Abnormal mood - depressed

Question 1

Match the following terms with the correct description of the term:

Terms:

• Anhedonia
• Anergia
• Amotivation
• Diurnal variation
• Early morning wakening
• Psychomotor retardation
• Stupor
• Euthymia

Description:

• lack of motivation
• lack of energy
• waking at least 2 hours before the expected/ normal waking time
• (mood) varies over the day
• the absence of relational functions, i.e. action and speech (a state of near-unconsciousness - the lack of critical mental function and a level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain)
• normal mood
• Loss of enjoyment/ pleasure
• subjective or objective slowing of thoughts and/ or movement

Answer 1

• Anhedonia – loss of enjoyment/ pleasure
• Anergia – lack of energy
• Amotivation – lack of motivation
• Diurnal variation – (mood) varies over the day
• Early morning wakening – waking at least 2 hours before the expected/ normal waking time
• Psychomotor retardation – subjective or objective slowing of thoughts and/ or movement
• Stupor - the absence of relational functions, i.e. action and speech (a state of near-unconsciousness - the lack of critical mental function and a level of consciousness wherein a sufferer is almost entirely unresponsive and only responds to base stimuli such as pain)
• Euthymia – normal mood

Question 2

How are mood disorders classified in the UK and Europe i.e. what is the main types of mood disorders? (4 of them)

Answer 2

International Classification of Diseases, version 10

4 main classes of mood disorders are:

1. Mania
2. Bipolar disorder
3. Depressive disorder - Major depressive disorder (MDD), also known simply as depression
4. Dysthymia - persistent mild depression.

Question 3

What typical signs in someones appearance and behaviour might you see suggesting they have depression ?

Answer 3

• Reduced facial expression
• Brow is classically ‘furrowed’
• Reduced eye contact
• Limited gesturing – movements may be slowed, or absent
• Rapport is often difficult to establish

Question 4

What are some of the typical signs in someones speech that might suggest they have depression?

Answer 4

• Reduced rate of speech – speech is slow
• Lowered in pitch
• Reduced in volume – speech is quiet
• Reduced intonation – speech is monotonous
• Increased speech latencies – longer time between end of a question and them starting to speak
• Limited content – answers are often short, brief, and unembellished

Question 5

Define mood

Answer 5

a prolonged prevailing state or disposition; typically associated with what the patient describes (i.e. subjective)

Question 6

Define what is meant by a patients affect

Answer 6

In essence, it’s mood applied to things (events, people, etc.). When taking a history, it’s how the patient’s feelings change in relation to the their surroundings and the context; it’s something that you typically observe or infer (i.e. objective)

Question 7

How is someones mood often described when they have depression ?

Answer 7

• Low, miserable, unhappy, sad
• Can be described as “flat”
• Often “empty”, “black”
• Suicidal ideation and apparent intent
• Feeling like being a burden to others

Question 8

How does someones affect often appear in someone with depression?

Answer 8

• Depressed (i.e. low)
• Reduced range (stays low throughout)
• Limited reactivity – affect doesn’t respond or react to changes in subject, context, or emotion

Question 9

What are someones thoughts often like in someone with depressive mood disorder ?

Answer 9

Flow:

• Thoughts slow, pondering
• Can be almost absent (subjectively or objectively)

Content:

• Negative, self-accusatory, failure, guilt, low selfesteem, pessimism
• Delusions can occur: guilt, poverty, nihilism, hypochondriasis

Question 10

Can patients with depression become paranoid ?

Answer 10

Yes!

Question 11

Define paranoia

Answer 11

self-referential thinking (e.g. “he’s talking about me”)

Question 12

What are the main differences in paranoia experienced by someone with depression and someone with psychosis ?

Answer 12

In depression:

• Increased sensitivity to the criticisms of others
• Much more self-concious and self-aware in busy places
• May feel like they are under scrutiny

In psychosis:

• Paranoia may have a bizarre quality to it e.g. I’m being watched by aliens/ the CIA/ the government
• Often has other symptoms e.g. persecutory ideas/delusions, altered perceptions etc
• Insight is often lost i.e. they think there real

Anxiety is common in both depression and psychosis

Question 13

Can someone get hallucinations in depression explain your answer ?

Answer 13

Yes

• Haullicinations if present are almost always auditory
• Usually second person and derogatory (e.g. “You are a bad person and you’re going to die”) – Typically reflect negative and depressive themes: the voices reflect the depression rather than someone getting depressed because of the voices

Question 14

How is someones cognition often affected in depression ?

Answer 14

• Subjectively, cognition is slow with complaints of poor memory (probably more to do with inattention)
• ‘Pseudo-dementia’ - a situation where a person who has depression also has cognitive impairment that looks like dementia.
• Typical deficits involve working memory, attention, and planning

Question 15

Are people usually aware of their symptoms (insight)?

Answer 15

• In contrast to disorders such as schizophrenia and mania, insight in depression is typically preserved
• People are usually aware of their symptoms – recognition is commonly intact
• There symptoms however may be blamed blamed on sins, physical illness, personal failings and weakness

Question 16

Appreciate this point:

• Major depression is not just being a bit sad or unhappy
• Major depression is not just some variation of normal (any more than leukaemia is just a version of normal blood cell development)
• It’s common (14-18% lifetime prevalence)
• It’s often chronic (20%)
• It blights lives (not just for the sufferer)
• It ends lives

Question 17

What are the 2 general criteria that someone must meet for a diagnosis of depression ?

Answer 17

1. The depressive episode should last at least 2 weeks
2. There have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episode at any time in the individual’s life

so the symptoms have to be present for >2wks and they cant have had any associated hypomanic or manic episodes in their life (as your thinkning more bipolar I think)

Question 18

What are the 3 core features of depression ?

