Types of Mental Disorders
- Mood
- Anxiety
- Personality
- Disruptive behavior
Although physicians are taught to diagnose mood disorders in medical school, they often fail to recognize these problems in themselves or their colleagues.
Disorders addressed in this module include those of mood, panic/anxiety, and obsessive-compulsive symptoms. The most commonly encountered personality disorder traits are narcissistic, obsessive-compulsive, and antisocial.
As concerned peers, we do not need to know how to diagnose and treat these problems. We need to recognize warning signs and be aware that physicians are at higher risk for some behaviors, including catastrophic judgment errors and even suicide. It is important to talk about mental health issues to decrease the stigma associated with persons who have mental disorder symptoms.
Mood Disorders
- Mood disorders are more common in single, divorced, and separated people
- Most common mood disorders
- Major Depression
- Dysthymic Disorder
- Bipolar Disorder
The most common mood disorders are Major Depression, Dysthymic Disorder, and Bipolar Disorder. Dysthymic Disorder is similar to a low grade fever and must be present for two years or more, but is not as severe as Major Depression.
Mood disorders are more common in single, divorced and separated people. There is no correlation with social class. Family history, personality factors, environmental stress and biological disturbances or imbalance of neurotransmitters all may play a role in the onset of depression.
Mood disorders often occur with substance use disorders. Substance use disorders can confuse the diagnosis.
Depression in Physicians
- Rate of depression similar to general population (13% of male physicians and 20% of female physicians)
- One-third of medical residents have diagnosable depression during residency
- Depression is a major risk factor for suicide
Major Depression has a surprisingly high prevalence. Women experience depression 2:1 over men. About 20% of women will develop Major Depression compared with 13% of men. Major Depression is episodic with normal function between episodes. However, as one gets older, episodes may be increasingly frequent or intense with 20-30% developing a chronic course. Only about 20-25% of people with Major Depression receive treatment. Even a fewer percentage of physicians receive appropriate treatment and care for their Major Depression. Suicide will be discussed later in this course.
Characteristics of Major Depression
SIGECAPS
- Sleep
- Interests
- Guilt
- Energy
- Concentration
- Appetite
- Psychomotor Agitation or Slowing
- Suicidal Ideation
The characteristic symptoms of Major Depression include depressed mood or the loss of interest or pleasure in nearly all activities, along with periods of tearfulness.
The SIGECAPS interview is a useful mnemonic to assist in assessing for depression. A person meets the criteria for Major Depression when he or she displays five or more of the SIGECAPS symptoms for two weeks or longer.
A depressed person may experience Sleep problems (hypersomnia or insomnia), loss of Interest in pleasurable activities, feelings of Guilt or worthlessness, increased or decreased Energy, impaired Concentration, increased or decreased Appetite (for food, sex), episodes of Psychomotor agitation or retardation, and/or recurrent thoughts of death or Suicide. A depressed person may attempt to self-medicate with alcohol or other drugs.
Antidepressant medication in combination with psychotherapy has been shown to be very effective in the treatment of Major Depression.
Depressed Resident (Ethical Dilemmas)
- 30 year-old female, second year Family Practice resident
- Single parent, moonlighting, taking care of her children
- Weight loss, decreased appetite, social withdrawal
Depression is common in resident physicians. Consider this case study.
After an unexpected illness and divorce, Dr. Gray, a 30 year-old female, second year family practice resident, continued seeing patients, doing hospital rounds, and taking call. As a single parent with a reduced household income, she took on moonlighting jobs while she continued to care for her children as well.
Over several months, she exhibited a profound weight loss, appeared at rounds hollow-eyed, was observed to eat only a few bites of her meals, became more withdrawn, and was visibly anxious and distracted during classes. During a meeting with her clinical supervisor, she became tearful.
What would you do or say as her supervisor or peer?
Hers suggested she shake it off and be strong. “Get over it. At least you don’t have a terminal illness.”
Outcome: The physician sought out another female physician who then referred the doctor to a psychiatrist for further help. The doctor participated in therapy, took medication, and ultimately took a brief leave of absence. She recovered, returned to her residency, finished, and has had no recurrence of depression.
Bipolar Disorders
- Bouts of depression alternating with periods of mania, hypomania or increased irritability
- 65-75% of bipolar disorders begin with depression
- Bipolar illness affects about 1% of the population
Affected individuals experience bouts of depression alternating with periods of mania, hypomania or simply increased irritability. There may or may not be periods of normal mood intervening. Bipolar disorders in 65-75% of cases begin with depression. Bipolar illness affects about 1% of the population, with males and females affected equally.
Typical characteristics of mania include decreased need for sleep (2-4 hours in 24 hours), high energy, elevated, expansive or irritable mood, rapid or pressured speech, thought processes often difficult to follow, jumping from one topic to another, grandiose thoughts and projects, and increased sexual activity. The impulsivity of mania/hypomania results in violent outbursts, spending sprees, and poor decisions which may involve family, patients or finances. Often the manic phase is denied by the patients because they think they never felt better. Alcohol and other drug abuse is common as an attempt to medicate the mood swings. The depression which follows a period of mania/hypomania is usually severe, and the person may become acutely suicidal.
The average age for a first manic episode is in the early twenties (and sometimes teens) and often occurs after about three episodes of depression. Mania in the absence of depression is seen in only 10-20% of bipolar patients. Bipolar illness is a spectrum disorder emerging mild to severe over months or within the same day.
Manic Physician (Ethical Dilemmas)
- Prominent surgical sub-specialist, small group practice
- Decreased need for sleep, spending sprees, binge drinking
- Grandiosity, intrusive behavior
Dr. Z is a prominent surgical sub-specialist, part of a small group practice with other sub-specialists. His wife has become increasing worried about behavior changes he shows at home, which includes sleeping only three hours a night, spending sprees, and binge drinking. He reluctantly agrees to an outpatient psychiatric evaluation if she attends with him.
He creates a disturbance in the waiting room, shaking everyone’s hands, and attempting to hug all of the women patients. In the examining room, he is loud and expansive, denying he has any problems and describes himself as “the greatest doctor in the world.”
The psychiatrist recommends hospitalization, but Dr. Z refuses, becomes belligerent, and says he just needs a career change and that he will simply fly to Mexico to open a bar, abandoning his patients. After a lengthy discussion, along with the possibility of involuntary hospitalization, Dr. Z finally agrees to admission. Three days after admission, the senior practice partner pressures the psychiatric hospitalist to release Dr. Z because “he generates a lot of money and we have a new office to pay for.” Dr. Z is still quite manic, has elevated liver function studies, and will need an extended stay in the hospital.
This is a case where this is an ethical dilemma between the practice group’s need for income, Dr. Z’s perception of his illness, and the reality that Dr. Z has a very serious mental disorder.
Warning Signs of Mood Disorders
- Decline in job performance
- Absenteeism
- Irritability, argumentativeness
- Change in personal appearance
- Increased physical complaints when depressed
Dr. J is an academic physician at a well known medical school. He has a reputation for being somewhat angry and irritable. These characteristics have intensified over the last three months, along with taking more sick days than usual, getting behind on grant writing, and has appeared disheveled at work compared to his usually meticulous appearance.
A crisis develops when he starts afternoon rounds, and all the trainees notice the smell of alcohol on his breath and slurred speech. One of the trainees contacts the local PHR committee, and after the events are verified, an intervention is conducted.
Dr. J becomes tearful, admits to being very depressed for the last three months, and states he has been drinking to treat his mood. He is terrified that he will lose his job and his license, and agrees to a 96-hour evaluation.
This is a case where a primary mood disorder is associated with self-medication, and with professional difficulties.
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