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Year 3 Psychiatry > Affective Disorders > Flashcards

Affective Disorders Flashcards

1
Q

What is the term for normal mood?

A

Euthymia

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2
Q

Name three disorders of mood.

A

Depression
Hypomania
Mania

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3
Q

What is a disorder of mood?

A

A pervasive change in mood which impacts on daily life

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4
Q

Name two subsyndromal mood disorders.

A

Dysthymia

Cyclothymia (mood goes up and down but doesn’t meet BPD threshold)

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5
Q

What is the difference between bipolar 1 and bipolar 2 disorder?

A

BPD1 = manic periods

BPD2 = no mania - hypomanic periods.

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6
Q

What would this be classified as?

Depressed mood / decreased interest
- most of the day, nearly every day
- more than 2 weeks

Can also have reduced energy, difficulty concentrating, feelings of worthlessness, guilt, hopelessness, death/suicidal thoughts, changes in appetite/sleep, psychomotor agitation or retardation.

Can get
- early morning waking
- diurnal variation with worse Sx in the morning
- loss of libido
- loss of emotional reactivity
- mild anxiety Sx

A

Depressive episode

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7
Q

How do you differentiate between mild, moderate and severe depressive episodes?

A

Number and intensity of depressive symptoms

Impact on function on daily life & social

Presence/absence of psychotic features

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8
Q

What are the categories or depressive episode?

A

Mild

Moderate with/without psychosis

Severe with/without psychosis

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9
Q

What possible differentials are there for depressive episodes?

A

Anaemia
Anxiety
ADHD
BPD
Chronic fatigue
Diabetes
Fibromyalgia
Hypercalcaemia (can cause lethargy, low mood, memory loss and instability)
Hypothyroidism
PTSD
PMDD
Vit D Deficiency

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10
Q

When thinking about a diagnosis in psychiatry - what is the pyramid of symptoms you should consider?

A

Organic causes
Primary psychotic disorders
Mood disorders
Stress-related, anxiety and OCDs
Personality disorders

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11
Q

What is the average age of onset of depressive disorders?

A

Bi-modal

Mid-20s
40-60s

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12
Q

How do life events cause depression on a neurochemical level?

A

Stressful events => raised cortisol = abnormal HPAA = effects on the 5HT and Nor system = depressive episode.

Often tied in with a genetic vulnerability to increased levels of cortisol

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13
Q

What are the 4 Ps you can use when formulating a cause of a psychiatric disorder?

A

Predisposing factors
Precipitating factors (stressor)
Perpetuating factors
Protective factors

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14
Q

What basic measures can you suggest for depression?

A

Psychoeducation about depression

Sleep hygiene
Exercise benefits
Diet
Avoiding alcohol

Social interventions (social prescribing) and active monitoring

Rx - SSRIs and CBT with close monitoring

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15
Q

How does CBT benefit Ps with depressive disorders?

A

Behavioural activation (encouraging more positive activities)

and

Cognitive restructuring (trying to replace negative automatic thoughts with more realistic thoughts)

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16
Q

Name two good SSRIs for depressive disorders.

A

Sertraline

Citalopram

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17
Q

How are the following depressions managed?
- All depressive Ps
- Mild/mod depression
- Mild/mod depression not responding to Rx
- Severe / Complex depression

A

All depressions = psychoeducation, sleep hygiene and active monitoring

Mild-mod = low intensity psychosocial and low intensity psychology. Consider medication if no improvement

Mild-mod not responding to Rx = ADs and high intensity psychology

Severe / Complex = ADs, high intensity psychology + consider specialist referral, crisis team or admission

ALL depression = needs biopsychosocial approach

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18
Q

If a P with depressive mood failed to respond to CBT and SSRIs and appeared to worsen with evidence of self-neglect - what should you do?

A

Refer for urgent assessment by community health team / or referral to specialist services

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19
Q

When should you refer to specialist services for depression?

A

Failure to respond to Rx
High risk to self or others
Uncertainty about diagnosis
If high intensity psychological therapy needed

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20
Q

If patients develop psychosis as part of a severe depressive episode - what type of medications can they be given?