Answer 18

1. Depressed mood to a degree that is definitely abnormal for the individual, present for most of the day and almost every day, largely uninfluenced by circumstances, and sustained for at least 2 weeks
2. Loss of interest or pleasure in activities that are normally pleasurable
3. Decreased energy or increased fatiguability

Think AAD - Ahedonia, Anergia, Depressed mood

Question 19

What are the additional symptoms for depression along with the 3 core symptoms

Answer 19

1. Loss of confidence or self esteem
2. Unreasonable feelings of self-reproach or excessive and unreasonable guilt
3. Recurrent thoughts of death or suicide, or any suicidal behaviour
4. Complaints or evidence of diminished ability to think or concentrate, such as indecisiveness
5. Psychomotor retardation (e.g. lack of spontaneous movement, or sluggish thought processes) or psychomotor agitation
6. Sleep disturbance
7. Change in appetite (decrease or increase)

Question 20

What are the 2 main classes for the severity of depression and how are the catergorised ?

Answer 20

ICD-10 classifies depression as Moderate or severe:

Moderate = 2/3 core features plus additional symptoms up to total of at least 6 (includes the 2 main ones)

Severe = 3/3 core features plus additional symptoms up to total of at least 8 (includes the main 3 ones)

Question 21

What are the 3 main subtypes of depression ?

Answer 21

1. Somatic syndrome
2. Atypical depression
3. Psychotic depression

Question 22

Describe the subtype of depression known as somatic syndrome

Answer 22

Four of the following symptoms should be present : essentially a physical manifestation of depressive symptoms (clue is in the name)

1. marked loss of interest or pleasure in activities that are normally pleasurable
2. lack of emotional reactions to events or activities that normally produce an emotional response
3. waking in the morning 2 hours or more before the usual time
4. depression worse in the morning
5. objective evidence of marked psychomotor retardation or agitation (remarked on or reported by other people)
6. marked loss of appetite
7. weight loss (5 % or more of body weight in the past month)
8. marked loss of libido

Question 23

Describe the subtype of depression known as atypical depression

Answer 23

Mood reactivity (that is, mood brightens in response to actual or potential positive events)

And 2 (or more) of the following:

1. significant weight gain or increase in appetite
2. hypersomnia - excessive sleepiness
3. leaden paralysis (that is, heavy, leaden feelings in arms or legs)
4. long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupational impairment

Basically think of the loner in his room playing video games all day

Question 24

Describe the subtype of depression known as psychotic depression and describe how it differs from other forms of psychosis

Answer 24

The difference with other forms of psychosis is it’s related to depressive themes

Ocassionally the patient is paranoid but usually they are hypochondrical (abnormal chronic anxiety about ones health) or ‘mood-congruant’ some examples are:

• “People are out to get me and kill me”
• “I’m being poisoned to punish me for my sins”
• “I’ve got cancer…I know I have…It’s because I deserve it”

Rarely may present as cotards syndrome comprised of any one of a series of delusions that range from:

• a belief that one has lost organs, blood, or body parts to insisting that one has lost one’s soul or is dead e.g. I can’t eat because my bowels have turned to dust”, may be as extreme as “I’m dead…the world doesn’t exist anymore”
• more common in the elderly

Question 25

Is it common to just have on episode of depression?

Answer 25

No - often people experience more than one episode in their lifetime who have had it

Question 26

What is the treatment for persistent subthreshold symptoms of depression or mild-moderate depression ?

Answer 26

• CBT
• Structured physical activity programme

Don’t usually use drugs but if refractory to treatment then consider giving an SSRI

Question 27

What is the treatment of moderate to severe depression ?

Answer 27

Anti-depressant medication + high intensity psychological intervention (CBT or IPT = interpersonal therapy)

Antidepressant medication:

1st line = SSRI (fluoxetine) and increase until maximal tolerated dose (give it 4-6 weeks duration before changing)

May consider mirtazapine 1st line if patient has insomnia and/or poor appetite

2nd line: Try a different SSRI

3rd line: Mirtazapine

4th line =SNRI – Venlaflaxine etc (serotonin noradrenaline uptake inhibitor)

5th line: TCA

6th line: MAOI

Question 28

How long do you give an anti-depressant to work before trying a different one (as often its what works best for the patient)?

Answer 28

If no improvement by 2-4wks check the drug is being taken regularly and at the correct dose

If response minimal after 3-4wks increase level of support e.g. weekly face to face and consider:

1. increasing dose
2. switching to another anti-depressant

If the person’s depression shows some improvement by 4 weeks, continue treatment for another 2 to 4 weeks. Consider switching to another antidepressant if:

1. response is still not adequate or
2. there are side effects or
3. the person prefers to change treatment.

Question 29

When do you use ECT (electrocompulsive therapy) in the treatment of depression ?

Answer 29

• Consider ECT for acute treatment of severe depression that is life‑threatening (e.g. suicide risk or refusing to eat/drink) and when a rapid response is required, or when other treatments have failed.
• Very effective for bad post natal depression as mother has to get to new child asap

Question 30

What are the 5 R’s of depression (or any chronic illness)?

Answer 30

1. Response - The first objective in the treatment of your depression is to get you to a response level. Response is clinically defined as an improvement from the initial onset of your illness.
2. Remission - 2nd goal, defined as the experience of being symptom-free from illness.
3. Relapse - defined as a full return of depressive symptoms once remission has occurred - but before recovery has taken hold.
4. Recovery - Recovery is clinically defined as the absence of symptoms for at least 4 months following the onset of remission.
5. Recurrence - another depressive episode after recovery has been attained.