Affective Disorders Flashcards
A 35-year-old woman complains of low mood after the death of her husband in a
car accident. She does not speak and remains immobile for long periods. What is
the most likely diagnosis?
A. Seasonal affective disorder
B. Dysthymia
C. Atypical depression
D. Depressive stupor
E. Post-partum depression
D. Depressive stupor
Depressive stupor (D) is a rare presentation of depressive disorder. It can
be characterized by mutism and akinesis (lack of movement). Depression
with severe psychomotor retardation can lead to dehydration and pressure
sores and should be treated urgently. Seasonal affective disorder (A)
is characterized by the same psychiatric and biological symptoms that
depressive patients face but is associated with the change of season.
Depression will be worse in autumn and winter but will usually resolve in
the warmer months. Patients may experience a lack of energy, difficulty
waking in the mornings and overeating. Dysthymia (B) consists of
chronic low grade mood symptoms not amounting to a depressive illness.
Symptoms of atypical depression (C) are the opposite of what is experienced
in conventional depression. Patients may have symptoms such as weight
gain, increased appetite and hypersomnia. Post-partum depression (E)
indicates a depressive disorder that appears after giving birth.
A 45-year-old female has had persistent mild depressive features since her late
teens. She sometimes experiences loss of energy and tearfulness. She believes her
low mood began after she was abused by her step-father as a teenager. She has no
other symptoms. What is the most likely diagnosis?
A. Depressive episode
B. Recurrent depressive disorder
C. Dysthymia
D. Cyclothymia
E. Bipolar affective disorder
C. Dysthymia
Dysthymia (C) is defined as a chronic low grade mood disorder.
Symptoms are not severe enough for a diagnosis of depressive episode
although discrete episodes of depression may occur in addition. For a
diagnosis of a depressive episode (A), at least one core symptom (low
mood, anhedonia and anergia) must be demonstrated for a minimum
period of 2 weeks. The grade of depression can be classified as mild,
moderate or severe, depending on the number and severity of symptoms.
Recurrent depressive disorder (B) is associated with repeated episodes of
depression but between episodes the patient is euthymic. Cyclothymia (D)
is diagnosed where there is persistent instability of mood with a cycle of
low grade elevated and depressed mood. This can be differentiated from
bipolar affective disorder (E) which is characterized by discrete episodes
of mania or hypomania which may or may not be accompanied by
episodes of depression.
What is the most likely condition causing a depressive episode in a 76-year-old
man with a history of smoking and hypertension?
A. Multiple sclerosis
B. Parkinson’s disease
C. Huntington’s disease
D. Stroke
E. Spinal cord injury
D. Stroke
Stroke (D) is a major risk factor for the development of depression
and occurs in approximately 30 per cent of patients. The patient has
significant risk factors for cerebrovascular disease in terms of his longterm
history of smoking and hypertension. Multiple sclerosis (A) is
sometimes associated with depression or elevation of mood. Depression
is common in Parkinson’s disease (B) but may be missed due to the
overlap of symptoms. Depression may be the presenting complaint in
patients with Huntington’s disease (C), preceding all other symptoms of
this neurodegenerative condition. Disability due to spinal cord injury (E)
is associated with depression, which may stem from physical factors such
as chronic pain, or psychological factors such as loss of independence.
A 35-year-old female visits her GP complaining of low mood and weight loss. On
questioning she also experiences fatigue which is exacerbated by pain in her legs.
Blood tests reveal high potassium. Which of the following is most likely to cause
her depression?
A. Cushing’s disease
B. Addison’s disease
C. Hypothyroidism
D. Primary hyperparathyroidism
E. Premenstrual tension syndrome
B. Addison’s disease
The most likely cause is Addison’s disease (B), caused by adrenocortical
insufficiency. Symptoms include fatigue, joint/muscle pain in the legs, skin
tanning and hyponatraemia and hyperkalaemia. As well as the biological
symptoms of Addison’s disease, the condition may present as depression
with other manifestations of the disease appearing later. Cushing’s
disease (A) results in high circulating cortisol levels and is associated
with irritability, aggression and depression. Signs and symptoms of
Cushing’s include centripetal obesity, cervical fat pads, plethoric facies
and bruising. Signs and symptoms of hypothyroidism (C) include cold
intolerance, bradycardia, weight gain and depression. Hypothyroidism
can also mimic depression with symptoms such as forgetfulness, low
energy and an inability to concentrate. Primary hyperparathyroidism
(D) results in an increased production of parathyroid hormone as well
as an elevated blood calcium level, leading to the symptoms of moans
(depression), groans (abdominal symptoms), stones (kidney stones) and
bones (osteoporosis). Premenstrual tension syndrome (E) (menstrual cycle
disorders), is characterized by low mood, irritability and stress, associated
with alterations in the balance of sex hormones.
