Abnormal Mood: Depression

Question 1

Occurrence of mental and mood disorders with relation to age?

Answer 1

50% of all mental disorders begin <14 years of age

50% of all mood disorders begin <30 years of age

Question 2

Symptoms and signs of depression?

Answer 2

Sleep disturbance (initial insomnia and broken sleep)

Poor self-care

Hopelessness and self-contempt

Suicidal thoughts

Question 3

Terminology often used to describe features of affective disorders?

Answer 3

Anhedonia - loss of enjoyment / pleasure

Anergia - lack of energy

Amotivation - lack of motivation

Diurnal variation - mood varies throughout the day; in classic melancholic depression is worst in the morning and mood improves throughout the day

Early morning wakening - waking at least 2 hours before the expected / normal waking time

Psychomotor retardation - subjective / objective slowing of thoughts and / or movement

Stupor - absence of relational functions, e.g: action and speech

Euthymia - normal mood

Question 4

Appearance and behaviour of those with depressed mood?

Answer 4

Reduced facial expression

Classically ‘furrowed’ brow

Reduced eye contact

Limited gesturing (movements may be slowed or absent)

Rapport often difficult to establish

Question 5

Features of speech in those with depressed mood?

Answer 5

Reduced rate of speech (slow)

Lowered in pitch

Reduced in volume (quiet) and intonation (monotonous)

Increased speech latencies (longer time between end of a question and them starting to speak)

Limited content (short answers, brief and unembellished)

Question 6

Define mood?

Answer 6

A prolonged, prevailing state or disposition; typically assoc. with what the patient describe, i.e: it is subjective, ‘how is your mood?’

Question 7

Define affect?

Answer 7

Mood applied to things (events, people, etc); how the patient’s feelings change in relation to their surroundings and the context

This is typically observed or inferred, i.e: it is objective

Question 8

Describe mood in depression

Answer 8

Low, miserable, unhappy, sad, ‘flat’, ‘empty’, ‘black’

NOTE - major depression is not just being a bit sad or unhappy; these states can occur normally in life but are transient

Question 9

Affect in depression?

Answer 9

Reduced range, i.e: low throughout everything and anything

Limited reactivity (affect does not respond to react to changes in subject, context or emotion)

Question 10

Features of thoughts in depression?

Answer 10

Flow is typically normal

Flow is slow and pondering; can be almost absent

Content is often negative, self-accusatory, about failure, guilt, low self-esteem and pessimistic

Delusions may occur, related to things like guilt, poverty, nihilism and hypochondriasis

Paranoia may occur (self-referential thinking)

Question 11

Features of paranoia in psychosis?

Answer 11

May have a BIZARRE quality, e.g: being watched by aliens, CIA, government

Assoc. with other symptoms:
• Persecutory ideas / delusions
• Altered perceptions

Insight is often lost

Question 12

Features of paranoia in depression?

Answer 12

Increased sensitivity to the criticisms of others; this is often tied to guilt or self-blame

Much more self-conscious and self-aware in busy places, e.g: crowds

Have the feeling of being under scrutiny (a bit like a social phobia)

Question 13

Anxiety in paranoia?

Answer 13

Common but is often not helpful in discriminating between depression and psychosis

Question 14

Hallucinations in depression?

Answer 14

Almost always AUDITORY, usually second person and derogatory (e.g: ‘you’re a bad person and you’re going to die’)

Usually reflect negative and depression themes

NOTE - voices reflect depression rather than someone getting depressed because of the voices

Question 15

Cognition in depression?

Answer 15

Slow cognition with complaints of poor memory (likely to do with inattention), AKA pseudo-dementia

Often, deficits inv. working memory, attention and planning

Question 16

Insight in depression?

Answer 16

Typically preserved, i.e: patients are usually aware of their symptoms and recognition is commonly intact

However, attribution is often affected; symptoms may be blamed on sins, physical illness, personal failings and weakness

NOTE - this is in contrast to disorders where insight is affected, like schizophrenia and mania

Question 17

Examples of what a mental state examination of a patient with depression may reveal?

