3. Mood and Anxiety Disorders Flashcards
Definition of anxiety.
Combination of fear, stress, and psychological and physiological symptoms
When does panic disorder usually develop?
early teens through 40 yo
When does social phobia (social anxiety disorder) usually develop?
bimodal (age 5 or early adolescence)
When do simple phobias to animals, blood and situations usually develop?
animals= 7 blood= 9 situations= 2-7 and early 20s
With equal exposure to trauma, what gender is more likely to develop PTSD?
females
When does OCD usually develop?
males 6-15
females 20-29 *especially post-partum
What gender is more likely to get OCD in childhood?
males
When does generalized anxiety disorder usually develop?
mid teens to mid twenties (especially after onset of chronic illness)
What gender is more likely to get general anxiety disorder and panic disorder?
females 2X > males
What gender is more likely to get social phobia?
females, but males are more likely to seek treatment
Which phobias are more common in males?
blood, injury and injection
Definition: discrete period of intense fear or discomfort during which at least 4 characteristic symptoms develop abruptly and reach a peak within 10 minutes.
panic attacks
What are the characteristic symptoms of panic attacks?
- Palpitations, pounding heart
- Sweating
- Trembling/shaking
- Dyspnea
- Choking sensation
- Chest pain/tightness
- Nausea
- Dizziness, fainting
- Paresthesias
- Chills/hot-flashes
- Fear of dying/going crazy
- Depersonalization/derealizaiton
True or false: panic disorder, by definition is relapsing (and may remit)
FALSE: it is chronic or relapsing (with remissions)
How do you treat panic attacks?
- EKG (rule out heart problem)
- Short acting benzodiazepine (alprazolam) to calm patient down
- Long term: SSRIs and CBT
How long must someone have recurrent panic attacks to be classified as having panic disorder?
1 month
Definition: fear (sometimes panic), often with blushing, of anticipated humiliation or rejection by others in social situations
Social Anxiety Disorder
What are the risk factors for social anxiety disorder?
- Familial modeling of social avoidance
- Being bullied
- Humiliation as form of discipline
- Disfiguring lesions (ex. burns)
What diagnosis is VERY similar to social anxiety disorder and what is the major difference?
Schizoid personality (but these people DO NOT DESIRE RELATIONSHIPS and in SAD they desire social relationships but they dread embarrassment so they avoid them)
What is the treatment for social anxiety disorder?
- Rehearsal
- Improved competence (Toastmaster’s International)
- Beta-blockers (propranolol) to reduce public speaking distress
Definition: fear responses to specific cues, encountered during a particularly frightening experience.
Phobia
What phobia may prevent you from getting an MRI on a patient?
claustrophobia (fear of enclosed spases)
What physiological reason may cause a person with a phobia to faint?
vasovagal responses
When do you treat a phobia?
only if the phobia inhibits some necessary activity (ex. air travel or health care) or fi the phobia creates excessive distress
What treatment provides symptomatic relief of phobias?
benzodiazepines
What treatment provides lasting relief for phobias?
Systemic desensitization (repeated, gradual exposure to a feared stimulus)
Definition: marked, persistent fear or anxiety about 2 or more situations (involving leaving the home/being in public) accompanied by avoidance of the situations.
Agoraphobia
What are the specific situations that are avoided by people with agoraphobia?
- Being outside the home alone
- Standing in line or being in a crowd
- Being in shops, theaters, cinemas
- Being in open spaces
- Using public transportation
True or false: agoraphobia is commonly associated with panic attacks.
FALSE–may or may not be accompanied by panic attacks (and if they are present, they are most likely due to an untreated or undiagnosed panic disorder)
What is the treatment for agoraphobia?
Systemic desensitization
SSRIs
Definition: persistent pattern of uncontrollable worries about health, safety, access to resources, and threats to other people (with the generalized fearfulness leading to constriction of behavior, avoidance of risk and inhibition of normal curiosity)
Generalized anxiety disorder
How long must symptoms occur before someone can be diagnosed with generalized anxiety disorder?
> 6 months
What type of symptoms are very common in a patient with generalized anxiety disorder?
somatic symptoms like HA, backaches, difficulty concentrating, muscle tension (often CC and patients cannot make the connection between anxiety and somatic symptoms)
What is the predominant symptom of substance/medication-induced anxiety disorder?
panic attacks
What drugs may lead to substance/medication-induced anxiety disorder?
Stimulants (cocaine, meth, ADHD meds, caffeine), Alcohol, OTC decongestants
What is required to diagnose medical-condition induced anxiety disorder?
- Condition must be proved to induce anxiety
- Condition must precede onset of anxiety
What sorts of medical conditions induce anxiety?