A

Antipsychotics

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21
Q

What type of hallucinations do patients with schizophrenia tend to get?

A

3rd person hallucinations

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22
Q

How can you identify a P with depression who has psychosis?

A

Can have
- delusions of guilt, poverty or illness
- hallucinations that are often second persons, derogatory
- often has psychomotor agitation or retardation

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23
Q

How is severe depression managed?

A

General psychosocial support
Can be admitted
Meds = ADs and APs
Psychological therapies
ECT

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24
Q

When is ECT used?

A

Severe depressive episodes when urgent response is needed.
- e.g. not eating or drinking, high risk of suicide, not responding to Rx

Also for prolonged and severe manic episodes
Catatonia

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25
Q

What is the CRHTT?

A

Crisis Resolution and Home Treatment Team

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26
Q

What percentage of Ps who experience a depressive episode will go onto have a further episode?

A

80%

Psychotic symptoms can be associated with poorer outcomes

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27
Q

How long should treatment be maintained for in depression?

A

Minimum 6m - longer if severe/recurrent

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28
Q

What can help prevent a further episode of depression?

A
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29
Q

What is the difference between mania and hypomania?

A

Is milder than mania.

Hypomania does not cause marked social or occupational dysfunction.

Do not have delusions or hallucinations with hypomania

Hypomania does not require hospital admission.

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30
Q

What can be seen in mania?

A

Elevated / irritable mood
Inc energy
Rapid / pressured speech
Flight of ideas
Increased self-esteem / grandiosity
Decreased need for sleep
Distractability
Impulsive / reckless behaviour

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31
Q

What is the average age of onset of bipolar disorder?

A

Before 25 - average age 18

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32
Q

If a P is on ADs and has a manic episode, what should you do?

A

STOP the ADs.

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33
Q

What is the best pharmacological Rx for mania?

A

STOP any ADs

Start Antipsychotics

If inadequate response - add lithium or sodium valproate

Benzodiazapines can also be used for reducing overactivity

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34
Q

What do you need to remember about sodium valproate?

A

Is tetraogenic - so dont prescribe to Fs of childbearing age

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35
Q

How do you reduce the risk of relapse in patients with bipolar disorder?

A

Maintain pharmacological Rx

Psychological therapies

Social support

Minimise substance use

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36
Q

What is the outlook for Ps with bipolar disorder?

A

Ps with BPD are symptomatic almost half their lives.

Single manic episodes are RARE - 90% will have further episodes - usually more depressive than manic.

Is reduced life expectancy - dec by 13yr M and 9 yr F

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37
Q

What is a chronic low mood - where the P spends much time feeling low, below euthymia, but not sufficiently to be labelled as a depressive episode?

A

Dysthymia

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38
Q

How long can depression last if
(a) treated
(b) untreated?

A

Treated = >6m

Untreated = 2-3m

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39
Q

What percentage of Ps who have a depressive episode will go onto have a further episode?

A

80%

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40
Q

What are the diagnostic features of a depressive episode?

A

Low mood, dec energy & anhedonia for most of the day, most days for over 2w.

Must not be a major life event occurring.

Can have diurnal variation

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41
Q

What are the main features of depression?

A
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42
Q

What are the biological features of depression?

A
  • Appetite
  • Sleep
  • Libido
  • Activity
43
Q

What are the psychological features of depression?

A
  • Cognition
  • Self-esteem
  • Negative thinking
  • Anxiety
44
Q

What other features can you sometimes get with depression?

A

Dissociation
Obsessions
Phobias
Physical Sx

45
Q

What psychotic features may you get in severe depression?

A

Delusions
Hallucinations (often 2nd person)

46
Q

Melancholic depression is a severe type of depression. What features can you usually identify in these Ps?

A
47
Q

What symptoms can you see in a P with atypical depression?

A
48
Q

How can you differentiate between depression and dementia?

A

In-depth cognitive testing can differentiate

Cognitive impairment due to depression should improve with Rx for depression

49
Q

How are depression and dementia linked?

A

Depression can be a x2 RF for dementia

Can also be a prodrome for dementia

Finally depression is common in Ps with dementia

50
Q

Which biological conditions may cause mood Sx?

