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Psychiatry > Affective Disorders > Flashcards

Affective Disorders Flashcards

1
Q

Spectrum of disorders

A

BAD
- type 1 and type 2

Unipolar disorder
- MDD

Others

  • cyclothymia
  • dysthymia
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2
Q

Kindling hypothesis of affective disorders

A

Major stressors trigger initial onset
Successive affective episodes become less tied to stressors and occur more spontaneously

More attacks = more destabilised (increase severity and recurrence)

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3
Q

Neuroanatomy and Neuroendocrinology in affective control - areas involved

A

Interplay among prefrontal cortex, basal ganglia, limbic system

  • neocortex - higher functions, behavioural response, perception
  • amygdala - fear/aggressive behaviour, emotions
  • hippocampus - memory (recent)
  • corpus striatum (bg) - automatic movement regulation

Cortico-striato-thalamo-cortical circuits

  • implicated in depression and OCD
  • theoretical basis of treating depression/OCD by DBS
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4
Q

Difficulty in diagnosis of affective disorders

A

Change in mood difficult to detect
Lack of insight
Under-reporting
Stigmatisation

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5
Q

Which stage of development is most critical/vulnerable to affective disorders?

A

Adolescence
– self awareness, early detection and early intervention is important

primary, secondary and tertiary prevention (illness, diagnosis, suicide)

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6
Q

Differential Diagnosis of low mood

A

Mood disorders

  • Major depressive disorder
  • BAD
  • Cyclothymia
  • Dysthymia
  • Recurrent depressive disorder

Anxiety disorders

Schizoaffective disorder
Secondary to medical condition e.g. hypothyroid
Secondary to substance abuse

Normal sadness/ grief

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7
Q

Classical symptoms of low mood - somatic, cognitive, psychotic

A

Somatic
- early morning (2hrs early) wakening with dysphoria, agitation +/- initial insomnia, frequent awakening
- diurnal variation - mood worse in the morning
- LOA and LOW
- Psychomotor agitation (restless, pacing, scratching) or retardation (slow speech, long pauses, limited expressions - mutism in severe cases)
- loss of libido/amenorrhea
(other physical symptoms e.g. aches, constipation)

Cognitive

  • poor concentration and memory
  • poor self esteem (helpless, worthless)
  • guilt 自責
  • hopelessness
  • suicide or self-harm

Psychotic (in severe cases)
- mood congruent delusions/hallucinations e.g guilt, disease (hypochondriacal), death, nihilism (such as blocked bowels in Cotard’s syndrome), derogatory voices

Other symptoms e.g. depersonalisation, obsessional symptoms, phobia, conversion

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8
Q

Severe depression with psychosis vs Schizophrenia

A 
Psychosis only during mood symptoms 
*Temporal relationship
*Mood congruent psychotic symptoms (vs incongruous affect and bizarre delusions in schizophrenia)
Determine predominant symptoms
Examine mental state
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9
Q

Assessment of low mood - Hx

A

Hx

  • core symptoms (low mood, anhedonia, fatigue)
  • biological symptoms
  • cognitive
  • r/o BAD (hx of elated mood), psychosis

MUST include

  • risk assessment
  • functional assessment
  • psychotic/manic features
  • common psychiatric comorbidities e.g. GAD, OCD, PTSD, SA, pain
  • physical comorbidities
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10
Q

Investigations for low mood - social, psychological, physical

A

Social
- collateral info from GP, family

Psychological

  • mood diary
  • self-report inventories
Physical
- CBC for anaemia, infection, high MCV
- TFT for hypothyroid
- Ca for hyperCa
- LFT and GGT for alcoholism
- RFT, Urea and electrolytes for hypoNa (prescribe SSRI)
- fasting BG for chronic illness
[Others e.g. urine drug screen, VitB12/folate if suspected]

(CT brain only when psychotic or poor cognition since organic disease rarely just presents with mood changes)

