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Yr4: Psychiatry > Affective Disorders > Flashcards

Affective Disorders Flashcards

1
Q

Remind yourself of the definition of:

  • Mood
  • Affect
A
  • Mood is a pt’s sustained, experienced emotional state over a period of time (can be sujective or objective)
  • Affect is the pt’s immediate expression of emotion/transient flow of emotion in response to a particular stimulus (what you observe)

*Can think of mood as the season and weather being the affect

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2
Q

Fluctuations in mood are normal; it only becomes a mood/affective disorder when….?

A

… the mood disturbance is severe enough to impair the activities of daily living

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3
Q

In the ICD-10 classification there are 7 categories of affective disorders; state these

A
  • Manic episode (includes hypomania, mania with psychotic symptoms & mania without pschotic symptoms)
  • Bipolar affective disorder
  • Depressive episode
  • Recurrent depressive episode
  • Persistent mood disorders (e.g. cyclothymia, dysthymia)
  • Other mood disorders (e.g. mixed affective disorder= symptoms of both mania and depression at same time)
  • Unspecified mood disorders
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4
Q

Aswell as the ICD classification, mood disorders can be classified as primary or secondary; explain the difference between primary and secondary mood disorders and discuss any further classification

*aim to be able to explain/draw out classification of mood disorders diagram from book

A
  • Primary: does not result from another medical condition.
    • Can be further classified as unipolar (depressive disorder, dysthymia) or bipolar (bipolar affective disorder, cyclothymia).
    • Depressive disorders can be classified as mild, moderate, severe and psychotic
    • Bipolar affective disorder can be classified as bipolar 1 or 2
  • Secondary: results from another medical or psychiatric condition or is drug induced
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5
Q

Define depressive disorder

A

Affective mood disorder characterised by persistent low mood, loss of pleasure and/or lack of energy accompanied by emotional, cognitive and biological symptoms.

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6
Q

Depressive disorder is not genetic; true or false?

A

False:

  • Monozygotic twin studies show that if 1 twin has depression there is 40-50% chance other twin will have depression hence likley mutliple genes involved

HOWEVER, it is multifactorial influenced by many biopsychosocial factors (it is not just genetic)

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7
Q

What is the monoamine hypothesis?

A

Deficieny of monamines (serotonin, noradrenaline & dopamine) causes depression

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8
Q

What is the evidence supports the monamine hypothesis?

A
  • Antidepressants improve depression and these increase the concentration of the monoamine neurotransmitters in synaptic cleft
  • 5HIAA a metabolite of serotonin low in CSF of pts wtih depresion
  • Tryptophan is a precursor for serotonin and it’s depletion causes depresion
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9
Q

Discuss the prevelance and epidemiology of depressive disorders, include:

  • How many people worldwide affected
  • Whether it causes disability
  • Which gender more common in
  • Age of onset
A
  • >300 million people worldwide
  • Leading cause of disability
  • Females > men
  • Age of onset:
    • Female: 30’s
    • Males: 40’s
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10
Q

State some predisposing factors for depressive disorder, include:

  • Biological
  • Psychological
  • Social
A
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11
Q

State some precipitating factors for depressive disorder, include:

  • Biological
  • Psychological
  • Social
A
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12
Q

State some perpetuating factors for depressive disorder, include:

  • Biological
  • Psychological
  • Social
A
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13
Q

Alongside thinking of the biopsychosocial model to think of predisposing, precipitating and perpetuating factors for depressive disorder you can also use the mneumonic FF, AA, PP, SS to quickly think of some risk factors

A
  • Female
  • Family history
  • Adverse event
  • Alcohol
  • Past depression
  • Physical co-morbidities
  • Social support (little)
  • Socioeconomic status (low)
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14
Q

Clinical features of depression can be grouped into 3 categories; state the categories and give examples of each

*You must include all 3 core symptoms

A

Core symptoms

  • Low mood (at least 2 weeks)
  • Lack of energy/anergia
  • Lack of interest and pleasure in things that were previously enjoyable/anhedonia

Cognitive symptoms

  • Lack of concentration
  • Excessive guilt (excessive or inappropriate guilt nearly every day)
  • Suicidal ideation
  • Hypochondrial thoughts (think that you are getting ill or are ill)
  • Hopelessness
  • Negative thoughts (Beck’s triad)

Biological symptoms

  • Sleep changes- usually EMW 2 hours before usual time (may have hypersomnia)
  • Loss of libido
  • Appetite or weight changes (usually loss)
  • Diurnal variation in mood (DVM)
  • Psychomotor retardation
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15
Q

DEAD SWAMP is a helpful mneumonic to help you remember common symptoms of depressive disorder; state the mneumonic

A
  • Depressed mood
  • Energy decreased
  • Anhedonia
  • Death thoughts (suicide)
  • Sleep disturbances
  • Worthlessness or guilt
  • Appetite and/or weight change
  • Mentation (concentration) reduced
  • Psychomotor retardation
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16
Q

What is Beck’s cognitive triad?