A

Brain disease

Endocrine disorders

Some infections - inc HIV

51
Q

Have they found a single gene that is linked to depression?

A

No - thought multiple genes have a small effect

Is x3 inc risk in 1st degree relatives. Mod heritability in twin studies.

52
Q

What is the strongest theory for the cause of depression?

A

Monoamine theory

Reserpine depletes monoamines - found to cause depression

Tricyclics and MOAIs inc monoamines and are effective at treating depression.

53
Q

What are the problems of the monoamine theory?

A
54
Q

What happens to the HPAA when a P is under stress?

A

Hypothalamus stimulated to release CRH -> pituitary gland to release ACTH -> adrenal glands to release cortisol (then negative feedback on the hypothalamus).

Increased plasma cortisol is associated with impaired cognitive function.

55
Q

Why should you be suspicious of first manic episode in older Ps?

A

Because bipolar often presents before 25 (ave = 18). In older Ps - first onset of mania is likely to have an organic cause.

56
Q

What is mixed affective state?

A

Ps have symptoms of both mania and depression - are very overactive and overtalkative, but at the same time are experiencing a great deal of negative thinking - can be difficult to diagnose.

57
Q

What are the clinical features of mania?

A

Needs significant impairment in function

58
Q

More severe mania can be associated with psychosis. What symptoms are seen in psychosis?

A

Delusions (mood-congruent)

Hallucinations - often mood-congruent auditory

59
Q

How does hypomania differ from mania?

A

Similar to mania but no psychotic features and NO marked impairment in social or occupational function.

60
Q

How is life expectancy affected by bipolar disorder?

A

Is reduced by 13 years for M and 9 years for F

61
Q

What are the risk factors for bipolar disorder?

A
62
Q

What is the heritable risk for bipolar disorder?

A

Approximately 70%

63
Q

What is the general management approach to depression?

A

+ antipsychotic meds for psychotic Sx

64
Q

What is discussed in psychoeducation?

A

Lifestyle factors and their impact

65
Q

What are the low intensity and high intensity psychological interventions for depression?

A
66
Q

How do antidepressant medications work?

A

Act by increasing neurotransmitter levels in the brain

67
Q

Which drug class is the first line choice in depression?

How long must they be taken for as a minimum?

A

SSRIs

Delayed onset of therapeutic effect

Continue for at least 6 months minimum

68
Q

What drug classes exist for the treatment of depression?

A

SSRIs
SNRIs
Tricyclic antidepressants
Monoamine oxidase inhibitors
Monoamine receptor antagonists

69
Q

How do SSRIs work?

A

Increase amount of serotonin in the synapse by blocking its reuptake

70
Q

What are the SEs of SSRIs?

Which ones are really important to remember?

A

Important = hyponatremia (esp older Ps)
Interaction with NSAIDs = can inc risk of upper GI bleeds

71
Q

How do SNRIs work?

A

Increase amounts of serotonin AND noradrenaline by blocking their reuptake

72
Q

What cautions do you need to know about SNRIs?

A

Are more toxic in OD than SSRIs

Caution in Ps with hypertension - they may increase blood pressure and heart rate due to increased Noradrenaline

73
Q

How do tricyclic antidepressants work?

A

Block monoamine reuptake - mostly serotonin and noradrenaline, less effect on dopamine

74
Q

What is the problem with TCAs?

A

More toxic and dangerous than SSRIs, esp in OD.
Also problematic interactions with other medications.
Avoid in the elderly especially

Cause sedation, confusion, loss of coordination, anticholinergic and cardiotoxic in OD

75
Q

How do MAOIs work?

A

Prevent breakdown of monoamines by the enzyme monoamine oxidase - increased 5HT, Nor and dopamine content of the brain

76
Q

What is the cheese reaction?

A

MOAIs block metabolism of tyrosine in cheese -> sympathomimetic effects => HT crisis and intracranial haemorrhage

77
Q

What are the side effects of mirtazapine?

A

Sedation
Weight gain

78
Q
A
79
Q

What is the link between antidepressants and increased suicidal thoughts?