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11
Q

Major Depressive Disorder Diagnostic Criteria

A
  1. FIVE OR MORE of the following for >TWO WEEKS
    - low mood MOST OF THE DAY, NEARLY EVERYDAY (pervasive) 低落
    - markedly diminished interest or pleasure in all activities (anhedonia) 提唔起徑
    - significant (>5% change in 1 month) LOW/weight gain or loss/gain of appetite
    - insomnia/hypersomnia
    - psychomotor agitation or retardation (observable and subjective e.g. restlessness)
    - loss of energy (anergia)
    - negative cognition – worthlessness/excessive guilt, hopelessness, helplessness
    - inability to concentrate leading to poor memory (depressive pseudodementia in severe cases of elderly)
    - recurrent thoughts of death/suicide/self-harm
  2. Cause significant impairment and distress
  3. Not attributable to physiological effects of substance or other medical condition
  4. Not better explained by schizophrenia, delusional disorder, schizoaffective etc
  5. Never been manic or hypomanic episode
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12
Q

MDD epidemiology - lifetime risk, F:M, peak age

A

Lifetime risk: 20% - one of the most important causes of disability
F>M 2:1
Peak onset late 20s-40s but higher prevalence in 65+

More common in urban populations/ adverse socio-economic factors e.g homeless

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13
Q

Diversity in clinical presentation - mood, somatic, stupor, atypical, memory

A

Mood

  • Agitated depression: more common in older patients
  • apathy, irritable, anger

Somatic
- pain, discomfort (could be main complaint) – may have hypochondriacal preoccupation

Retarded depression
- prominent psychomotor retardation

Depressive stupor

  • rare, severe case
  • motionless, mute, refuse to eat and drink
  • can be manic, depressive or psychotic

Atypical depression
- increased sleep, appetite/weight, severe anxiety and interpersonal sensitivity
(suggestive of BAD, or seasonal affective disorder)

Memory
- pseudo-dementia in elderly

Post-psychotic depression
- depression syndrome after tx of psychotic symptoms of schizophrenia

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14
Q

MDD - aetiology endogenous - genetics and personality

A

Genetics
- parents, siblings, children of severely depressed patients have higher lifetime risk for mood disorder (10-15%) than general population (1-2%)
- 30-40% heritability
- 7% of first degree relatives, 37% concordance in twin studies
(no genes consistently identified - 5HT transport/receptor, BDNF, tryptophan hydroxylase)

Personality

  • no single personality type a/w MDD
  • coping style, resilience, neuroticism (easily stressed, moody, anxious, shy)
  • borderline, OCD
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15
Q

MDD - aetiology reactive

A

Environmental factors:

  • predisposing:
  • –> chronic stress e.g. social support, unemployment, marriage difficulties, raising young children, chronic pain or illness (Parkinson’s, malignancy)
  • –> early life experiences e.g. parental separation (<11yrs old), poor upbringing
  • precipitating: acute stressors e.g. bereavement, childbirth, (infection)
  • –> not causal but a/w increased risk of depression 6x in the 6 months after moderately severe life events
  • perpetuating:
  • –> abnormal psychological mediation e.g. emotional processing, tendency to rmb unhappy events, unrealistic beliefs, cognitive distortions in overgeneralising
  • –> abnormal biochemical processes – reduced 5HT and NA
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16
Q

MDD - neuroanatomy and neuroendocrinology

A

Brain

  • reduced volume of hippocampus (temporal lobe), amygdala, prefrontal cortex, basal ganglia
  • white matter hyper intensities on imaging

Hormonal factors

  • increase CRH, ACTH, cortisol (50% patients) with loss of diurnal rhythm of cortisol
  • subclinical hypothyroid in 30%
  • MONOAMINE DEFICIENCY hypothesis (NA, 5HT, DA)
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17
Q

“Organic” causes of depression - suspicious symptoms, possible causes

A

Suspect when:

  • acute, severe, atypical onset
  • late-onset
  • no apparent stress or precipitating events

Possible causes:

  • endocrine - hypothyroid, Cushing’s, Addison’s, hyperPTH
  • alcohol and SA
  • drugs e.g. sedatives, Parkinson’s drugs, steroids, anti-HT (beta blockers, methyldopa), statins, opiates
  • infection e.g. influenza, tertiary neurosyphilis, HIV
  • SOL of brain causing structural damage to areas regulating mood e.g. tumour, CVA
  • MS, Parkinson’s, Huntington’s
  • others: chronic pain, malignancy