A
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17
Q

Examples of how to ask questions in depressive disorder

A
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18
Q

Pts with depressive disorder may have psychotic symptoms; state two common psychotic symptoms in depression

A
  • Delusions: usually hypochondriacal, guilt, nilhilistic or persecutory in nature
  • Hallucinations: usually second person auditory
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19
Q

What does nihilistic mean?

What is a nilhilistic delusion?

A

Rejecting all religious and moral principles in the belief that life is meaningless.

Belief that they are worthless or dying. In severe cases they claim that everything is non-existent including themselves (Cotard’s syndrome)

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20
Q

According to the ICD-10 classification, how many symptoms do pts need to have in order to be diagnosed with:

  • Mild depression
  • Moderate depression
  • Severe depression
  • Severe depression with psychosis
A
  • Mild depression: 2 core + 2 other
  • Moderate depression: 2 core + 3-4 others
  • Severe depression: 3 core + >/=4 others
  • Severe depression with psychosis: 3 core + >/= 4 others + psychosis

Episode must have lasted at least 2 weeks.

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21
Q

Depressive disorder it can occur with our without somatic syndrome. Discuss:

  • What somatic syndrome is
  • Criteria for somatic syndrome in mild & moderate depression
  • Whether somatic syndrome is present in severe depression
A

Somatic syndrome involves a person having a significant focus on physical symptoms/pt is highly affected by the somatic symptoms of depression. Criteria is as follows:

  • Mild & moderate without somatic syndrome: few if any somatic symptoms
  • Mild & moderate with somatic syndrome: four or more of somatic symptoms are present (if have two or three but are severe then may be able to put in this category)
  • Severe: presumed that somatic syndrome will almost always be present
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22
Q

Discuss what investigations you may consider in depression

*Hint: remember your three categories: bedside, bloods, imaging

A

Investigations are usually done to exclude organic causes of depression- they are not mandatory.

Bedside:

  • Diagnostic questionnaires (e.g. PHQ-9, Beck’s depression inventory)
  • Plasma glucose (diabetes causing anergia)

Bloods:

  • FBC (anaemia causing anergia)
  • TFTs (hypothyroidism)
  • U&E’s, LFTs, calcium (biochemical abnormalities can cause somatic symptoms that mimic depressive symptoms)
  • HbA1c (diabetes)

Imaging:

  • CT or MRI head (if suspicous of intracranial pathology e.g. they have unexplained headaches or marked personality changes)
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23
Q

Discuss what you may find on MSE of a pt with depressive disorder

*remember, ASEPTIC

A
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24
Q

State some differential diagnoses for depressive disorder

A
  • Other mood disorders e.g. bipolar affective disorder, cyclothymia, seasonal affective disorder, dysthymia, baby blues, post-natal depression
  • Secondary to physical condition e.g. hypothyroidism
  • Secondary to other psychiatric disorders e.g. psychotic disorders, anxiety disorders, personality disorder, eating disorder
  • Secondary to psychoactive substance abuse
  • Normal bereavement
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25
Q

Management of all depression uses the biopsychosocial approach; however, management depends on severity. Discuss the management of mild to moderate depression (split your answer into biological, psychological and social)

A

Biological

  • Not recommended first line unless certain criteria are filled

Psychological

  • Watchful waiting & education surrounding depression: reassess pt in two weeks (if mild depression & don’t want intervention or subthreshold depression)
  • Low intensity psychosocial interventions
    • Self-help programmes
    • CBT(computerised or group if refuse other)
    • Physical activity programme e.g. group exercise class

Social

  • Depression support groups
  • Helping them to find support for finances, accomodation, employment etc…
  • Advice regarding general coping strategies e.g. regula routines
  • Safeguarding
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26
Q

Antidepressants are not recommended first line for mild to moderate depression unless… (4)

A
  • Depression has lasted a long time/subthreshold depression lasted >2 years
  • Past history of moderate or severe depression
  • Symptoms persist after other interventions
  • Depression complicates care of other physical health problem
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27
Q

Management of all depression uses the biopsychosocial approach; however, management depends on severity. Discuss the management of severe depression +/- pyschosis (split your answer into biological, psychological and social)