A

Evidence that both SSRIs and SNRIs can increase suicidal thoughts in the first few weeks of taking them.

Esp in children, adolescents and young adults

Actively monitor

80
Q

All ADs have the potential to cause hyponatreamia - SSRIs being the worst. Why is hyponatreamia problematic in Ps?

A

It can cause delirium, seizures and it is potentially fatal.

Is more common in older Ps - esp with other drug interactions.

81
Q

You must decrease antidepressants slowly rather than suddenly stopping them due to SEs. What are these SEs?

A
82
Q

Why do we think Ps get withdrawal Sx from ADs?

A
83
Q

What is lithium used for?

A

Mood stabilisation
Needs monitoring as narrow therapeutic window!

84
Q

Do we understand how lithium works?

A

Not really

85
Q

What are the potential adverse effects of lithium?

A

Tremor and dry mouth are the most common

86
Q

How often should lithium be monitored?

A

Frequently when establishing the dose
Then 6 monthly

87
Q

What do you need to check when monitoring lithium?

A

Lithium levels
Renal function - U&Es, eGFR
Thyroid function tests

88
Q

When is ECT utilised?

A

When life is threatened (not eating / drinking, very intense suicidal ideation)

When there is lack of response to other treatments

89
Q

How is bipolar disorder managed?

A

Treat the acute mood episode
Give mood stabilisers
Work on preventing relapse

90
Q

What pharmacological management can be used for acute mania?

A

STOP ADs
Give antipsychotic if not already on
If on - check compliance

Can use benzos as a an adjunctive to reduce overactivity and restore sleep

91
Q

What is the pharmacological Tx for maintenance in BPD?

A

Lithium
Sodium valproate can also be used.

Both are slower to act than antipsychotics

92
Q

How is depression managed in bipolar disorder?

A
93
Q

What treatments are being proposed for the future treatment of affective disorders?

A

Ketamine
Psilocybin

94
Q

1) Which condition most typically presents in early adulthood rather than at other life stages?
a. Bipolar disorder
b. Dysthymia
c. Unipolar depression
d. Generalised anxiety disorder
e. Post traumatic stress disorder

A

Correct answer: a. Bipolar disorder. All of the other conditions can have an onset in early adult life, but also more often at other life stages. The first mood episode is bipolar disorder usually in early adulthood, e.g. age 18-25.

95
Q

2) A patient is admitted to the acute psychiatric ward with a 3 week history of increasingly elated mood, rapid and pressured speech and impulsive behaviour. They are irritable and sleeping less than they usually do. They recently experienced a difficult end to their relationship with their partner. They have been working from home but their boss contacted their family to raise concerns about inappropriate behaviour in online meetings. Their family do not feel able to support them at home and they are admitted to the ward following an assessment by the Crisis Resolution and Home Treatment Team. There are no delusions or hallucinations and a urine drug screen and medical assessment do not reveal a cause. Based on the available information, what is the most likely diagnosis?
a. Adjustment disorder
b. Cyclothymia
c. Dysthymia
d. Hypomanic episode
e. Manic episode

A

Correct answer: e. Manic episode. The patient has clinical features of a manic episode which have caused significant disruption to their life and necessitated admission to hospital. Psychotic symptoms are not required for a diagnosis of mania. In hypomania, there is not marked social or occupational dysfunction and the patient does not require admission to hospital. The symptoms are too severe and specific to be an adjustment disorder or cyclothymia. Dysthymia refers to chronic subsyndromal depressive symptoms.

96
Q

3) A patient on the psychiatric ward has severe depression and has been having ECT. Which factor would most likely have indicated the need for this treatment?
a. Agitation and aggression
b. Not eating and drinking for several days
c. Psychotic symptoms which are causing significant distress
d. Refusing antidepressant medication
e. Self-neglect

A

Correct answer: b. Not eating and drinking. The main indications for ECT are severe depression where urgent response to treatment is needed, or non-response to other treatments. When a patient with depression is not eating and drinking, this can become life-threatening and therefore urgent response to treatment is needed. Another urgent situation is when there is high suicide risk. ECT would not be used to treat agitation and aggression specifically, because other strategies are available (e.g. supportive interventions, medication). Psychotic symptoms in and of themselves are not an indication for ECT, although if psychotic and depressive symptoms are severe, persistent and non-responsive to treatment, ECT may be considered. If a patient is refusing medication, other strategies are available, and this is not a specific indication for ECT. Again, self-neglect would not be a specific indication for ECT, unless severe and associated with dangerous reduction of oral intake.