- Endocrinopathies (ex, pheochromocytoma, hyperthyroidism, hypoglycemia)
- Metabolic problems
- Neurological problems (ex. vestibular dysfunction)
Definintion: disorder with intrusive, arousal and avoidance symptoms
OCD
Definition: fears of contamination or danger, unjustified guild, fears of doing something violent or socially inappropriate
Obsessions
What is interesting about the obsessions of OCD?
they are recurrent, persistent, and UNWANTED (person cannot suppress them but realizes they are not normal)
Definition: checking, washing, counting, confessing, symmetry/precision, hoarding
Compulsions (also UNWANTED)
What leads tot he “cycle” of OCD?
relief of arousal (from obsession) after patient acts out compulsions will reinforce it and cause behaviors to proliferate until they become disabling
True or false: onset for OCD is sudden.
False (gradual onset and waxes and wanes with stress)
What predisposes to worse prognosis in OCD (ex. the 15% that severely deteriorate)?
early onset
Definition: OCD-like condition with somatic concerns predominating (imagined defects, constant plastic surgeries).
body dysmorphic disorder
What medical conditions can be caused by compulsions of OCD?
trichotillomania (hair pulling)
excoriation (skin picking)
What is the treatment for OCD?
- SSRIs at very high doses (TCAs have worse side effects)
- CBT or benzodiazepines for compulsions
What is on the differential diagnosis for OCD?
brain lesions medications substance abuse/withdrawal anorexia schizophrenia PANDA (repeated strep throat in children can lead to OCD like traits)
Definition: persistent subjective state, expressed in through, emotion, behavior, and bodily functions
Mood
Definition: major depressive episodes that may be isolated or recurrent and categorized as mild (few symptoms), moderate, or severe (marked effect on social/occupational functioning).
Major Depressive disorder
How long must you have a persistent, severely depressed mood to be diagnosed with major depressive disorder?
2 weeks
What are the risk factors for MDD?
- 1st degree relative with MDD (2X risk)
- Bereavement that extends too long
What is the mnemonic for classic presentations of depression?
SIG: E CAPS
What are the SIG: E CAPS?
Sleep disturbances Loss of interest Guilt Energy loss Concentration difficulties Appetite disturbance Psychomotor retardation/agitation Suicidal thoughts
Definition: depressed mood for 2+ years (never without symptoms) causing clinically significant distress or impairment
persistent depressive disorder
What is the course of Persistent Depressive Disorder?
- May be lifelong quality or personality trait
- May be superimposed episodes of major depression and may occur on top of depression (causing “double depression”)
Definition: in week before menses onset, patient suffers form combination of symptoms
Premenstrual Dysphoric Disorder
What are the symptoms of premenstrual dysphoric disorder?
- Marked affective liability
- Irritability
- Anger
- Interpersonal conflicts
- Feel “on edge,” anxious, depressed, out of control or overwhelmed
- Over-eating and food cravings
- Sleep problems
What is the timeline for premenstrual dysphoric disorder?
- Symtpoms lasted for the better part of a year
- Must be documented PROSPECTIVELY for at least 2 menstrual cycles
- Must disappear shortly after onset of menses
- NOT just exacerbation of interpersonal conflicts
Definition: rapidly alternating mood states, occurring for at least 2 years, but never meeting criteria for MDD, mania or hypomania.
Cyclothymic disorder
What condition is very similar to cyclothymic disorder, and what is the major differentiating factor?
Borderline personality disorder (patient may have both but BPD is more commonly associated with chaotic life circumstances, self-injurious behaivor, and history of abuse)
Definition: “manic depression” with full blown mania at least 1 time and a major depressive episode may or may not occur
Bipolar 1
What is mania?
lose contact with reality (grandiose, quick speech, irritable), severely impaired judgement, but still logical in their own way
What must you do before diagnosing bipolar 1?
rule out drugs and medical conditions that cause mania
Definition: distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormal/persistently increased activity or energy in a patient with a history of a major depressive episode.
Bipolar 2
How long must the hypomania last to diagnose bipolar 2?
at least 4 days consecutive days
How long must the depressive episode have lasted to diagnose bipolar 2?
at least 2 weeks
Why don’t people seek attention for hypomania in bipolar 2?
they are energetic, creative, and more efficient than usual
What are risk factors for bipolar?
- First degree relative with BP (5-10X risk)
- BPD is bridge between psychotic disorders and depressive disorders.
How long must you have symptoms to be diagnosed with a simple phobia?
> 6 months
How long must a manic attack last in bipolar 1 for diagnosis?
> 1 week
Which brain structure is responsible for short-term memory?
hippocampus
Which brain structure contains nuclei that are part of 3 distinct circuits that link cortical areas with sensory cortices and subcortical structures (and regulate emotion, motivation, arousal and attention)?
thalamus
Which brain structure is responsible for conscious thought and executive functions (selection among alternatives, anticipation, inhibition of impulses, sequencing)?
dorsolateral prefrontal cortex
Which brain structure is used to assess risk in pursuit of reward, relate new information to context (memory and environment)?
orbitofrontal cortex
Which brain structure is used for integration of emotion and cognition?
anterior cingulate gyrus
Which brain structure is responsible for fear, rage, and selective attention?
amygdala
Which brain structure is responsible for reward?
nucleus accumbens
Which brain structure is responsible for sleep, appetite, sexual behavior, metabolic rate, adaptation to acute or chronic environmental or social stress?