Answer 17

Classic furrowed brow, tearfulness, sleep issues

Feelings of guilt, pessimism, low self-esteem and being a burden to others

Suicidal ideation and apparent intent

Question 18

Describe the affective spectrum

Answer 18

There is a mood scale (from depression to mania)

There is a psychosis scale (to schizophrenia)

Patients can have mixtures of both scales, e.g: psychotic depression, schizaffectve disorder, bipolar disorder

Question 19

Classifications of psychiatric disorders?

Answer 19

DSM-5 uses the term depressive disorders:
• Major depressive disorders
• Persistent depressive disorder

ICD-10 uses the term mood (affective) disorders:
• Mania
• Bipolar disorder
• Depressive disorder
• Dysthymia (AKA persistent depressive disorder)

Question 20

Mood disorders as defined by ICD-10?

Answer 20

• Manic episode
• Bipolar Affective Disorder (BPAD)
• Depressive episode
• Recurrent depressive disorder
• Persistent mood disorders
• Unspecified mood disorder

Question 21

Levels of depression in ICD-10?

Answer 21

Mild depressive episode

Moderate depressive episode

Severe depressive episode without psychotic symptoms

Severe depressive episode with psychotic symptoms

Other depressive episodes

Depressive episodes, unspecified

Question 22

Difference between grief and depression?

Answer 22

Similar in quality (following bereavement) but there are differences

Question 23

General diagnostic criteria for depression?

Answer 23

Depressive episodes should last at least 2 weeks

There must have been no hypomanic or manic symptoms sufficient to meet the criteria for hypomanic or manic episodes, at any time in the patient’s life

At least 2 of the following:

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

An additional symptom, to give a total of at least 4 must be present

Question 24

Additional symptoms of depression?

Answer 24

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 thing or concentrate, such as indecisiveness or vacillation
5. Change in psychomotor activity, with agitation or retardation (either subjective or objective)
6. Sleep disturbance of any type (sleeping more or disturbed sleep)
7. Change in appetite (decrease or increase) with corresponding weight change

Question 25

For a diagnosis of depression, why must there have been no hypomanic or manic episodes?

Answer 25

If these occur along with depressive episodes, this is BPAD

Question 26

Assessment of depression severity?

Answer 26

Rating scales:

•

Question 27

Criteria for a moderate depressive episode?

Answer 27

At least 2 of the 3 symptoms must be present:
• Depressed mood
• Reduced enjoyment or interest
• Decreased energy

Additional symptoms must be present to give a total of 6:
• Loss of confidence
• Guilt
• Suicidal ideas or behaviours
• Poor concentration 
• Agitation / retardation
• Sleep disturbance
• Changes in appetites 

NOTE - 6 symptoms for moderate depressive episodes

Question 28

Criteria for a severe depressive episode?

Answer 28

All 3 symptoms must be present:

Additional symptoms must be present to give a total of at least 8:

NOTE - 8 symptoms for severe depressive episodes

Question 29

Occurrence of mild depression?

Answer 29

Comprises the majority of depression found in primary care

Generally, this gets better by itself

Question 30

Sub-type of depression (different syndromes of symptoms)?

Answer 30

Somatic syndrome

Atypical depression

Psychotic depression

Question 31

Diagnostic criteria for somatic syndrome?

Answer 31

4 of the following symptoms should be present:
1. Marked loss of interest or pleasure in activities that are normally pleasurable
2. Lack of emotional reaction to events / 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 / 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 32

Diagnostic criteria for atypical depression?

Answer 32

Mood reactivity, i.e: mood brightens in response to actual or potential positive events

2 or more of the following:
• Significant weight gain or increase in appetite
• Hypersomnia
• Leaden paralysis, i.e: heavy / leaden feeling in arms/legs
• Long-standing pattern of interpersonal rejection sensitivity (not limited to episodes of mood disturbance) that results in significant social or occupation impairment

Question 33

Types of psychotic depression?

Answer 33

Occasionally paranoid (typically mood-congruent or hypochondrial), e.g: ‘people are trying to kill me’ , ‘I’ve got cancer’

Cotard’s syndrome - more common in the elderly and often inv. nihilistic delusions (e.g: ‘I cannot eat because my bowels have turned to dust’)

Question 34

5 Rs of major depression?

Answer 34

1. Response
2. Remission
3. Relapse
4. Recovery
5. Recurrence