HD:

Psychiatric Disorders

Affective Disorders / Depression
Irritability
Apathy
Anxiety
Psychosis
Obsessive-Compulsive Disorder

Resulting Emotional Behavior

apathy
impulsiveness
irritability
social withdrawal
obsessive compulsive behaviors
depression
anxiety
sleep reversal or insomnia
suicidal thoughts or acts

“Agitated” is not descriptive, try…
irritable
labile
inflexible
combative
angry
disinhibited
perseverative

“Confused” is not descriptive, try…
failing to orient to place
failing to comprehend or to recall
lethargic, inattentive
speaking clear-sounding nonsense
hallucinating

Signs include: loss of interest, energy, appetite, concentration, libido, agitation.
Treat with one drug, titrate dose slowly, and give full trial. Antidepressants rarely worsen motor disorder.

Lifetime prevalence of affective disorder (major depression and mania) was 41% in Maryland survey
Affective Disorder may precede the motor manifestations by an average of 5 years or more
Affective disorder may cluster in some families
Suicide occurs 4-8 times as often as in the general population
Risk factors for suicide include: living alone, being male, having a family history of suicide and most importantly being childless

Early HD: anticipated loss of control, morbid pessimism, threat to role - identity and productivity, failure of frontal lobe function
Mid-Stage HD: impulsivity, inability to experience pleasure, loss of insight, catastrophic reaction
Late HD: exhaustion, isolation, dependence, attack on residual self

Management of HD Depression

Fluoxetine: 10mg qd, titrate, max 60mg side effects - insomnia, restlessness, nausea, headache, diarrhea, decreased libido
Sertraline: 25mg qd, titrate, max 200mg side effects - insomnia, restlessness, nausea, headache, diarrhea, decreased libido
Nortriptilline: 10mg, titrate, max 150mg side effects - dry mouth blurred vision, urinary retention, cardiac dysrhythmias

Common, disturbing to families
Loss of initiative, lack of spontaneity, indifference
May be interpreted as depression
No specific pharmacotherapy
Try structured group activities, give choices

May occur alone, or in conjunction with major depression or obsessive-compulsive disorder
Try non-pharmacologic strategies first
Pharmacologic strategies include
Benzodiazepines - lorazepam 0.5mg BID or TID or clonazepam 0.5mg qhs
Buspirone - 5mg BID

Problem Solving: No one is to blame, Consult the person and those who know him, Identify solution for every problem
Define Origin of Problem Behavior: Ask “what happened?”, Was there a precipitating disappointment - change or challenge, What are cognitive blind spots?
Daily Routine as Therapy:
reduces anxiety, promotes restful sleep, allows person to anticipate, permits adequate assessment
Therapeutic Principles
focus on specific symptom, try non-pharmacologic treatment first, drug dosage (start low, go slow), re-evaluate treatment periodically

Fluoxetine: see prior
Sertraline: see prior
Clomipramine: 25mg qhs, titrate, max 250mg side effects - sedation, anticholinergic, sexual dysfunction, GI upset
Buspirone: 5mg BID-TID, titrate, max 20-60mg side effects - dizziness, nausea, headache, nervousness

Psychosis occurred in 4% of the Maryland sample
Neuroleptics are generally effective
begin haloperidol 0.5mg BID
doses above 10mg may not be more effective
Atypical Neuroleptics may also be effective
clozapine 25mg qhs, increase slowly

Neuroleptic Medications in HD

Used to treat psychosis
Side effect: increased bradykinesia; may lessen chorea in very low doses; sedation and apathy
Neuroleptics do not improve motor function
(patients will thank-you twice for use of neuroleptics: once when putting them on, second time when taking them off)

Most HD patients do not find obsessions or compulsions dysphoric
May present as preseveration with certain ideas
Treatment
SSRI’s in doses higher than that used typically for depression
Clomipramine