97
Q

4) Patients who have ECT must be monitored over the course of their treatment. This includes monitoring their response to treatment in terms of their affective symptoms. Which other specific symptoms must be assessed?
a. Anxiety
b. Behavioural
c. Cognitive
d. Extrapyramidal
e. Sleep and appetite

A

Answer: b. Cognitive. It is common for people to experience cognitive symptoms after ECT; these symptoms usually relate to short term memory and improve over time. It is something that must be monitored with formal cognitive testing as well as asking the patient about the subjective experience of any cognitive symptoms.

98
Q

5) A 30 year old patient has been admitted with a manic episode. A thorough assessment has excluded medical or substance-related causes. They are agitated and have been aggressive. Which regular medication would be most appropriate as first line in their treatment plan?
a. Olanzapine 10mg im od
b. Olanzapine 10 mg po od
c. Haloperidol 5mg im tds
d. Lorazepam 1mg im bd
e. Lorazepam 1mg po bd

A

Correct answer: a) Olanzapine 10mg po od. Antipsychotic medication is the first line medical treatment for a manic episode. If a patient is willing to take medication orally, then i.m. medication is not appropriate. Haloperidol and lorazepam are sometimes used as rapid tranquillization but would not be prescribed regularly for im administration. Some people with mania are prescribed benzodiazepines regularly to reduce overactivity, but antipsychotics are first line treatment in mania.

99
Q

6) A patient with depression is experiencing psychosis. Which type of hallucination are they most likely to experience?
a. Olfactory hallucinations of unpleasant smells
b. Second person auditory hallucinations, derogatory
c. Third person auditory hallucinations, running commentary
d. Tactile hallucinations of insects crawling
e. Unpleasant visual hallucinations

A

Correct answer: b. second person auditory hallucinations which are derogatory are more common than other types of auditory hallucinations in psychotic depression. Hallucinations in other modalities are uncommon.

100
Q

7) A 22 year old has experienced a manic episode. How likely are they to experience another affective episode in their life?
a. 15%
b. 30%
c. 45%
d. 65%
e. 90%

A

Correct answer: e. 90%. These figures can only be an estimate, but a very high proportion of people who have a manic episode will experience further mood episodes during their life. NB: bipolar disorder is diagnosed even if the only affective episode at that point is a manic episode.

101
Q

8) In CBT for depression, patients are encouraged to plan and engage in activities that they enjoy and that are satisfying. What is this approach known as?
a. Behavioural activation
b. Cognitive behavioural processing
c. Dynamic therapy
d. Social prescribing
e. Action formation

A

Correct answer: a. behavioural activation. The other options are non-specific terms and do not apply here.

102
Q

9) In CBT for depression, patients are supported to identify negative automatic thoughts and replace them with more realistic thoughts. What is this approach to therapy known as?
a. Cognitive restructuring
b. Remodelling
c. Socratic questioning
d. Thought interference
e. Transference

A

Correct answer: a. Cognitive restructuring. Remodelling is a non-specific term in this context. Socratic questioning is a technique that is often used in CBT but is not specific to this scenario. Thought interference is a psychotic symptom. Transference refers to the redirection of a patient’s feelings about another person to the therapist.

103
Q

10) Which symptom(s) (other than overt elation/euphoria) is seen as representative of mood disturbance in mania?
a. Anxiety
b. Grandiose delusions
c. Obsessional thinking
d. Hallucinations
e. Irritability

A

Correct answer: d. Irritability. Mood disturbance in mania often presents as irritability. Anxiety, grandiose delusions, obsessional thinking and hallucinations may be present but are associated with other aspects of the mental state. This is important because it is the disturbance of mood that is central to mania.

Year 3 Psychiatry (11 decks)

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