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Psychiatry > Affective Disorder's > Flashcards

Affective Disorder's Flashcards

1
Q

What are affective disorders?

A

Illnesses where the main feature is excessively high (e.g mania) or low mood (e.g depression)

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2
Q

What neurochemical theories are there for depression?

A

Monoamine hypothesis (depression results from a deficiency in brain monoamine neurotransmitters):

  • Noradrenaline (affects mood and energy)
  • Serotonin (affects sleep, appetite, memory and mood)
  • Dopamine (affects psychomotor activity)
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3
Q

What are the core symptoms of depression (3)?

A
  • Low mood
  • Anergia (low energy)
  • Anhedonia (inability to feel pleasure from normally pleasurable activities)
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4
Q

What is the core symptoms-related diagnostic criteria for depression? (2)

A

At least 2 core symptoms

At least 2 weeks of symptoms

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5
Q

What are the cognitive symptoms of depression?

A

Worthless
Helpless
Hopeless

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6
Q

What are the biological symptoms of depression?

A
  • Altered sleep
  • Initial insomnia
    Early morning wakening (waking at least 2 hours earlier than normal)
    Hypersomnia is possible (may coexist with hyperphagia)
  • Reduced appetite
  • Reduced libido
  • Constipation, aches and pains and dysmenorrhoea
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7
Q

What are the psychotic symptoms of depression?

A

Occur in severe depression:
Auditory hallucinations
Visual hallucinations
Delusions: often nihilistic and persecutory

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8
Q

Describe 4 subtypes of depression

A

Seasonal Affective Disorder: presents predictably with low mood in the winter. Usually reversed biological symptoms of overeating and oversleeping

Atypical Depression: no seasonal variation but shows reversed biological symptoms and may retain mood reactivity

Agitated Depression: depression with psychomotor agitation (instead of retardation) such as restlessness and pacing

Depressive Stupor: wen psychomotor retardation is so profound that the person grinds to a halt, hey become mute and stop eating, drinking or moving

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9
Q

Give some differentials for depression

A

Physical/organic causes (e.g. hypothyroidism, MS)
Adjustment disorder (unpleasant but mild affective symptoms follow a life event, but do not reach the severity needed to diagnose depression)
Normal sadness
Bereavement
BPAD/schizoaffective disorder/schizophrenia
Substance misuse
Postnatal depression/puerperal illness
Dementia

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10
Q

Give some investigations for depression

A
  • Collateral history
  • Physical examination
  • Blood tests
    TFT
    FBC (anaemia causes fatigue)
    Glucose and HbA1c (DM can cause fatigue)
  • Rating scales to monitor severity and treatment response (e.g. PHQ-9 questionnaire)
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11
Q

What is the treatment for mild depression?

A
  • Referral to supportive counselling/community mental health teams (home treatment)
  • Advice on; sleep hygiene, exercise, self-help
  • Access to CBT & counselling
  • Social stressors intervention (e.g time off work, refuge from abusers, debt advice etc)
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12
Q

What are the principles of CBT (cognitive behavioural therapy), a type of psychological treatment?

A
  • Identification of NATs (negative automatic thoughts)
  • Influencing thought and behaviour, to improve mood
    Examples of NATs that will be challenged in CBT:
  • Generalisations - ‘always messing up everything’
  • Distorted beliefs - ‘no one cares about me/wants to spend time with me’

CBT can introduce behavioural experiments (e.g inviting friends over to dinner)
–> building up a set of more realistic beliefs

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13
Q

Describe psychodynamic psychotherapy for depression

A
  • Identifying transferences (application of unconscious templates of relationships, derived from the past, to new situations)
  • Allows pt to recognise hidden beliefs
  • -> can re-evaluate based on current reality
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14
Q

What classes of drugs can be given for depression, and what is the main aim of action?

A

SSRIs, SNRIs, TCAs

  • Aim to increase overall level of monoamines at the synapse (can lead to downregulation of serotonin and central beta-adrenergic receptors –> 4-6 week delay in antidepressant effects)
  • Indicated for moderate-severe depression, in combination with psychotherapy
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15
Q

Give examples of SSRIs used in depression and some side effects

A

Fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram

  • Nausea and vomiting
  • Appetite/weight change
  • Anxiety and agitation
  • Insomnia, tremor, dizziness
  • Headache
  • Sweating
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16
Q

Give examples of SNRIs used in depression and some side effects

A 
Venlafaxine, duloxetine 
Side effects are same as SSRIs but also… 
- Constipation  
- Hypertension  
- Raised cholesterol
17
Q

Give examples of TCAs used in depression and some side effects

A 
Amitriptyline, clomipramine, imipramine, lofepramine, dosulepin 
Side-effects: 
- Tachycardia, arrhythmias  
- Dry mouth  
- Constipation  
- Urinary retention  
- Postural hypotension  
- Nausea 
- Weight gain
18
Q

What are some important considerations of taking antidepressants?