Remember medical problems can precipitate depression but depression can aggravate medical problems as well e.g. DM, MI, dementia

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18
Q

MDD - associations with DM + PPS, and diet

A

DM-MDD (double burden)
- risk doubled of comorbid MDD in DM patients
- depression a/w 60% increased risk of T2DM
(may be due to lifestyle, decreased activity, hyperplagia, decreased QOL, drugs S/E)

High prevalence of painful physical symptoms (PPS) comorbid with MDD
- a/w more severe illness, poorer QOL, lower response and remission rates

Diet
- lower levels of tryptophan (5HT precursor) and VitB12/Folate (synthesis of DNA, 5HT, NA, DA)

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19
Q

MDD comorbidities

A

Anxiety disorders esp GAD, OCD
Eating disorders
Substance abuse
Psychosis

20
Q

Normal bereavement vs Depression

A 
Normal bereavement:
NO
- functional impairment 
- morbid preoccupation with worthlessness, guilt, pessimistic thoughts
- psychomotor retardation
- suicidal ideation
- psychotic symptoms

Such symptoms persisting more than 2 months after bereavement is suggestive of depressive disorder

21
Q

Determining severity of depression

A

Mild

  • few symptoms (just enough for diagnosis)
  • may not have significant functional impairment
  • no suicidal ideas

Moderate

  • more symptoms and functional impairment
  • suicidal ideas
  • may have delusions

Severe

  • suicidal risk with neglect
  • markedly interfere with functioning
  • psychosis (though not always)
22
Q

MDD course and prognosis - length of episodes, recurrence rates, risk of suicide, BAD switch

A

Untreated cases last 6 months or more with a significant minority lasting for years

With treatment – each episode lasts 2-3 months on avg

Recurrences are common – 60-75% have >1 recurrence with the risk of recurrence increasing with each episode
- high chronicity with 30% remaining ill after 1 yr, 20% after 2 yrs, 10% after 5 yrs

10-15% lifetime risk of completed suicide

10% BAD SWITCH
- RFs: early onset, FHx of bipolar, more recurrences, super responsive to SSRI

23
Q

Management of MDD - tx goals, initial assessment and treatment options

A

Tx goals: symptom relief, restore function, decrease risk of recurrence

Assess for inpatient or outpatient Mx

  • inpatient –> psychosis, active suicidal ideation, lack of motivation with risk of self-neglect, lack of social support
  • alert nurse for careful observation if hospitalised (SUICIDAL OBSERVATION)
  • organic workup (as mentioned previously)
  • outpatient
  • -> lifestyle advice for all cases: sleep hygiene, regular physical activity, healthy diet
  • -> contact social worker to aid reintegration into society (increase social stimulation)
  • -> drug treatment in moderate to severe cases
  • -> psychotherapy for all cases
24
Q

MDD - drug treatment - 1st line, side effects, other options, how to choose

A

1st line - SSRI

  • DELAYED ONSET for 2-3 wks (time for down regulating receptors; if early response then suspect BAD)
  • paradoxical S/E on initiation –> agitation, increased anxiety, increased risk of suicide as patients regain energy/sleep/appetite
  • -> NEED WEEKLY FU initially and plan to deal with original stressors
  • well tolerated and safe in overdose
  • GI symptoms, sleep/sexual disturbances, SIADH in elderly

Other options:

  • SNRI –> HT risk, less S/E than TCA
  • Mirtazapine –> sedation and weight gain S/E
  • TCA –> less well tolerated due to S/E profile (anti-cholinergic, anti-adrenergic, histaminergic, cardiotoxicity)
  • MAOi –> rarely used due to risk of hypertensive crisis, serotonin syndrome with SSRI

Choice depends on:
- symptoms, tolerability, S/E profile
e.g. insomniac –> sedative antidepressant mirtazapine
atypical depression –> SSRI, MAOi
highly suicidal –> avoid TCA
elderly –> avoid TCA (postural hypotension, falls)
pregnancy –> older TCA
drug interactions –> warfarin/tamoxifen affected by CYP450 inhibition by SSRI

25
Q

MDD - drug treatment regime

A

Acute treatment

Continuation treatment (1st episode)

