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BRS Psychiatry > 1b// Mood Disorders > Flashcards

1b// Mood Disorders Flashcards

1
Q

Is there an increase or decrease rate of major depressive disorder?

A

increasing rate of MDD with an earlier age of onset

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2
Q

What is the gender distribution of major depressive disorder?

A

2:1 F:M

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3
Q

Describe disease classifications- history.

A
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4
Q

What are the current definitions for mood (or affective) disorders according to ICD-10?

A
  • …where the fundamental disturbance is a change in affect/mood to depression (with or without associated anxiety) or to elation.
  • The mood change is usually accompanied by a change in the overall level of activity
  • Most of the other symptoms are either secondary to, or easily understood in the context of, the change in mood and activity.
  • Most of these disorders tend to be recurrent and the onset of individual episodes can often be related to stressful events or situations.
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5
Q

What criteria do you use for depressive episodes?

A

DSM-5 criteria

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6
Q

What is the DSM-5 criteria for depressive episode?

A

DSM-5 criteria for depressive episode:

Occurrence of 2 weeks or more of depressed mood AND the presence of 4 of 8 out of the following:

  • Sleep alterations (insomnia or hypersomnia)
  • Appetite alterations (increased or decreased)
  • Diminished interest or anhedonia
  • Decreased concentration
  • Low energy
  • Guilt
  • Psychomotor changes (agitation or retardation)
  • Suicidal thoughts
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7
Q

What are the subtypes in DSM-5 for major depressive disorders (MDD)?

A
  • Atypical features (which represent mainly increased sleep and appetite, along with heightened mood reactivity)
  • Melancholic features (defined by no mood reactivity, along with marked psychomotor retardation and anhedonia)
  • Psychotic features (the presence of delusions/hallucinations).
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8
Q

What leads to a longitudinal diagnosis of MDD?

A

If no manic or hypomanic episodes in the past are identified, then the diagnosis of a current major depressive episode leads to a longitudinal diagnosis of Major Depressive Disorder (MDD).

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9
Q

What are the 3 triads of depression symptoms?

A

Core symptoms

Biological symptoms

Psychological symptoms

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10
Q

What are the core symptoms of depression?

A

Low mood
Anergia
Anhedonia

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11
Q

What are the biological symptoms of depression?

A

Sleep
Libido
Appetite

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12
Q

What are the psychological symptoms of depression?

A

the world
oneself
the future

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13
Q

What is the typical cycle of low mood? (unipolar and bipolar)

A
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14
Q

What is the typical cycle of high mood?

A
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15
Q

What is a manic episode according to DSM-5?

A

Euphoric or irritable mood with 3 or more of 7 manic criteria:

  • Decreased need for sleep with increased energy
  • Distractibility
  • Grandiosity or inflated self-esteem
  • Flight of ideas or racing thoughts
  • Increased talkativeness or pressured speech
  • Increased goal-directed activities or psychomotor agitation
  • Impulsive behaviour (such as sexual impulsivity or spending sprees)
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16
Q

What leads to a DSM-5 diagnosis of type I bipolar disorder?

A

If such symptoms are present for minimum 1 week with notable functional impairment, a manic episode is diagnosed, leading to a DSM-5 diagnosis of type I bipolar disorder.

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17
Q

What leads to a diagnosis of a hypomanic episode according to DSM-5?

A

If such symptoms are present for at minimum 4 days, but without notable functional impairment, a hypomanic episode is diagnosed.

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18
Q

How is a DSM-5 diagnosis of type II bipolar disorder made?

A

If not a single manic episode had occurred ever, but only hypomanic episodes are present, along with at least one major depressive episode, then the DSM-5 diagnosis of type II bipolar disorder is made.

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19
Q

How is a diagnosis of an unspecified bipolar disorder made according to DSM-5?

