06 Affective Disorders Flashcards
dysthymia vs. hyperthymia
- dysthymia: prolonged grief / love sickness
- hyperthymia: in love / ecstasy
depressive episode, manic episode, bipolar disorder
- depressive episode: depressed for more than 2 weeks
- manic episode: abnormally elevated mood for more than 1 week
- bipolar disorder: depressive episode + at least 1 (hypomanic) episode
prevalence of affective disorders in Europe
- depression: 6,9% (30,3 mio.)
- bipolar disorder: 0,9% (3,0 mio.)
outdated triadic system for mental disorders
- somatically caused mental syndroms (exogene Psychose)
- mental disease (endogene Psychose) (assumed somatic etiology)
- mental disorder
primary vs. secondary disorder
- primary disorder: no apparent somatic cause (e.g. bipolar disorder, MDD)
- secondary disorder: somatic cause (e.g. premenstrual dysphoric disorder, substance-induced mood disorder)
- for all primary disorders, there are also secondary types
treatment strategies for mood disorders
not severe
- lifestyle treatments (e.g. exercise, diet, sleep, activity, stress reduction)
- social treatments (e.g. family, psychoeducation, housing)
- psychological treatments (e.g. CBT, mindfulness)
- biological treatments (e.g. antidepressants, antipsychotics, mood stabilizers, ECT, TMS, new: Esketamin)
severe
symptoms of depression
3 core symptoms:
- decreased mood
- decreased drive & energy
- anhedonia (reduced interest and pleasure)
other symptoms:
- appetite, negative and pessimistic thoughts about the future (rumination), sleeping problems, low self-worth and self-confidence, feelings of guilt and worthlessness, impaired cognition, suicidality
severity of depression
symptoms at least two weeks for most of the time
- mild: 2 core symptoms, 2 additional symptoms
- moderate: 2 core symptoms, 3-4 additional symptoms
- severe: 3 core symptoms, 4 or more additional symptoms
diagnostic criteria for depressive episode
at least 5 out of 9 symptoms - including either 1 or 2 - for at least 2 weeks
- depressed mood
- markedly diminished interest or pleasure in (almost) all activities
- weight loss or decrease or increase in appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or excessive or inappropriate guilt
- diminished ability to think or concentrate, or indecisiveness
- recurrent thoughts of death, recurrent suicidal ideation, or specific suicide plan or suicide attempt
- hopelessness
best predictor for depression
hopelessness
frequency of somatic symptoms (pain in particular)
2/3 of all patients
depression - course of illness
- often episodic (33%), can be recurrent (36%) or even chronic (32%)
- impairment/disability persists often beyond depressive episode
- 50% of major depressive episodes remit within 3 months
- severe and comorbid depression average duration: 7,6 months
- the longer the episode, the lower the probability of remission
MDD - epidemiology
- 1-year prevalence: 6.9%, 30.3 mio.
- 20% of German citiziens suffer from at least 1 MDD episode in life: 25% of women, 10% of men, 5% under 20, 2% under 12
- only half of all patients are diagnosed
- only half of diagnosed patients receive therapy (75% untreated)
- 50% or worldwide suicides during depressive episode
- 15% of all former inpatients with recurrent MDD commit suicide
further clinical symptoms
- epiosde duration: 8-16 weeks, 6 months in the past
- irritability and anger frequent in males, children, adolescent, early warning sign for relapse
- cognitive dysfunction frequent (pseudodementia)
- psychiatric comorbidity with anxiety, also addiction and others
- non-psychiatric comorbidity like DM II, obesity, hypertension, arteriosclerosis, immunological disorders
- only 50% of patients respond to first treatment
- 30% turn from episodic to chronic = persistent depressive disorder (> 2 years)
recent developments in depression therapy
- Ketamin: either intravenous (not-approved, cheap) or nasal (approved, costly)
- psychedelic supported psychotherapy: psylocibin
- intensive TMS: 6-8 times per day for 1 week
- deep brain stimulation: high hopes, but evidence not really promising
dysregulated HPA axis in MDD
brain effects of cortisol
- impaired cognition
- increased psychopathology
- hippocampal atrophy
bodily effects of cortisol
- increased blood pressure
- decreased heart rate variability
- increase in glucose
- higher insulin resistance
- higher visceral fat
MDD: overactive circuit with increased cortisol and impaired negative feedback, induced by chronic, uncontrollable stress
evidence:
- (moderate) elevation in cortisol in patients
- cortisol treatment increases MDD risk by factor 2-3 and for suicide by factor 7
doubts:
- only 50% of patients show change in cortisol after effective treatment
monoamin deficit hypothesis
- a deficit in monoaminergic neuromodulators (serotonin, norepinephrine, dopamine) that has to be substituted for the whole life
bipolar disorder - symptoms
mania
- euphoria, grandiosity, logorrhea, high energy, low impulse control, high libido, risky behavior, less sleep
psychotic symptoms
- delusions, hallucinations
depression/irritability
- depressed mood, anxiety, loss of energy, irritability, aggression, suicidal ideation/behavior
cognitive impairment / thought disorders
- increased speed of thought, attention deficits, concentration deficits, impaired executive functions
diagnostic criteria for mania
- elevation of mood
- high energy and activity
- pressure of speech
- decreased need for sleep
- marked distractability
- inflated self-esteem and grandiosity
- loss of social inhibition, inappropriate behavior
- psychotic symptoms (in 75% of manic episodes)
diagnostic criteria for hypomania
- mild elevation of mood
- high energy and activity
- feeling of well-being and efficiency
- higher sociability
- higher sexual energy
- irritability
- no disruption of social relationships
- no psychotic symptoms
bipolar disorder - subtypes
- bipolar 1: at least 1 manic episode, at least 1 week
- bipolar 2: at least 1 hypomanic episode, at least 4 days
both usually start with depressive episode - unipolar mania: 5% of all bipolar disorders
bipolar disorder - epidemiology
- lifetime prevalence: BD1 = 0.6%, BD2 = 0.4% (more female) + 1.4% subthreshold
- cultural variation: China 0.1% EU 0.9%
- onset around 20, 5 years delay to diagnosis
- high psychiatric and nonpsychiatric comorbidity
- high suicide rate: 1/3 to half attempt suicide at once (15-20% lethal)
- strong biological basis: Heritability = 85%
