18. Mood disorders Flashcards
What are 2 types of mood disorders?
depressive and bipolar
What are the core symptoms of depression?
- low mood/sadness
- lack of energy
- Lack of enjoyment and interest
What are some other typical symptoms of depression?
o Depressive thoughts
▪ worthlessness/inappropriate or excessive guilt
▪ suicidal ideation
▪ diminished ability to think/concentrate or indecisiveness
o Somatic/biological symptoms ▪ Lack of appetite ▪ Pain ▪ psychomotor agitation or retardation ▪ insomnia/hypersomnia o Severe cases might have psychotic symptoms (e.g. delusions)
What is required to make a diagnosis of depression?
If the person has at least 5 symptoms with at least one of these being a core symptom
What may be a differential for depression?
Adjustment reaction
What is the difference between adjustment reaction and depression?
▪ Essentially, an adjustment reaction typically occurs after some kind of traumatic event and has fewer somatic features
compared to depression
▪ Adjustment reactions do not last as long as depression and tend to have a fluctuating course
What are the features of mania?
- Elated Mood
- Increased energy
- Pressure of speech
- Decreased need for sleep
- Flight of ideas
- Normal social inhibitions are lost • Attention cannot be sustained
- Self esteem is inflated, often grandiose
- May have psychotic symptoms
what is hypomania?
Hypomania refers to symptoms that are still clearly manic but don’t
necessarily reach full diagnostic criteria for mania
What is bipolar I?
Discrete episodes of mania only or mania and depression
What is bipolar II?
Discrete episodes of hypomania or hypomania and depression
when is diagnosis of bipolar mood disorder made?
Diagnosis is made following 2 episodes of a mood disorder at least one of which is mania or hypomania.
What are some physical health differentials for depression?
▪ Hypothyroidism ▪ B12 deficiency ▪ Chronic disease e.g. renal, CVS & liver failure ▪ Substance misuse ▪ Hypoactive delirium
What are some physical health differentials for mania?
Diagnosis is made following 2 episodes of a mood disorder at least one of which is mania or hypomania.
What different brain structures are involved in mood disorders?
- Limbic system
- Frontal lobe
- Basal ganglia
What is the main hypothesis for what determines mood?
Mood is determined by functional circuits between these brain areas (limbic system, frontal lobe and basal ganglia).
E.g. the frontal lobe projects to parts of the limbic system which in turn connects to the basal ganglia and the brainstem.
What does the circuits between these different areas affect?
- Cognitive processed (thoughts)
- Sympathetic output
- Parasympathetic output
- Motor systems
WHat are the main parts of the limbic system?
Amygdala, hippocampus, thalamus, hypothalamus, basal ganglia, cingulate gyrus
What are the 3 main functions of the limbic system?
• Emotion • Motivation • Memory
what is the main emotion circuit of the limbic system?
papez circuit
describe the papez circuit
o Various cortical areas send input to the
o Hippocampus, which projects to the
o Mammillary bodies
o Via the fornix (white matter, output pathway of the
hippocampus)
o The mamillary bodies project to the thalamus and
hypothalamus
o The thalamus projects back to the cortex
o The hypothalamus projects down to the pituitary
and autonomics mediating some of the somatic
effects
o The amygdala is another part of the limbic system,
but can be grouped with hippocampus in terms if
its connections
what is th paper circuit also responsible for?
memory consolidation
What are the possible limbic system changes in unipolar depression?
- Decreased hippocampal volume (in patients with recurrent depressive disorder)
- Decreased cerebral blood flow and metabolism in the amygdala
What are the possible limbic system changes in bipolar disorder?
- Altered amygdala volume
- Increased amygdala activation & volume in mania
- Decreases in volume in anterior paralimbic cortices (inc ventral prefrontal cortex, insular cortex and temporopolar cortex) & activation
What are the functions of the frontal lobe? (7)
- Motor function
- Language (Broca’s area)
- Executive functions (purposeful goal directed behaviours)
- Attention
- Memory
- Mood
- Social and moral reasoning
What are the functions of the prefrontal cortex?