A

If manic symptoms occur for less than 4 days, or if other specific thresholds are not met for manic or hypomanic episodes, then the DSM-5 diagnosis:
“Unspecified Bipolar Disorder”

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20
Q

How can manic episodes be characterized?

A

by psychotic features (presence of delusions/ hallucinations)

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21
Q

How can hypomania NOT be diagnosed?

A

If psychotic features are present, then hypomania cannot be diagnosed (since such features involve notable impairment by definition)

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22
Q

What happens is a patient is hospitalized, irrespective of duration of manic symptoms?

A

a manic episode is diagnosed, not a hypomanic episode

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23
Q

What happens if manic or hypomanic episodes are caused by antidepressants?

A

If manic or hypomanic episodes are caused by antidepressants, then the diagnosis of bipolar disorder is still made in DSM-5.

(an important change from DSM-IV where antidepressant- related mania/hypomania was viewed as an exclusion factor)

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24
Q

Why can it be challenged whether bipolar disorders are mood disorders?

A

Importantly, it can be challenged whether Bipolar Disorders are “mood disorders”: Some argue; MDD can be without sad mood and mania without euphoric mood
In fact, mood is variable in the phenomenology of these conditions, and the most consistent clinical features for diagnosis are psychomotor changes.

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25
Q

What is the illness course of bipolar disroder?

A
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26
Q

What are the majority of the first episodes of bipolar-I?

A

depressive

85% depressive
10% manic
3-5% mixed episode

most patients (90-100%) will develop more episodes after their first manic episode

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27
Q

What is the long term symptomatic status of patients with bipolar disroder?

A
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28
Q

What other mood is important despite main focus being on depression and mania?

A

anxiety

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29
Q

History of bipolar vs unipolar.

A
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30
Q

What is the new evidence to challenge the original arguments that lead to separation of bipolar and unipolar? (aka why are they similar)

A
  • MDD is commonly diagnosed in children, far below the mean onset of the late 20s.
  • Brief depressive episodes that occur multiple times yearly are diagnosed in patients with MDD commonly, whereas such course of illness should be rare if MDD was a different illness than bipolar disorder.
  • Genetic studies have found high rates of depressive episodes, without mania, in persons with bipolar illness, and also frequent occurrence of bipolar illness in relatives of those with unipolar depression.
  • Treatment now overlaps considerably, with neuroleptic agents proven effective not only for mania, but also for depression, both in bipolar and unipolar types.
  • Lithium has been well known to be effective not only for mania, but also for depression, both in bipolar and unipolar types.
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31
Q

What are the differences in heritability and insight of bi and unipolar?

A
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32
Q

What are attention biases more typical of?

A

anxiety

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33
Q

What is depression characterised by when it comes to attention bias?

A

Depression is characterised by biases in maintaining/shifting attention = difficulties for depressed people to disengage from negative material.

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34
Q

What else is depression biased for and what does it mean?

A

strong evidence for biased memory processes

Preferential recall of negative compared to positive material = one of the most robust findings in the depression literature

bias towards negative material or away from positive material

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35
Q

Where is memory biases also present?

A

in individuals at risk (neuroticism) and in recovered depressive individuals

36
Q

What is perceptual bias?

A

facial expression recognition

37
Q

What happens to perceptual bias in depression?

A

increased recognition of negative faces and/ or decreased recognition of happy faces

Robust strong evidence of emotion recognition deficits in MDD
Reduced recognition of all basic emotions except for sadness
Small effect size: may be confounded by medication?

38
Q

Who else is at risk of perceptual biases?

A

in neuroticism reduced recognition of happy faces

39
Q

What happens to the brain in people with depression with facial expression processing?

A

neurofunctional abnormalities

incidental/ passive viewing of emotional facial expressions

Enhanced amygdala response to negative faces
Even in the absence of awareness
But not always replicated

40
Q

What is the amygdala?