A
  • Lower seizure threshold (careful in epilepsy)
  • Avoid in mania/hypomania
  • Do not drink alcohol (increased sedation), do not drive if feeling drowsy
  • Onset of action is delayed

Stopping:
- Discontinuation symptoms (flu-like, electric shock sensations, headache)
Therefore should be withdrawn over a few weeks
- Serotonin syndrome (giving 2 antidepressants at once) –> life threatening

19
Q

Give some other treatments for depression

A

Augmentation: lithium, thyroxine
ECT (electroconvulsive therapy)
Light therapy (for seasonal affective disorder)

20
Q

Differentiate between mania and hypomania

A

Manic episode: symptoms should last at least a week and prevent work and ordinary social activities

Hypomania: less severe symptoms that do NOT entirely disrupt the patient’s ability to function

21
Q

Give some core symptoms of mania

A
  • Mood, energy and enjoyment are elevated
  • Raised mood can range from cheerfulness to elation and uncontrollable excitement, through irritability and aggression
  • Labile mood
  • Pt indulges in many new activities
22
Q

Give some cognitive symptoms of mania

A
  • Inflated self-esteem and confidence
  • Belief they are; gifted, attractive, creative, intelligent and extremely special
  • Thoughts race
  • Concentration dissolves
  • Despite being very distractible, the patient may feel that they can think more clearly than ever
  • Speech becomes pressured and topics change rapidly (flight of ideas)
23
Q

Give some biological symptoms of mania

A
  • Reduced sleep
  • Voracious appetites for food and sex
  • Reckless, disinhibited behaviour
  • Tendencies to; spend excessively, drive recklessly or gamble their money
  • Drugs or alcohol become new interests and make the patient more disinhibited
24
Q

Give some psychotic symptoms of mania

A
  • Grandiose delusions: optimism develops (e.g fame, special powers)
  • Persecutory delusions: pt believes other are jealous of them
  • Auditory hallucinations
25
Q

When can a diagnosis of bipolar affective disorder be made?

A
  • Manic episode

- AND any other affective disorder (e.g depression, hypomanic, manic or mixed)

26
Q

Describe the features of the 3 types of bipolar disorder: Type I, Type II, Rapid cycling

A

Type I :
- Manic episodes interspersed with depressive episodes
Type II:
- Mainly recurrent depressive episodes, with less prominent hypomanic episodes
Rapid Cycling BPAD:
- Four or more affective episodes in a year
- More common in women
- May respond better to sodium valproate

27
Q

What is the DDx for BPAD?

A

Exclude organic causes:

  • Drug induced (amphetamines, cocaine)
  • Dementia
  • Frontal lobe disease, delirium, cerebral HIV

Schizophrenia:
- Psychotic symptoms would outweigh the affective symptoms

Cyclothymia:
- Mood instability, but not severe/prolonged enough to meet criteria for depression or hypomania

Puerperal disorders

28
Q

What are the 3 pharmacological mood stabilisers for mania?

A

Lithium
Sodium valproate
Carbamazepine

29
Q

What is the level for lithium toxicity, what are the symptoms of toxicity

A

Therapeutic range: 0.6-1.0mmol/L
Toxicity: 1.2mmol/L and greater

Life threatening (GI disturbance, sluggishness, ataxia, fits, renal failure)

30
Q

What are the main mania indications for valproate?

A

Acute mania, rapid cycling BPAD (prophylaxis)

31
Q

What needs to be particularly considered about the patient before giving mood stabilisers?

A

Pregnancy - mood stabilisers are teratogenic

Lithium - Ebstein’s anomaly
Valproate + carbamazepine - spina bifida

Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate

32
Q

Describe the acute treatment for mania/hypomania

A
  • Stop all medications that may include symptoms (e.g. anti-depressants, drugs of abuse, steroids and dopamine agonists)
  • Monitor food and fluid intake to prevent dehydration

If treatment free:

  • Antipsychotic OR mood stabiliser (can be given together if not responding)
  • Consider benzodiazepines for sedation

If already on treatment:

  • Optimise the medication, check compliance, adjust doses
  • Consider adding another agent (e.g. antipsychotic as well as mood stabiliser)
  • Consider benzodiazepines for sedation

ECT may be used if patients are unresponsive to medication

33
Q

What needs to be considered when treating for BPAD?

A

Antidepressants can cause switch to mania

  • Antidepressants should be given WITH mood stabilisers or antipsychotics
  • Monitor closely for mania, and stop antidepressants if required
34
Q

Describe the psychological-social therapy for mania

A

CBT:
- Relapse prevention strategies (develop a routine, healthy sleep, healthy lifestyle, avoid stressors

Psychodynamic psychotherapy

Social: family support/therapy, aiding return to education/work

Psychiatry (14 decks)

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