A

Biological

  • Antidepressants
    • First line= SSRIs (if it is reccurrent depressive disorder consider an antidepressant they previously had good respone to)
    • Others e.g. TCA’s, SNRIs, MAOIs
  • Adjuvants e.g. antipsychotics, lithium
  • ECT

Psychological

  • High intensity psychosocial interventions:
    • ​Individual CBT
    • Interpersonal therapy
    • Behavioural activation
    • Counselling
    • Psychodynamic therapy

Social

  • Depression support groups
  • Helping them to find support for finances, accomodation, employment etc…
  • Advice regarding general coping strategies e.g. regula routines
  • Safeguarding
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28
Q

You can refer pts who are being discharged from hosp with depression to crisis team as they can provide support initially whilst awaiting allocation of CPN; true or false?

A

True

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29
Q

When should pt’s with severe depression referred to psychiatry?

A
  • Suicide risk is high
  • Depression is severe
  • Recurrent depression
  • Unresponsive to initial treatment
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30
Q

How long should a pt be treated with antidepressants for if it’s their:

  • First depressive episode
  • Second depressive episode
  • Third or more episode
A
  • First depressive episode: 6 months after resolution of symptoms
  • Second depressive episode: 2 years after resolution of symptoms
  • Third or more episode: long term
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31
Q

What are the 4 indications for ECT specific to depression?

A
  • Acute treatment of severe depression which is life-threatening
  • Severe psychomotor retardation or stupor
  • Failure of other treatments
  • Depression with psychotic symptoms

*NOTE: there are more indications for ECT, these are just ones related to depressive disorder

32
Q

Which antidepressant is often preferred if pt has physical health problems?

A

Sertraline

Lower risk of drug interactions

33
Q

Describe/outline the purposes of the following psychotherapies which are used in depression:

  • ​Individual CBT
  • Interpersonal therapy
  • Behavioural activation
  • Counselling
  • Psychodynamic therapy
A
34
Q

You should do a suicide risk assessment on all pts with depressive disorder; true or false?

A

True

35
Q

Discuss the prognosis of depressive disorder

A
  • With treatment most episodes of depression last about 3-6 months
    • >50% with major depressive episode recover in 6 months
  • Likelihood of recurrence is high and increases with each episode (first= 50%, second= 80%)
  • About 10% develop persistent depression
  • The prognosis is worse for people with psychotic features, personality disorders, prominent anxiety, severe symptoms

*Taken from NICE guidance, accessed in 08/21.

36
Q

Other depressive disorders include:

  • Recurrent depressive disorder
  • Seasonal affective disorder
  • Masked depression
  • Atypical depression
  • Dysthymia
  • Cyclothymia
  • Baby blues
  • Post-natal depression

… for each briefly describe what it is

A
37
Q

State some risk factors for post-natal depression

A
  • Personal or family history of depression
  • Previous PND
  • Older age
  • Single mother
  • Unwanted pregnancy
  • Poor social support
38
Q

One of the categories in the ICD-10 classification of mood disorders is ‘other mood disorders’; one of these is mixed affective disorder. What is mixed affective disorder?

A

Characterised by a mixture or a rapid alternation (usually hours) of symptoms of hypomnia or mania and depression

39
Q

What is bipolar affective disorder?

A

Chronic episodic mood disorder, characterised by at least 1 episode of mania or hypomania and a further episode of mania or hypomania or depression.

  • Any of depression or mania can occur first. People may be diagnosed with bipolar when only had manic or hypomanic episodes however all cases eventually develop depression (rare just to have manic episodes)*
  • Requires at least 2 episodes in which person’s mood is disturbed; one of which must be mania or hypomania*
40
Q

What is the prevelance of bipolar affective disorder?

Does it affect males or females more?

What is the mean age of onset?

Incidence is higher in what ethnic groups in the UK?

A
  • ~1.3 million people in UK (1 in 50 people)
  • Females = males
  • 19yrs
  • Black and other ethnic minorities
41
Q

Bipolar affective disorder has both biological and environmental factors; state some biological factors and some environmental factors

*Hint: split biological into neurochemical, endocrine and genetic

A

Biological

  • Monoamine hypothesis
    • Mania: central monamines increased
    • Depression: central monamines decreased
  • Dysfunction of HPA and HPT axis (hypothyroid present with depression, hyperthyroid present with mania)
  • Genetic
    • In monozygotic twins if one has bipolar affective disorder other has 40-70% chance
    • 1st degree relatives of BPAD pt is 5-10%