Generation of emotions and emotional responses
What are the possible frontal lobe changes in unipolar depression?
- Decreased activity (bloodflow) in dorsolateral PFC
- Decreased volume of orbitofrontal PFC
What are the possible frontal lobe changes in bipolar disorder?
Reduced dorsolateral PFC activation
What are the psychological functions of the basal ganglia?
- Emotion - Cognition - Behaviour
What are the possible basal ganglia changes in unipolar depression?
- Decreased basal ganglia volume
- Reduced activation between striatum, amygdala and PFC
What are the possible basal ganglia changes in bipolar disorder?
Possible functional changes in the striatum
what is th over-all involvement of the circuits in depression?
• Prefrontal cortex: Slowing of thought, executive dysfunction.
Altered emotional processing.
• Amgydala: Abnormal emotional processing
pless carry out
• Basal ganglia: Impaired incentive behaviour. Psychomotor
changes.
WHat are the 2 main neurotransmitters for depressive disorders?
- Serotonin
- Noradrenaline (aka norepinephrine)
where is serotonin produced and distributed to?
Produced in brainstem (raphe nuclei) and distributed to
cortex and limbic system
What is serotonin thought to have roles in as a neurotransmitter?
- Sleep
- Impulse control (link with suicide)
- Appetite
- Mood
What is levels of serotonin thought to be in mood disorders, what is the evidence to support?
Low
- SSRI’s, SNRI, TCA’s & MAOi’s all successfully treat depression by increasing levels of serotonin in synaptic cleft
- 5HIAA (metabolite of serotonin) is low in the CSF of patients with depression (particularly those who have attempted suicide).
- Tryptophan (precursor for serotonin) depletion causes depression
where is noradrenaline produced?
Produced in the locus coeruleus of the brainstem and
distributed to cortex and limbic system
What are the functions of noradrenaline in the brain?
o Mood
o Arousal
o Memory
What is levels of noradrenaline thought to be in mood disorders, what is the evidence to support?
Low
- Antidepressants (e.g. SNRI’s, NARI’s and some TCA’s) that increase NA successfully treat depression.
- Patients who have recovered from depression who show decreased NA levels, have significantly higher rates of relapse.
- Postmortem studies of depressed patients vs controls
What are the biological treatments for depression?
- First line = Selective Serotonin Reuptake inhibitors
- Other options: SNRI’s, TCA’s etc
- Life threatening/treatment resistant: Electric Convulsive Therapy
WHat are SSRIs, SNRIs, TCAs, and MAOis?
- Selective Serotonin Reuptake inhibitors
- Serotonin Noradrenaline reuptake inhibitors
- Tricyclic antidepressants
- Monoamine oxidase inhibitors
What psychological and social treatment can be used for depression?
- psychological: CBT
- social: Help with e.g. isolation, social stressors (including housing, finances)
What is the biological treatment for mania?
- Biological - First line: antipsychotics
- Alternatively: mood stabiliser
What type of drugs are antipsychotics?
Dopamine receptor antagonists
Give examples of mood stabalisers used to treat mania?
- lithium
- sodium valporate (teratogenic)
What is the psychological and social treatment for mania?
- Psychological - Acutely unlikely to be helpful, longer term - psychoeducation re. BPAD, triggers and signs of relapse
- Social - Treat in a place of safety - where risk to self and others is minimal. Consideration of implications of mania e.g. debts (excessive spending)
What is the biological treatment for bipolar depression?
Can use antidepressant - but ONLY with mood stabiliser cover. - ECT Lithium
What is the psychological and social treatment for bipolar depression?
Same as for unipolar depression:
- CBT
- helping with isolation, stressors etc.
What is the biological treatment for maintaining stability in bipolar disorder?
- Mood stabilisers e.g. lithium, sodium valproate
- Antipsychotic (used as a mood stabiliser e.g. Quetiapine)
What is the psychological and social treatment for maintaining stability in bipolar disorder?
Psychological
- Psychoeducation re. bipolar affective disorder
- CBT - to help prevent relapses
Social
- Consideration of BPAD on employment e.g. shift work. Involvement of family, education of family etc