  • 6-9 MONTHS after remission with the SAME DOSAGE
  • FU to review residual symptoms, ongoing stress etc

Maintenance treatment

  • if high risk of relapse e.g. >2 episodes in the past with functional impairment
  • at least 2 YEARS
26
Q

MDD - approach to resistant depression, indications for ECT

A

Resistant depression = failed 2 classes of antidepressants with max dose for adequate duration

  • review Dx, comorbid Dx, persisting stressors
  • check compliance
  • SWITCH to different class
  • AUGMENT with Li, T3, atypical antipsychotics
  • COMBINATION e.g. SSRI+mirtazapine, SSRI + bupropion
  • ECT

Consider ECT if:

  • poor response to drugs
  • severe suicidal ideation
  • severe psychomotor retardation, psychotic features
  • severe self-neglect
  • intolerance to S/E
27
Q

MDD - psychotherapy and other options

A

Not effective in very severe cases (since patient has cognitive impairment - need to wait for them to improve a bit)

COGNITIVE THERAPY (refer CP/OT)

  • comparable short term efficacy to drugs in mild-mod cases
  • addressing patient’s irrational beliefs and explaining dysfunctional thought processes
  • may prevent relapse
  • 12-16 sessions, once a week
  • only suitable for those with good insight and motivation to change

Mindfulness based therapy (accept thoughts)
Interpersonal therapy (interpersonal functioning, identify problem a/w onset)
Psychodynamic therapy
Coping strategies + problem solving

Social - family, work, finance (refer SW)

Bright light therapy for seasonal affective disorder

Others: transcranial direct current stimulation, repetitive transcranial magnetic stimulation, deep brain stimulation

28
Q

Childhood depression Tx

A

Mainstay - CBT/Play therapy

SSRI may increase suicidal risk – use fluoxetine with lower risk

29
Q

Recurrent depressive disorder and Persistent depressive disorder diagnostic criteria

A

Recurrent:

  • 80% patients who have one episode will go on to have more episodes
  • 5 episodes in lifetime on avg

Persistent (dysthymia):

  • CHRONICALLY depressed mood for AT LEAST 2 YEARS (1 YEAR IN CHILDREN and adolescents) for more days than not
  • with mild depressive symptoms (2 of the following):
  • -> change in appetite, sleep disturbance, anergia, low self esteem, poor concentration, hopelessness
  • never been without the symptoms/low mood for more than 2 months
  • criteria for MDD may be continuously present for 2yrs
  • never been manic or hypomanic episode; not cyclothymia
  • not schizoaffective, schizophrenia, delusional
  • not SA or other medical condition
  • cause significant distress or impairment
  • -> usually onset in early adulthood
  • -> less severe than MDD
  • -> double depression - occurrence of MDD on top of dysthymic moods (poorer prognosis)
30
Q

Differential diagnosis of elevated/irritable mood

A

Mood disorders

  • mania, hypomania, mixed affective episode (isolated or part of BAD)
  • depression - agitated, responding to ECT/drugs, recently resolved may misidentify euthymia for hypomania
  • cyclothymia

Psychotic disorders

  • Schizoaffective
  • Schizophrenia

Secondary to substance abuse
Secondary to another medical condition

Personality disorder/Neurodevelopmental
Dementia (esp elderly with no past Hx of BAD and no gross mood disorder with only social disinhibition - consider frontal lobe pathology)/Delirium

31
Q

Classical symptoms in patients with elevated mood

A

Biological

  • decreased need for sleep which is not associated with fatigue
  • increased energy: initially goal-directed, can become repetitive in severe cases and rarely manic stupor; MSE psychomotor agitation –> may lead to physical exhaustion
  • increased appetite

Cognitive

  • increased self-esteem + grandiosity (idea, identity, plan)
  • poor concentration
  • accelerated thinking –> racing thoughts, PRESSURE OF SPEECH, FLIGHT OF IDEAS, jumping topics, talkative
  • impaired judgement –> costly indiscretions, disinhibitions, increased sexual acitivity, extravagant expenses, gambling, investment
  • impaired insight
  • LABILE MOOD