Environmental

  • Adverse life events
  • Bereavement
  • Post partum
42
Q

State some risk factors for BPAD

  • *Think about biological, psychological and social predisposing, preciptating & perpetuating factors*
  • *Also use mneumonic Aggressive Spenders*
A

Predisposing

  • Biological: FH, age, HPA & HPT axis abnormalities
  • Psychological: other psychiatric conditions e.g. anxiety disorders
  • Social:

Precipitating

  • Biological: poor compliance with meds
  • Psychological: stressful life event
  • Social: working shifts, employment issues, housing issues etc…

Perpetuating

  • ​Biological: poor compliance meds
  • Psychological: lack of insight
  • Social: disrupted sleep pattern, social isolation, substance misuse
43
Q

Mania can be divided into three categories; state these

A
  • Hypomania
  • Mania without pyschosis
  • Mania with psychosis
44
Q

Mania can be divided into three categories: hypomania, mania without psychosis and mania with psychosis. Compare and contrast each of these

*Be sure to include any specific durations, affect on work & social activities

A
45
Q

State symptoms of mania

*HINT: mneumonic I DIG FASTER

A
46
Q

What is the ICD criteria for mania, include:

  • How many symptoms must be present
  • List of symptoms
A

Need 3/9 symptoms to be present:

  • Grandiosity/increased self esteem
  • Decreased sleep
  • Pressure of speech
  • Flight of ideas
  • Distractability
  • Psychomotor agitation (restelessness)
  • Reckless behaviour e.g. spending, driving
  • Loss of social inhibitions
  • Marked sexual energy/increased libido
47
Q

Examples of how you can ask questions to screen for mania

A
48
Q

BPAD can be classified as bipolar type 1, type 2 or rapid cycling; compare bipolar type 1 and 2

A

Bipolar 1

  • 1 or more manic or mixed episodes
  • +/- 1 or more depressive episodes

*remember if don’t have a depressive episode must have had two mania or mixed episodes

Bipolar 2

  • 1 or more hypomanic episodes
    • 1 or more dpressive episodes

**KEY DIFFERENCES: bipolar 1 must have mania or mixed affective episode- don’t need to have depression. Bipolar 2 must haveat least 1 hypomanic episode and at least 1 depressive episode.

49
Q

BPAD can be classified as bipolar type 1, type 2 or rapid cycling; describe rapid cycling

A

More than 4 mood swings in a 12 month period with no intervening asymptomatic periods.

50
Q

Which epsisodes last longer in BPAD; mania/hypomania or depression?

A
  • Mania/hypomania: 2 weeks to 4/5 months (median= 4 months. Usually abrupt onset)
  • Depression: median= 6 months
51
Q

You must always screen for mania in a depressed pt; true or false?

A

TRUE

May not disclose if you don’t ask and they may have bipolar not depressive disorder or recurrent depressive disorder

52
Q

Suggest what investigations may you do if a pt is manic?

A

Bedside

  • Urine drug test

Bloods

  • TFTs (hyperthyroidism)
  • U&Es (baseline renal func for starting lithium)
  • LFTs (baseline liver function start mood stabilisers)
  • Calcium (biochemical disturbances can affect mood)

Imaging

  • CT or MRI head
53
Q

Discuss what the MSE may be for a pt who is manic

A
54
Q

State some potential differential diagnoses for a pt presenting with manic-like symptoms

A
55
Q

Mania and depression can be triggered by the initiation as well as the withdrawal of steroids; true or false?

A

TRUE

56
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; however, there are also other things to consider in the management- discuss these

A
  • Risk assessment
    • Suicidal ideation
    • Financial
    • Children?
    • Risk to others e.g. driving
  • Do you need to contact DVLA?
  • Will the pt go to hospital voluntarily, if necessary, or wil they need sectioning under MHA?
57
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; biological management can be further split management of:

  • Acute manic/mixed episodes
  • Bipolar depressive episode
  • Long term managmeent

Discuss the management of acute manic/mixed episodes

A
  • First line= antipsychotic (e.g. olanzapine, resperidone, quetiapine, haloperidol) *if first is not tolerated or poorly affective offer a second
  • Second line= add mood stabiliser (e.g. lithium, valporate)
  • If pt taking antidepressant taper and discontinue
  • Benzodiazepines may be required to help sleep & agitation
  • Haloperidol and/or lorazepam may be used for rapid tranquilisation
  • *NOTE: antipsychotics are used as they have rapid onset of action compared to mood stabilisers*
  • *NOTE: mixed episodes treated in same way as manic episodes*
58
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; biological management can be further split management of:

  • Acute manic/mixed episodes
  • Bipolar depressive episode
  • Long term managmeent