HPA axis
In a mood disorder, which brain structure causes: lack of pleasure (depression), decreased or increased motivation
nucleus accumbens
In a mood disorder, which brain structure causes: helplessness, indecisiveness, hopelessness, distorted sense of time (slowed in depression, accelerated in mania)?
dorsolateral prefrontal cortex
In a mood disorder, which brain structure causes: cognitive inefficiency and recolleciton bias (depressed people cannot access happy memory; mania makes sad memories inaccessible)?
hippocampus
In a mood disorder, which brain structure causes: overestimation of risk and reduced reward in depression, underestimation of risk in mania.
orbitofrontal cortex
In a mood disorder, which brain structure causes: insomnia/hypersomnia, lack of or increased sexual interest, hyperphagia or anorexia?
HPA axis
In a mood disorder, which brain structure causes:
- Erratic arousal, subjective distress, compromised attention/concentration
- Loss of pleasurable responses to sensation in depression
- Potential hypersensitivity to sensory input in mania
Thalamus
In a mood disorder, which brain structure causes: abnormal motivation (apathy in depression) and dysregulation of arousal?
anterior cingulate gyrus
In a mood disorder, which brain structure causes: anxiety, irritability, vigilance, hypersensitivity to negative environmental cues
amygdala
Definition: explaining diagnosis in terms of etiology/particular symptoms while offering ways to improve coping
Psychoeducaiton
Definition: identification of distortions in thinking and maladaptive behavior that contribute to depressed mood then altering the reinforcing conditions that sustain it
Cognitive Behavioral Therapy
Definition: focuses on link between depression and 4 interpersonal issues (loss, conflict or detachment, life transition, and deficits in social skills) so that patients can recognize and change patterns to prevent relapses
interpersonal psychotherapy
What is response latency?
though mood disorders can be treated with SSRIs, TCAs, and MAOIs, it may take 6-8 weeks before full therapeutic response can be differentiated from a placebo response.
How long should a patient stay on an antidepressant to prevent relapse?
4-6 months
What type of DSM defined mood features are: overeating, oversleeping while depressed, preserved reactivity to reward?
atypical features
What type of DSM defined mood features are: dense anhedonia, lack of response to reward, terminal insomnia (early morning awakening), dinural variation (mornings are worse)?
melancholic features
What type of DSM defined mood features are: detachment form environment while awake; negativism including immobility, mutism, refusal to eat or drink and potential threat to life?
catatonic features
What type of DSM defined mood features are: delusions of poverty, guild, nihilism, illness, self-disgust and derogatory auditory hallucinations?
psychotic features (mood congruent in depression)
What type of DSM defined mood features are: delusions of special powers or unlimited resources, paranoia and auditory hallucinations?
psychotic features (mood congruent in mania)
List the 4 categories of core signs and symptoms of mood disorders.
- Pathological moods
- Neurovegetative dysregulation
- Cognitive qualities
- Motor behavior
What does a typical depressed child look like?
irritable with labile sadness (more common than prolonged, persistent sadness or anhedonia)
What does mania in a child look like?
VERY similar to ADHD
What are some motor behaviors (with speech) of depression?
- Slow, sparse speech
- Leaden paralysis
- Agitation
What are some motor behaviors (with speech) of mania?
- Restlessness
- Hyperactivity
- Rapid, pressured speech
- Difficult to interupt
What are some pathological moods of depression?
- Sadness
- Negative mood
- Anhedonia
- Anxiety
What are some mixed pathological moods?
- Oscillating sadness
- Euphoria
- Anger
- Anxiety
What are some manic pathological moods?
- Euphoria
- Expansiveness
- Irritability
- Anger
What are some neurovegetative dysregulations seen in depression?
- Difficulty fallying or staying asleep
- Early AM awakening
- Exhaustion
- Loss of appetite or overeating
- Loss of sexual interest
- Crying spells
- Bodily symptoms of anxiety
- Pain sensitivity
- Slow GI activity (constipation)
What are some neurovegetative dysregulations seen in mania?
- Lack of need for sleep
- Increased energy
- Increased sexual interest and activity
- Impulsivity
- Hyperpahgia
What are some cognitive qualities of depression?
- Guilt
- Worthlessness
- Hopelessness
- Helplessness
- Suicidal thoughts
- Difficulty concentrating or remembering
- Memory biased toward negative experiences
What are some cognitive qualities of mania?
- Grandiosity
- Suspiciousness or paranoia
- Catastrophic loss of judgement with overspending
- Thought disorder (circumstantiality, tangentiality, flight of ideas)
After the first episode of major depression, how many patient have recurrence?
50%
AFter the third episode of major depression, how many patients have recurrence?
90%
If not treated, what is the recurrence rate for bipolar after 1 year? After 3 years?
50%; 90%
What is rapid cycling?
four or more episodes of either mood in a bipolar patient within a year