A

ABOUT AMYGDALA:

This medial temporal lobe region is involved in the perception and encoding of stimuli relevant to current or chronic affective goals, ranging from rewards or punishments to facial expressions of emotion to aversive or pleasant images and films.
While amygdala generally is sensitive to detecting and triggering responses to arousing stimuli, it exhibits a bias towards detecting cues signalling potential threats, like expressions of fear

41
Q

What is a common type of anti-depressant?

A

SSRIs= serotonin re-uptake selective inhibitors

42
Q

Describe facial expression recognition modulation by antidepressants.

A
43
Q

What is the “monoamine deficiency hypothesis”?

A

The “monoamine deficiency hypothesis” of depression postulates that depressive symptoms arise from insufficient levels of monoamine neurotransmitters serotonin (or 5-hydroxytryptamine , 5-HT), norepinephrine, and/or dopamine.

44
Q

What is indirect evidence for 5-HT hypofunction in depression? (10)

A

5-HT depletion by the antihypertensive drug reserpine could cause
depression.

Clinically useful antidepressants all increase synaptic monoamine (some selectively 5-HT) concentrations.

Post-mortem evidence of reduced 5-HT levels in brainstem of individuals who committed suicide.

Lower levels of 5-HT1A-receptors and 5-HT4-receptors

Monoamine oxidase A increased in MDD

Blockade of serotonin synthesis by the tryptophan hydroxylase inhibitor p-chlorophenylalanine prevents the antidepressant effects of both MAOIs and TCAs

Tryptophan depletion ( ➔brain serotonin decreasing) triggers relapse in MDD successfully treated with SSRIs or cognitive behavioural therapy (CBT)

Monoamine depletion correlates with decreased mood both in at risk and MDD in remission

Depression-related traits; “pessimism” and “dysfunctional attitudes” in MDD, and traits “negativism” and “neuroticism” in healthy, related to 5-HT2A-receptor increase (? Serotonin decrease).

45
Q

Why don’t you just measure the serotonin in the living brain?

A

it is quite hard

46
Q

How can you measure receptors and transmitters in the living human brain?

A

PET (positron emissions tomography)

PET imaging;

Injection of a radioactive pharmaceutical (= tracer= ligand)
The tracer binds to a sp[ecific target (e.g., a receptor)

47
Q

How does PET imaging compare to fMRI? (5)

A

Selective,
but invasive,
radioactive,
and expensive,
and with less optimal temporal and spatial resolution.

48
Q

How do we quantify dopamine receptors?

A
49
Q

What is the challenge for measuring serotonin?

A

We don’t have a ligand to use

50
Q

How do we now measure the release of cerebral 5-HT?

A

using a 5-HT2A agonist PET tracer

New method using a combination of an agonist radioligand 11C-CIMBI-36 and amphetamine

51
Q

Why have past methods of measuring 5-HT not been good?

A

these agonist PET tracers have not been sufficiently sensitive to pharmacological challenges

52
Q

How can you apply the 11C-CIMBI-36 PET method to depression?

A
53
Q

What is evidence for reduced 5-HT release capacity in depression?

A
54
Q

Do you understand all of these points?

A
55
Q

How do psychedelics work (v basic) and which other drug is similar?

A
  • Psychedelics have their action in the brain’s serotonin system.
  • Medications such as “SSRIs” also work in this system but via different mechanisms
56
Q

What is the effect of psychedelics?

A
57
Q

What is the safety of psychedelics?

A

Safe…
Non-adictive
Low physiological and brain toxicity
Good therapeutic index

Risks/ SEs…
Dysphoria
Anxiety
Nausea
Headache

58
Q

What conditions do psychedelics have rapid and enduring positive changes for?

A

Well-being increases
✔ OCD decreases
✔ End-of-life distress ↓
✔ Addiction ↓
✔ Depression ↓
✔ Suicidality ↓

Across trials; long-lasting
antidepressant effects after single interventions

59
Q

Does this make sense?

A

yes/ no

60
Q

What are the 2 used disease classification systems?

