affective disorders Flashcards
what are mood disorders
disorders of mental status and function where altered mood is the core feature
term referring to states of depression and mania
commonest group of mental disorders
how can mood disorders present
can present as a 1y problem or as a consequence of other disorder or illness e.g. cancer, dementia, drug misuse, medical treatment
what are mood disorders often associated with
anxiety symptoms and anxiety disorders
focus on the depressive disorders when treating - the treatment of this often helps with the anxiety symptoms
what is depression - symptom
an emotion within the range of normal experience
describes a mood that can range from normal experience to severe life-threatening illness
systemic symptoms with similarities to fatigue and pain
typically considered as a form of sadness, not just an absence of happiness
depression as an illness
combination of symptoms and signs
can be recurrent
leading cause of disability worldwide
common
when does depression become abnormal
no clear and convenient division
generally:
- persistence of symptoms (at least 2 wks)
- pervasiveness of symptoms (most of the time)
- degree of impairment
- presence of specific symptoms or signs
3 areas of symptoms of depressive illness
psychological
physical
social
psychological symptoms of depression
CHANGES IN MOOD
- depression (may find diurnal variation)
- anxiety (inability to relax)
- perplexity (feeling of being overwhelmed, particularly in puerperal illness)
- anhedonia (inability to experience pleasure in things you normally would)
CHANGE IN THOUGHT CONTENT
- guilt
- hopelessness
- worthlessness
- any neurotic symptoms (hypochondriasis, agoraphobia, obsessions and compulsions, panic attacks)
- ideas of reference
- psychotic symptoms: delusions and hallucinations if severe
what are ideas of reference
an individual is thinking that in their environment something is happening that is specifically relating to them, even when there may be no evidence to suggest that’s true
physical symptoms of depression
CHANGE IN BODILY FUNCTION
- energy (fatigue)
- sleep (too much or disturbed)
- appetite (weight gain/loss)
- libido
- constipation
- pain
CHANGE IN PSYCHOMOTOR FUNCTIONING
- agitation
- retardation
social symptoms of depression
loss of interests
irritability
apathy
withdrawal, loss of confidence, indecisive
loss of concentration, registration and memory
define agitation
a state of restless overactivity, aimless or ineffective
define anhedonia
loss of ability to derive pleasure from experience
define apathy
loss of interest in own surroundings
define anxiety
an unpleasant emotion in which thoughts of apprehension or fear predominate
define retardation
a slowing of motor responses including speech
define stupor
a state of extreme retardation in which consciousness is intact
patient stops moving, speaking, eating and drinking
on recovery can describe clearly events which occurred whilst stuporose
depression ICD 10
symptoms last for at least 2 wks
no hypomanic or manic episodes in lifetime
not attributable to psychoactive substance use or organic mental disorder
if psychotic symptoms or stupor then severe depression w/ psychotic symptoms
- need to exclude other psychotic illnesses first e.g. Sz
depression ICD 10 - somatic syndrome
marked loss of interest/pleasure in activities that are normally pleasurable
lack of emotional reactions to events/activities that normally produce an emotional response
waking 2hrs before the normal time
depression worse in the morning
objective evidence of psychomotor agitation or retardation
marked loss of appetite
weight loss (5%+ of body weight in a month)
marked loss of libido
mild depression ICD 10
general criteria
at least 2 of:
- depressed mood that is abnormal for most of the day almost everyday for the past 2 weeks, largely uninfluenced by circumstances
- loss of interest/pleasure
- decreased energy/increased fatiguability
additional from this list to give at least 4:
- loss of confidence or self esteem
- unreasonable feelings of guilt/self reproach or excessive guilt
- recurrent thoughts of death by suicide or any suicidal behaviour
- decreased concentration
- agitation or retardation
- sleep disturbance of any sort
- change in appetite
moderate depression ICD 10
general criteria
at least 2 of:
- depressed mood that is abnormal for most of the day almost everyday for the past 2 weeks, largely uninfluenced by circumstances
- loss of interest/pleasure
- decreased energy/increased fatiguability
additional from this list to give at least 6:
- loss of confidence or self esteem
- unreasonable feelings of guilt/self reproach or excessive guilt
- recurrent thoughts of death by suicide or any suicidal behaviour
- decreased concentration
- agitation or retardation
- sleep disturbance of any sort
- change in appetite
severe depression ICD10
general criteria
all of:
- depressed mood that is abnormal for most of the day almost everyday for the past 2 weeks, largely uninfluenced by circumstances
- loss of interest/pleasure
- decreased energy/increased fatiguability
additional from this list to give at least 8:
- loss of confidence or self esteem
- unreasonable feelings of guilt/self reproach or excessive guilt
- recurrent thoughts of death by suicide or any suicidal behaviour
- decreased concentration
- agitation or retardation
- sleep disturbance of any sort
- change in appetite
postnatal depression
- when is risk of admission increased
- how common is it
- puerperal psychosis
increased risk of psychiatric admission in the 30 days following childbirth (risk for 24mths)
- 75% of women experience blues within 2wks
