4.5 - Depression (tutorial) Flashcards
What are the three triads of depression?
- core symptoms
- biological symptoms
- cognitive symptoms
What are the three core symptoms of depression?
- low mood
- anergia
- anhedonia
What are the three biological symptoms of depression?
- sleep
- libido
- appetite
What are the three cognitive symptoms/aspects of depression?
- the world
- oneself
- the future
How long must symptoms be present for to diagnose depression?
Symptoms must be present for more days than not over a period of at least two weeks
What do we assess in a mental state examination?
- appearance and behaviour
- speech
- mood/affect
- thought (content and form)
- perceptions
- cognition
- insight
What do we look out for in appearance and behaviour in depression? (6)
- clothes
- poor self-care e.g. greasy hair, smell
- tearful
- limited eye contact, looking down
- usually no evidence of psychomotor agitation/retardation
- normal movements
What do we look out for in speech in depression? (3)
- quietly spoken
- monotonous
- normal/slightly reduced rate
What do we look out for in mood (objective) in depression? (3)
- low in mood
- flattened affect (reduced emotional range)
- tearful
What do we look out for in mood (subjective) in depression? (6)
- fed up, miserable
- reduced energy and motivation
- anhedonia
- feels guilty and useless
- poor concentration
- biological symptoms - disturbed sleep, early morning waking, reduced appetite, reduced libido
What do we look out for in thought form in depression?
Thoughts are logically connected and easy to follow - no evidence of formal thought disorder
What do we look out for in thought content in depression?
Evidence of hopelessness (‘what is the point’, ‘everything seems black’)
What do we look out for in perceptions in depression? (2)
- objective - not objectively responding to perceptual stimuli
- subjective - no hallucinatory experiences reported
What do we look out for in cognition in depression?
- not formally assessed using a validated measure (e.g. ACE-III)
- cognition intact, oriented to time, place and person
- no obvious confusional state
- NB pseudodementia important differential to consider in older adults presenting with cognitive symptoms
What do we look out for in insight in depression?
- reasonable in depression
- consider insight in several domains - unwell? physical/psychiatric? treatment? risk to themself/others?
What are the key features to look for on mental state examination in depression? (5)
- low mood
- poor self-care (self neglect)
- reduced eye contact
- flattened affect
- speech that is monotonous and lacking in prosody
When can depression present with a mood congruent psychosis?
E.g. delusions of nihilism guilt or Cotard’s syndrome
What makes up the psychiatric history - depression? (5)
- history of presenting complaint
- past psychiatric history
- family history
- treatment history
- substance misuse
What do we ask about history of presenting complaint? (8)
- insidious vs acute onset (i.e. due to life event)
- core/cognitive/biological symptoms
- current episode duration?
- diurnal variation?
- suicidal ideation/plans/intent?
- thoughts/acts of self-harm?
- exacerbating and relieving factors - are they taking meds and is it helping? psychological stressors/support?
- relevant physical health conditions e.g. hypothyroidism, anaemia, Cushing’s, chronic pain
What do we ask about past psychiatric history as part of psychiatric history (depression)? (7)
- previous episodes? duration?
- did previous episodes resolve with/without treatment?
- history of any other mental illness? (important to rule out manic episodes)
- previous admissions (informal vs under mental health act)
- collateral history (important if patient guarded/poor historian)
- medical notes if available
- previous self harm/suicide attempts
What do we ask about family history as part of psychiatric history (depression)? (3)
- any mental illness/intellectual disability/neurodevelopmental diagnoses?
- who e.g. first degree relative?
- what are family relationships like?
What do we ask about treatment history as part of psychiatric history (depression)? (7)
- antidepressants?
- antipsychotics?
- mood stabilisers?
- side effects?
- ECT?
- psychology?
- ask: when? how long? what exact medication? doses? well tolerated? did it help?
What do we ask about substance misuse as part of psychiatric history (depression)? (2)
- cannabis/alcohol/cocaine/heroin (opiates)/hallucinogens?
- used as self-medicating?
What do we ask about forensic history as part of psychiatric history (depression)? (4)
- offending as a youth (consider oppositional defiance disorder and conduct disorder), Youth Rehabilitation Orders
- arrests/cautions/incarcerations/forensic mental health act admissions/probation involvement
- include offences that were perpetrated but for which they were not caught
- NB comorbid substance misuse is biggest risk factor for offending
What do we ask about personal history as part of psychiatric history (depression)? (6)
- birth and early developmental (antenatal/perinatal complications, developmental milestones)
- schooling (academic performance, truancy at school, peer relationships/bullying)
- higher/further education
- employment
- psychosexual history
- premorbid personality
How is the risk assessment for depression classified?
