilt
about being sick).
viii. diminished ability to think or concentrate, or indecisiveness, nearly
every day (either by subjective account or as observed by others).
ix. recurrent though of death (not just fear of dying), recurrent suicidal
ideation without specific plan, or a suicidal attempt or a specific plan
B.Thefor symptoms do not
committing meet criteria for a mixed episode.
suicide.
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 either
 A subtype of schizophrenia
 A subtype of affective disorder
 A heterogenousdisorder (intermediate between
schizophrenia and affective disorder)-Continuum
model (schizomanicand schizodepressivesubtype)
Differential Diagnosis Positive Negative

Bipolar Manic episode

Depressive episode

Cyclothymic Depressive episode Manic episode

Dysthymic Depressive episode Manic episode

Schizoaffective Hallucination No prominent perceptual

Delusion and thought disturbance
Mood disorder
Schizophrenia Hallucination No prominent perceptual
Delusion and thought disturbance
Mood disorder
Management and Treatment
Pharmacology : Mood Stabilisers
• MOOD STABILIZERS : agents used to stabilise the mood
swings of depression and mania
1. Lithium (priadle® or camcolit®)
2. 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 episodes
PSYCHOSOCIAL TREATMENTS
Cognitive 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 occur
 Family therapy
 To reduce level of distress within the family that may either contribute to
or result from the ill person’s symptoms
 Interpersonal and social rhythm therapy
 Improve interpersonal relationships and regularize their daily routines.
Regular daily routines and sleep schedules may help protect against
manic episodes
OTHER TREATMENTS
ELECTROCONVULSIVE 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 suicidality
 Used when medications are too risky ( pregnancy)
 Highly effective treatment for severe depressive,
manic or mixed episodes
Thank you