06 Affective Disorders

Question 1

dysthymia vs. hyperthymia

Answer 1

• dysthymia: prolonged grief / love sickness
• hyperthymia: in love / ecstasy

Question 2

depressive episode, manic episode, bipolar disorder

Answer 2

• 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

Question 3

prevalence of affective disorders in Europe

Answer 3

• depression: 6,9% (30,3 mio.)
• bipolar disorder: 0,9% (3,0 mio.)

Question 4

outdated triadic system for mental disorders

Answer 4

• somatically caused mental syndroms (exogene Psychose)
• mental disease (endogene Psychose) (assumed somatic etiology)
• mental disorder

Question 5

primary vs. secondary disorder

Answer 5

• 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

Question 6

treatment strategies for mood disorders

Answer 6

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

Question 7

symptoms of depression

Answer 7

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

Question 8

severity of depression

Answer 8

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

Question 9

diagnostic criteria for depressive episode

Answer 9

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

Question 10

best predictor for depression

Answer 10

hopelessness

Question 11

frequency of somatic symptoms (pain in particular)

Answer 11

2/3 of all patients

Question 12

depression - course of illness

Answer 12

• 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

Question 13

MDD - epidemiology

Answer 13

• 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

Question 14

further clinical symptoms

Answer 14

• 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)

Question 15

recent developments in depression therapy

Answer 15

• 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

Question 16

dysregulated HPA axis in MDD

Answer 16

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

Question 17

monoamin deficit hypothesis

Answer 17

• a deficit in monoaminergic neuromodulators (serotonin, norepinephrine, dopamine) that has to be substituted for the whole life

Question 18

bipolar disorder - symptoms

Answer 18

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

Question 19

diagnostic criteria for mania

Answer 19

• 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)

Question 20

diagnostic criteria for hypomania

Answer 20

• 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

Question 21

bipolar disorder - subtypes

Answer 21

• 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

Question 22

bipolar disorder - epidemiology

Answer 22

• 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%