A
  1. US manual: DSM
  2. WHO manual: ICD
61
Q

What mood disorder diagnosis can easily be missed and what diagnosis is a patient in that case likely to be (mis)-diagnosed with?

A

Bipolar diagnosis might be missed xin a patient due to lack of insight about mania/ hypomania. Patient might end up with a MDD diagnosis despite a history of manic episodes. Collateral information often useful, in particular if you start being in doubt about details in the history taking. Family members report manic symptoms twice as frequently as patients themselves.

62
Q

IS there a therapeutic relevance of a distinction between MDD and bipolar?

A
63
Q

What is the difference between bipolar 1, 2 and cyclothymia?

A
  • BIPOLAR 1:
    • manic symptoms for AT LEAST 1 WEEK, with functional impairment (MANIC EPISODE)
  • BIPOLAR 2:
    • manic symptoms for MINIMUM 4 DAYS, NO functional impairment (HYPOMANIC EPISODE) + at least ONE MAJOR DEPRESSIVE EPISODE
  • CYCLOTHYMIA:
    • emotional ups and downs, but they’re not as extreme as those in bipolar I or II disorder.
64
Q

What is the most common long term symptom status of patients with bipolar disorder?

A
65
Q

What is the difference in heritability and insight between uni and bipolar?

A
66
Q

Describe attention biases in depression and neurofunctional abnormalities present.

A
67
Q

What is neuroticism?

A

Neuroticism is thetrait disposition to experience negative affects, including anger, anxiety, self‐consciousness, irritability, emotional instability, and depression

68
Q

Describe the prediction of treatment response.

A
69
Q

What is the prediction of clinical response?

A

Elevated baseline ACC activity in depressed patients during tasks that probe affective circuitry (but also executive functions, or self-referential processes e.g., resting state)

Predict positive response to treatment (I.e., decrease in depression severity following interventions. Both medication, neurostimulation and CBT)

70
Q

What is new early evidence to support 5-HT deficiency in depression?

A

Measurable 5-HT release in health
No measurable 5-HT release in patients with depression

71
Q

Almost all of the symptoms listed below were elicited by the doctor. Which of these represent the three core symptoms of depression ?

  • Low mood
  • Lack of appetite
  • Impaired sleep
  • Mood worse in the morning
  • Low energy (anergia)
  • Anhedonia
  • Suicidal thought
  • Poor concentration
  • Impaired libido
  • Feelings of guilt
A

low mood
low energy (anergia)
anhedonia

72
Q

What are the three symptoms of biological symptoms of depression?

A

sleep
appetite
libido

73
Q

What are the three symptoms of cognitive symptoms of depression?

A

oneself
the world
the future

74
Q

What are some common differentials to consider when presenting with mood disorders?

A
  • Bipolar disorder vs unipolar depression
  • Bipolar disorder vs borderline personality disorder/EUPD
  • Depression vs psychotic prodrome
  • Psychotic depression vs schizoaffective disorder (depressive type)
  • Mania vs schizoaffective disorder (manic type)
  • Mania vs Attention Deficit Hyperactivity Disorder
75
Q

Is there therapeutic relevance to the distinction between bipolar and unipolar?

A
76
Q

What are personality disorders?

A

Maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual’s culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.

77
Q

What are the differentials between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?

A
78
Q

What are the differentials between bipolar affective disorder (BPAD) and schizoaffective disorder?

A
79
Q

What are the differentials between bipolar affective disorder (BPAD) and attention deficit hyperactivity disorder (ADHD)?

A
80
Q

What are organic and iatrogenic causes of mood disorders?

A
81
Q

Does this infographic make sense?

A
82
Q

Does this infographic make sense?

A
83
Q

Does this infographic make sense?

A
84
Q

Does this infographic make sense?

A
85
Q

Does this infographic make sense?

A
86
Q

Does this infographic make sense?

A

BRS Psychiatry (11 decks)

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