Psychotic symptoms

  • disordered thought form –> circumstantiality, tangentiality
  • delusions (in severe cases, not 100%) –> grandiose (elated mood), persecutory or referential (irritable mood) - often change in content over days
  • perceptual disturbance (not 100%) e.g. hyperacusis, mood congruent hallucinations in mania
  • first rank symptoms in 10-15%

Others: appearance may reflect mood e.g. bright coloured clothing, heavy makeup, untidy

32
Q

Ix for elevated mood

A

Similar to depressive mood

33
Q

Diagnostic criteria for hypomanic, manic and mixed affective episodes

A

Manic episode:

  1. abnormally persistently elevated, expansive or irritable mood and abnormally persistently increased energy LASTING AT LEAST 1 WEEK and present MOST OF THE DAY NEARLY EVERYDAY
  2. THREE OR MORE of the following
    - inflated self-esteem/grandiosity
    - decreased need for sleep
    - more talkative than usual 開籠雀
    - flight of ideas or feeling that thoughts are racing
    - poor concentration/distractibility
    - increased goal directed activity or psychomotor agitation
    - impaired judgement – risk taking behaviour 衝動 e.g. promiscuity, overspending, investments
  3. causes marked functional impairment and distress or necessitates hospitalisation or have psychotic features
  4. not due to SA or medical condition

Hypomanic

  1. Same as manic but for 4 CONSECUTIVE DAYS
  2. same as manic
  3. a/w clear change in functioning that is uncharacteristic of patient when not symptomatic
  4. NOT SEVERE ENOUGH TO CAUSE MARKED DISTRESS or TO REQUIRE HOSPITALISATION, no psychotic features (presence of psychosis = manic)
  5. not due to SA or medical condition

Mixed episode
- rapidly alternative manic and depressive symptoms e.g. overtalkative patient with profound depressive thoughts and suicidal ideation

34
Q

Bipolar affective disorder diagnosis 躁鬱症, definition of rapid cycling BAD

A

Suffer from episodes of depressed or elevated mood (mood swings)
- often with periods of normal mood in between

Bipolar I Disorder

  1. AT LEAST ONE MANIC EPISODE
  2. episodes not better explained by other psychotic disorders

Bipolar II Disorder

  1. AT LEAST ONE HYPOMANIC EPISODE and ONE MAJOR DEPRESSIVE EPISODE
  2. NEVER HAD MANIC EPISODE
  3. not better explained by other psychotic disorders
  4. symptoms of depression or frequent alternation causes significant distress and functional impairment

–> in OSCE, remember to say what the current episode is in Ddx!

Rapid cycling BAD
- >4 episodes of mood disorder occurring in 1 year

35
Q

Mania vs Schizophrenia - thought form, delusions, speech, biological, psychomotor function

A

Thought form
- circumstantiality, tangentiality, flight of ideas
vs
- loosening of association, thought blocking, neologisms

Delusions
- change quickly in content, mood congruent
vs
- bizarre, mood incongruent, delusion of passivity

Speech
- pressured speech
vs
- difficult or hesitant

Biological
- reduced need for sleep and hyperactivity
vs
- sleep less disturbed and less hyperactive

Psychomotor function
- agitation
vs
- agitation, catatonia, negative symptoms

36
Q

Bipolar disorders epidemiology - prevalence, lifetime risk, F:M ratio, which type is more common

A

Prevalence 1-6/1000
Lifetime risk <1%
F=M
Peak onset 25-30 (90% before age 50)

In 2007 BAD I 1.4%, BAD II 0.5%

37
Q

Bipolar disorders aetiology

A

GENETICS
- 65-80% heritability
- 1st degree relatives have 12% lifetime risk of bipolar disorder, 12% risk of recurrent depressive disorder, 12% risk of dysthymia or other mood disorders
(beware if first depressive episode and +FHx of BAD)
- 70% concordance in monozygotic twins
- CLOCK/PERIOD genes, mitochondrial genes

Environment
- childbirth

(mania a/w increased levels of monoamines)

38
Q

Bipolar disorders course and prognosis

A

RECURRING course

  • > 90% patients will have future episodes
  • frequency of episodes varies considerably
  • each episode lasts several months (around 3 mths avg)
  • recovery in between

5-15% rapid cycling (poorer prognosis)