Discuss the management of bipolar depressive episodes

A
  • Atypical antipsychotics (e.g. olanzapine alone, olanzapine combined with fluoxetine, quetiapine)
  • Mood stabilisers (e.g. lamotrigine, lithium)

*NOTE: antidepressants alone are avoided, even if pt is predominantly depressed, as they can induce mania. Only be prescribed in conjuction with an anti-manic medication

59
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; biological management can be further split management of:

  • Acute manic/mixed episodes
  • Bipolar depressive episode
  • Long term managmeent

Discuss the long term management of BAPD

A
  • First line= lithium
    • Should be offered 4 weeks after acute episode has resolved to prevent relapses if not already added to regime
  • Second line=
    • Other mood stabiliser e.g. valporate can be added to lithium regime or tried on it’s own if lithium not tolerated
    • Antipsychotic e.g. olanzapine, quetiapine
60
Q

Summary of biological management of BAPD

A
61
Q

What is the first line treatment for rapid cycling BAPD?

A

Lithium & sodium valporate

62
Q

How long should someone continue to take mood stabilisers following an episode?

A
  • For at least two years after one episode of bipolar disorder.
  • Five years if there have been:
    • frequent previous relapses
    • psychotic episodes
    • alcohol or substance misuse
    • continuing stress at home or at work.
63
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; discuss the psychological management of BAPD

A
  • For bipolar depression offer high intensity psychosocial intervention e.g. CBT

According to NICE there are psychological interventions that have been specially developed for bipolar depression which may include:

  • Family focused therapy
  • Psychoeducation
  • Interpersonal social rhythm therapy (help regulate sleep, social & daily activities)
64
Q

Management of bipolar affective disorder is centred around the biopsychosocial model; discuss the social management of BAPD

A
  • Support groups
  • Self-help groups
  • Encourage calming activities
  • Encourage routines
  • Helping to manage e.g. accomodation, finances (particularly after manic episode if spending)
65
Q

Is ECT used in BAPD?

A

Not first line but may be used if antipsychotic drugs ineffective and pt is so disturbed that trying fruther medication or waiting for natural recovery is too risky.

66
Q

How often should a pt who presents with mania, but is not hospitalised, be monitored?

A
  • Initially once a week
  • Every 2-4 weeks for first few months
67
Q

When would hospitilisation be required for someone with BAPD?

A
  • Behaviour means they are a risk to others or themselves
  • Severe psychotic symptoms
  • Impaired judgement
  • Psychomotor agitation
68
Q

Severely manic pts can become mute; true or false?

A

True

69
Q

For catatonia, discuss:

  • What it is
  • Causes
  • Signs & symptoms
  • Management
A
  • Catatonia is a severe neuropsychiatric disorder that affects movement, speech and activity levels (a psychomotor sydnrome)
  • Causes:
    • Psychiatric: depression, bipolar, psychosis e.g. schizophrenia, withdrawal from medications such as clopazine
    • Organic: CNS infections, normal pressure hydrocephalus, delerium, vit b12 deficiency, Parkinson’s disease, subarachnoid haemorrhage
  • See image for signs & symptoms
  • Management:
    • Benzodiazepines
    • ECT
70
Q

Discuss how depression may present in elderly

A

Compared with younger adults more likley to presetn with:

  • Disturbed sleep
  • Dependency having previously been independent
  • Motor disturbance e.g. retardation or agitiation
  • Multiple physical problems for which no cause can be found

Less likely to present with low mood and express duicidal ideation.

Management is similar but be cautious with medications due to interactions, issues with compliance etc.. Reducing social isolation is key.

71
Q

Discuss how mania may present in the elderly

A

Elderly pts with mania often have:

  • Irritability
  • Labile mood
  • Perplexity (inability to deal with or understand something much like that in delerium but they have clear consciousness)
  • Grandoise ideation

Less likely to preset with overt elation.

Treatment is with antipsychotics but be careful in pts with dementia or vascular risk factors due to increased risk of stroke. Lithium can be used although a proportion of elderly ptsdevelop neurotoxicity; would have to be certain pt is capable of understanding and implementing lithium taking instructions.

72
Q

Patients may experience pseudohallucinations as part of normal grief reaction; true or false?

A

True; may experience pseudohallucinations of deceased (both auditory & visual) and sometimes people focus on physical objects that remind them of that person or even prepare meals for them.

73
Q

Summary of NICE updates on Passmed

A
74
Q

Summary of NICE updates on Passmed

A
75
Q

Summary of NICE updates on Passmed

A

Yr4: Psychiatry (17 decks)

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