- to self
- to others
- from others
How can one pose a risk to oneself? (5)
- current suicidal ideation/plans/intent
- previous attempts (method/how many episodes/how did they feel when they survived)
- self harm/cutting
- self neglect/poor care of physical illness
- risk of misadventure (accidental injury due to impulsive and disinhibited acts e.g. in mania)
How does one pose a risk to others (depression)?
- rarer in depression but still ask
- thoughts/plans to harm others?
- command hallucinations (general risk factor for violence)
- relevant forensic history - arson, violent offending etc
How are depression patients at risk from others?
- vulnerability to exploitation
- risk of retaliation from others (esp in manic states when overfamiliar, irritable, disinhibited)
What are some differentials to consider when thinking about depression and mania? (6)
- 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 ADHD
Why aren’t antidepressants used for bipolar disorder?
- appear to be mostly ineffective in acute bipolar depression and in prophylaxis
- can cause acute manic/hypomanic episodes
- have been shown to worsen the long-term course of bipolar illness in some subjects, especially those with a rapid-cycling course (>4 mood episodes in 12 months)
- in rapid-cycling cases they appear to lead to more mood episodes, including depressive states
What is a personality disorder?
- maladaptive patterns of behaviour, 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
How do the signs of personality disorder manifest?
As clusters (A, B, C), with each cluster containing different signs
What signs of personality disorder are in cluster A? (3)
- paranoid - pattern of irrational suspicion and mistrust of others
- schizoid - lack of interest and detachment from social relationships, apathy, and restricted emotional expression
- schizotypal - extreme discomfort interacting socially, and distorted cognition and perceptions
What signs of personality disorder are in cluster B? (4)
- antisocial - pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behaviour
- borderline - pervasive pattern of abrupt mood swings, instability in relationships, self-image, identity, behaviour and affect, often leading to self-harm and impulsivity
- histrionic - pervasive pattern of attention-seeking behaviour and excessive emotions
- narcissistic - pervasive pattern of grandiosity, need for admiration, and a perceived or real lack of empathy
Antisocial, borderline and narcissism make this hard to distinguish with bipolar affective disorder (BPAD)
What signs of personality disorder are in cluster C? (3)
- avoidant - pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation
- dependent - pervasive psychological need to be cared for by other people
- obsessive-compulsive personality disorder - rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships (distinct from OCD)
What are the similarities between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?
- rapid mood changes
- unstable interpersonal relationships
- impulsive sexual behaviour
- suicidality
What are the differences between bipolar affective disorder (BPAD) and borderline personality disorder (BPD)?
- BPAD - episodic, genetic, grandiosity, mood states typically less affected by environment
- BPD - mood changes over course of hours/days rather than days/weeks, poor self image, fear of abandonment, feeling of emptiness, history of self-harm, history of trauma/disrupted attachment
What are the similarities between bipolar affective disorder (BPAD) and schizoaffective disorder?
Both can present with psychosis and mood symptoms (depression and mania)
What are the differences between bipolar affective disorder (BPAD) and schizoaffective disorder?
- BPAD - episodic delusions/hallucinations (rarely chronic)
- schizoaffective disorder - episodic delusions/hallucinations (residual symptoms more likely); more prominent disorganisation of thought, paranoid delusional beliefs and auditory hallucinations
What are the similarities between bipolar affective disorder (BPAD) and attention deficit hyperactivity disorder (ADHD)?
- hyperactivity
- impulsivity
- impaired concentration
- impairment of executive function
- abnormal working and short term memory
What are the differences between bipolar affective disorder (BPAD) and attention deficit hyperactivity disorder (ADHD)?
BPAD:
- not necessarily present in childhood
- episodic
- family history (genetic)
- recurrent depressive episodes
- amphetamines worsen mania
What are some organic/iatrogenic causes of depression? (5)
- endocrine - hyper/hypothyroidism, hyper/hypoparathyroidism, hypoglycaemia, Cushing’s syndrome, Addison’s disease
- systemic - viral infections, SLE, HIV, cancers (cytokines can cause depression)
- deficiencies - vitamin B12, folic acid
- neurological - MS, Alzheimer’s, Parkinson’s
- medications - beta blockers, steroids, anti-Parkinson’s, some antibiotics (e.g. ciprofloxacin), statins, oestrogen, opiates, acne medications
What are two types of depression caused by organic causes?
- vascular depression (subcortical ischaemic depression)
- poststroke depression
What is vascular depression (subcortical ischaemic depression)?
- associated with white matter hyperintensities
- these can impact on cognitive function making the individual more vulnerable to stressors
- important to treat vascular risk factors e.g. diabetes/hypertension and address smoking and alcohol use
What is poststroke depression?
- sometimes becomes persistent
- retardation in thinking and behaviour is sometimes prominent
- it has been reported that lesions in left frontal lobe or basal ganglia are able to cause depression
- more frontal the lesion, more severe the symptoms