39
Q

Management of bipolar disorder - initial assessment

A

Inpatient vs outpatient care
- inpatient: reckless behaviour (high risk), significant psychotic symptoms, impaired judgement, excessive psychomotor agitation with risk of self-injury/exhaustion, thoughts of harming self or others

Rapid mood fluctuations are common so need frequent monitoring

40
Q

Management of bipolar disorder - psychosocial

A

Social

  • advice on reducing negative consequences of manic symptoms
    e. g. avoid excessive stress/stimulation, decrease activities, delay important decisions, structured routine (sleep pattern)
  • education to recognise prodromal symptoms of mania with agreed plan of action

Psychotherapy

  • less commonly performed, may be used as support in bipolar depression
  • family therapy may help prevent relapse`
41
Q

Management of bipolar disorder - biological

A

Acute mania or hypomania

  • **Atypical antipsychotics - quetiapine, risperidone, olanzapine (rapid acting)
  • **Mood stabiliser - valproate
  • –> higher efficacy in rapid cycling BAD
  • –> can give high loading dose for rapid response
  • –> less effective than SGA but less side effects
  • –> S/E: hair loss, weight gain, teratogenicity
  • Li less effective in acute cases (delayed action)
  • BZD as short term symptomatic relief for behavioural disturbance
  • discontinue antidepressants

Acute bipolar depression

  • Atypical antipsychotics - quetiapine (metabolite has antidepressant effect), olanzapine + fluoxetine, lurasidone
  • Mood stabiliser - lamotrigine
  • Antidepressants given with mood stabiliser for manic cover
42
Q

Bipolar disorder continuation and maintenance therapy - when to consider relapse prevention

A

Continuation

  • acute phase Tx continued for several wks/months then gradually discontinued
  • uncertain about continuation in bipolar depression since may precipitate manic episode

Consider relapse prevention if: severe episode, repeated episodes (>3), significant impairment or risk, manic with another disorder mood episode, strong FHx

Maintenance

  • AT LEAST 2 YEARS, 0.4-0.8 mmol/L
  • LITHIUM first line (takes 2 wks to start working)
  • other choices: valproate, carbamazepine, lamotrigine (if majority depressive), olanzapine if psychotic
43
Q

Management of bipolar disorder recurrence - manic, depression

A

Manic

  • check compliance
  • take off antidepressants if present
  • switch class if due to intolerable S/E
  • consider combination therapy
  • if treatment resistant –> review Dx, consider ECT (if very severe mania), clozapine

Bipolar depression

  • give antidepressants
  • –> concerns of manic switch (5-10% risk)
  • –> SSRI preferred (AVOID TCA as higher risk of switch)
  • concurrent use of mood stabiliser to cover for switch
  • –> quetiapine, lamotrigine, olanzapine+fluoxetine
44
Q

Problems in management of BAD

A 
Rapid cycling cases
Treatment resistance 
Mono vs polypharmacy
Refractoriness after years of well being on maintenance or after discontinuation
Kindling phenomenon
Li rebound (need to monitor closely)
45
Q

Cyclothymia diagnosis

A

Usually begins in early adulthood, chronic course with instability of mood and mild symptoms

  1. AT LEAST 2 YEARS (1 YEAR in children/adolescents) with numerous periods of hypomanic symptoms and depressive symptoms that DO NOT MEET CRITERIA FOR MDD OR HYPOMANIA
  2. symptoms/mood present for AT LEAST HALF THE TIME and not been without the symptoms for more than 2 months
  3. criteria for MDD, manic and hypomanic episode never been met
  4. not better explained by psychotic disorders
  5. not attributable to SA or medical condition
  6. cause significant impairment and distress
46
Q

“Organic” causes of elevated mood

A

Most common:

  • opiates
  • stimulants (ICE, cocaine, hallucinogens)
  • alcohol
  • agitated depression

Others:

  • Cushing’s disease, hyperthyroidism
  • Neuro: SOL, infection e.g. HIV, trauma, MS, Huntington’s, temporal lobe epilepsy
  • VitB12 deficiency

Prescribed drugs e.g. steroids, antidepressants, DA agonists

Psychiatry (16 decks)

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