- 10% develop major depressive disorder within 3-6mths
- puerperal psychosis (1/500 deliveries, risk of recurrence of 1-3 w/ subsequent deliveries)
- no demonstrated associated w/ hormonal changes
depression - differential diagnosis
normal reaction to life event SAD dysthymia cyclothymia bipolar stroke, tumour, dementia hypothyroidism, Addison's, hyperparathyroidism infections - flu, infectious mononucleosis, hepatitis, HIV/AIDS drugs
treatments for depression
ANTIDEPRESSANTS
- selective serotonin reuptake inhibitors (SSRIs)
- tricyclic antidepressants (TCAs)
- monamine oxidase inhibitors
- others
PSYCHOLOGICAL
- CBT, IPT, individual dynamic psychotherapy, family therapy
PHYSICAL
- ECT, psychosurgery, DBS, VNS
measurement tools for depression and other psychiatric disorders
SCID - structured clinical interview for DSM disorders
SCAN - schedules for clinical assessment in neuropsychiatry
- structured ways of diagnosing depressive disorders and other psychiatric disorders
HRDA - hamilton depression rating scale
BDI-II - beck depression inventory II
HADS - hospital anxiety and depression scale
PHQ-9 - patient health questionnaire 9
- self-completed checklists to measure severity of depressive symptoms
what is mania
a mood that can range from near-normal experience to severe, life-threatening illness
rarely a symptom - often associated w/ grandiose ideas, disinhibition, loss of judgement; w/ similarities to the mental effects of stimulant drugs (AMPH, cocaine)
typically considered as a form of pathological, inappropriate elevated mood
when does mania become abnormal
no clear devision
generally emphasis is on:
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
ICD 10 - different manic disorders
hypomania mania w/o psychotic symptoms mania w/ psychotic symptoms other manic episodes unspecified manic episode
ICD classification of hypomania
- lesser degree of mania, no psychosis
- mild elevation of mood for several days on end
- increased energy and activity, marked feeling of wellbeing
- increased sociability, talkativeness, overfamiliarity, increased sexual energy, decreased need for sleep
- may be irritable
- concentration reduced, new interests, mild overspending
- not to the extent of severe disruption of work or social rejection
ICD 10 mania classification (w/ or w/o psychosis)
- 1 week, severe enough to disrupt ordinary work and social activities more or less completely
- elevated mood, increased energy, overactivity, pressure of speech, decreased need for sleep
- disinhibition
- grandiosity
- alteration of senses
- extravagant spending
- can be irritable rather than elated
differential diagnosis for manic/hypomanic episode
PSYCHIATRIC
- mixed affective state
- schizoaffective disorder
- schizophrenia
- cyclothymia
- ADHD
- drugs and alcohol
MEDICAL
- stroke, MS, tumour, epilepsy, AIDS, neurosyphilis
- endocrine - cushing’s, hyperthyroidism
- SLE
tools to measure mania
SCID
SCAN
YMRS - young mania rating scale - measure changes in severity of symptoms
treatment for mania
ANTIPSYCHOTICS
- olanzapine
- risperidone
- quetiapine
MOOD STABILISERS
- sodium valproate
- lamotrigene
- carbamazepine
- lithium
- ECT
ICD 10 diagnosis for bipolar affective disorder
consists of repeated (2+) episodes of depression and mania or hypomania
if no mania/hypomania then diagnosis is recurrent depression
if no depression the diagnosis is hypomania or bipolar disorder
in DSM 5 a single episode of mania is sufficient to diagnose bipolar disorder
epidemiology of mood disorder - why have there been difficulties and how have improvements been made
studies hindered by differences in diagnostic classification
greatest agreement for most severe forms
greater agreement as a result from improved case definition and funding for large scale community surveys
structured, standardised interview schedules have shown greater agreement
epidemiology of bipolar disorder - prevalence
difference between countries and gender
lifetime prevalence rate 0.7-1.6/100
point prevalance rate of mania 0.08-0.8
industrialised nations = non-industrialised
M=F
no differential prevalence according to income, occupation or educational status
prevalence consistently increased in 1st degree relatives
other forms of depression also more common
age of onset of bipolar disorder
mean age of onset = 21, unusual >30, some studies 1/3 onset <20
early onset (15-19) usually w/ +ve FHx
prevalence of depression
lifetime risk
lifetime prevalence rate 2.9-12/100
point prevalence rate of depression 3.7-7.7
lifetime risk for less severe manifestations - 20
rates for F>M (2:1)
age of onset of depression
highest risk from age 18-44 (median 25)
mean age of onset = 27
onset during old age isn’t unusual
prevalence of depression and financial, educational and relationship status
no overall association w/ socioeconomic status
MDD less common in those employed
MDD less common in those financially independent
association w/ lower educational attainment
stable marriage -vely associated w/ MDD
risk of depression in families
onset of depression
increased risk in 1st degree relatives where proband has MDD (3x) or BPD (2x)
twin studies: MZ vs DZ 27% vs 12%
onset of depression (1st episode) associated w/ XS of adverse life events
- exit events e.g. separations, losses
clinical course and outcome for major depression
typical episode lasts 4-6mths 54% recovered at 26wks 12% fail to recover ≥80% have further episodes (40% for those treated within 1y care) 15% die by suicide
clinical course and outcome for bipolar disorder/mania
typical manic episode lasts 1-3mths 60% recovered at 10wks 5% fail to recover 90% have further episodes 1/3 have poor outcome 1/3-1/4 have good outcome 10% die by suicide
