1. Dr Neil Hunt Consultant Psychiatrist
Depression
& Mood Instabilty : recognition and management
Dr Neil Hunt Consultant Psychiatrist
Drneilhunt.com

3. Elation Depression Anxiety Anger
What Moods do we recognise?
Elation Depression Anxiety Anger

4. What is Personality?
Temperament is what we are born with Personality is what develops through your life

5. Personality disorders: recognition and management
Borderline personality
Antisocial personality
Paranoid personality
Anankastic personality

6. Recognition Self harming Relationship problems Emotional crises
Behavioural problems
Addictions
Somatic complaints
Difficulties in multiple domains

7. Recognition Emotional instability
Intense episodes of dysphoria
Irritability, anxiety, depression
Emptiness, boredom, intolerance of being alone
Highly reactive to interpersonal events
– esp criticism, rejection

8. Hans-Ulrich Wittchen

9. Diagnostic criteria for mania
A. Elevated, or irritable mood I N S G H T
B. with at least 3 of:
Grandiosity
Decreased need for sleep
Increased talkativeness
Flight of ideas (or racing thoughts)
Distractibility
Increased energy
Loss of inhibitions
C. Marked impairment of social or occupational functioning
D. No psychotic symptoms in the absence of mood disturbance
E. No organic factor (except antidepressants)

10. - + Five or more of the following for BPD: Present in (hypo)mani a
Present in depression
Present in euthymia
frantic efforts to avoid real or imagined abandonment -
a pattern of unstable and intense interpersonal relationships - extremes of idealization and devaluation
identity disturbance: markedly and persistently unstable self-image or sense of self
Impulsivity, self-damaging (e.g., spending, sex, substances). +
recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
affective instability due to a marked reactivity of mood
chronic feelings of emptiness 
inappropriate, intense anger or difficulty controlling anger
transient, stress-related paranoid ideation or severe dissociative symptoms

11. Differentiating between BPII and EUPD
Symptoms
Course
Family history
How to manage
Treatment response

12. Differentiating between BPII and EUPD
Family history
Breeding true
History of bipolar or severe depression
Differentiating between BPII and EUPD

13. Differentiating between BPII and EUPD
Age of onset
Bipolar starts
late teens / early 20s
EUPD – “always been there”
Differentiating between BPII and EUPD

14. Clinical staging model of bipolar disorder
Clinical staging model of bipolar disorder in high-risk offspring subgroups.
Duffy A et al. BJP 2014;204:
©2014 by The Royal College of Psychiatrists

15. Differentiating between BPII and EUPD
Symptoms
Depressive – suicidal
BPII – melancholic persistent
EUPD – self disgust / hatred
reactivity
Differentiating between BPII and EUPD

18. Differentiating between BPII and EUPD
Symptoms
Elated
BPII overconfident , grandiose
loss of anxiety impulsive
EUPD – agitation, anger , hyper
Differentiating between BPII and EUPD

19. Differentiating between BPII and EUPD
Symptoms
BPII Persistence dysphoric low energy but episodic
EUPD reactive – criticism, rejection
abandonment
Differentiating between BPII and EUPD

20. Identity Do you know who you are? Beliefs, fantasy, sexuality
Is your body part of you?
Self Disgust

21. Relationships BPII - affected by mood states
EUPD – intense and coflictual
idealise / denigrate
friendships centre around difficulties

22. Is borderline personality disorder a type of bipolar disorder?
Family history: only 2% of relatives are bipolar I
10% of borderlines also have a bipolar diagnosis
Paris et al 2007

23. & Mood Instabilty : recognition and management
Depression
& Mood Instabilty : recognition and management
Dr Neil Hunt

24. & Mood Instabilty : recognition and management
Depression
& Mood Instabilty : recognition and management
Dr Neil Hunt

25. How do you discuss diagnosis?
Continuous v episodic disorder?
Has there always been a problem?
Does it affect every aspect of life?
Patient choice (as long as its the right choice!)

26. Prognosis
How much did your personality change between 15 and 25 years old?
But what is the residium?

27. Treatment of comorbid conditions
Depression
Anxiety
Substance misuse

28. Treatment Recognition Social change Consistent approach
Optimism tempered by realism
Help them to use their own solutions

29. Treatment Non directive counselling is probably counterproductive
Need a well supported therapist
Specific therapies: Mentalisation DBT

30. Thinking patterns
Black and White – “need to learn to live in the Grey”
Split you – perfect to rubbish
Need you to sort me

31. Medication Antidepressants BPII Either not effective or destabilising
Quetiapine lamotrigine
Lithium is an effective preventitive
Lamotrigine not effective for EUPD

32. Medication
Crawford et al 2018

33. What not to do Help them to get addicted to benzos
Piss them off by being judgemental
Be unrealistic and give solutions

34. Suicidal acts Self harm and suicide are connected behaviours
Risk taking with your own life and impulsivity

35. Suicide In those with a severe borderline personality disorder
1 in 10 die by suicide