A 43-year-old female visits her GP complaining of a 4-week history of fever,
fatigue, low mood and lower back pain. She had visited China in the previous
month and mentioned she was drinking plenty of goat’s milk as this was the only
type of milk available. What is the most likely infective cause?
A. Hepatitis C
B. Infectious mononucleosis
C. Herpes simplex
D. Brucellosis
E. Syphilis
D. Brucellosis
Brucellosis (D) is a contagious zoonosis transmitted via unpasteurized
goat’s milk or contact with infected animals. The infection induces
fevers, headaches, fatigue, pain and depression. Hepatitis C (A) is a
viral infection transmitted by intravenous drug use, sexual contact and
exposure to infected blood products. As well as the generalized symptoms
of fever, appetite loss and nausea, depression can ensue. It is hypothesized
that the association with depression may be a due to a direct effect of
the virus on neuronal pathways. Infectious mononucleosis (B), a viral
disease caused by the Epstein–Barr virus, is characterized by symptoms
such as fever, sore throat, fatigue and depression. Herpes simplex (C)
infection may sometimes cause depressive symptoms. Syphilis (E) is a
sexually transmitted disease that may lead to neurological involvement.
Neurosyphilis is associated with several psychiatric conditions including
psychosis, dementia, mania and depression.
A 35-year-old woman has had a low mood for 2 months associated with fever,
fatigue and joint pain. She has a rash on her face which gets worse with exposure
to the sun. What is the most likely cause of her low mood?
A. Pancreatic cancer
B. Systemic lupus erythematosus (SLE)
C. Rheumatoid arthritis
D. Porphyria
E. Pellagra
B. Systemic lupus erythematosus (SLE)
SLE (B) is a multiorgan autoimmune disease associated with anti-nuclear
antibodies. The classic manifestation is joint pain and a butterfly shaped
malar rash on the face. Neurological involvement can cause headaches,
seizures and/or depression. Depression is commonly associated with
pancreatic cancer (A) and low mood is sometimes the first symptom
of this condition. Rheumatoid arthritis (C) is a chronic inflammatory
condition with primarily small joint involvement sometimes associated
with depression. Patients do not usually develop a rash. In porphyria (D)
there is a deficiency of enzymes in haemoglobin metabolism. Neurological
involvement can cause anxiety, hallucinations and/or depression. Patients
usually present with abdominal rather than joint pain. Pellagra (E) is caused
by deficiency of vitamin B3 (niacin). Sensitivity to sunlight predominates
the symptom cluster, which includes dementia and diarrhoea.
Which of the following is most likely to cause depression?
A. Methyldopa
B. Atenolol
C. Ibuprofen
D. Prednisolone
E. Amlodipine
A. Methyldopa
Corticosteroids (D) such as prednisolone, hydrocortisone and
dexamethasone are associated with mania but may also cause depression.
The side effects of methyldopa include depression, suicidal ideation and
nightmares. Some beta-blockers which cross the blood–brain barrier, such
as propranolol, may cause depression but atenolol (B) does not. Ibuprofen
(C) is a non-steroidal anti-inflammatory drug and is rarely associated
with depression. Amlodipine (E) is a calcium-channel blocker, indicated
for the treatment of hypertension. Depression is an occasional side effect
of calcium channel blockers.
A 25-year-old woman visits her GP complaining of low mood, fatigue and weight
gain. She is observed to be wearing several layers despite its being a warm day.
On examination she is found to have a pulse rate of 55. What is the most likely
underlying diagnosis?
A. Cushing’s disease
B. Hypocalcaemia
C. Addison’s disease
D. Hypothyroidism
E. Diabetes mellitus
D. Hypothyroidism
Hypothyroidism is associated with fatigue, weight gain and cold
intolerance. On examination the patient may be bradycardic and have
slow-relaxing reflexes. Low circulating thyroxine is associated with
depression and should be further investigated with thyroid function tests
(D). Cushing’s disease (A) may be associated with depression (and other
psychiatric disorders) and is characterized by centripetal obesity, cervical
fat pads, plethoric complexion and bruising, but not cold intolerance
or bradycardia. Hypocalcaemia (B) is rarely associated with depression.
Addison’s disease (C) can be associated with depression but not cold
intolerance or bradycardia. Diabetes mellitus (E) can be associated with
depression but would usually be associated with weight loss in a woman
of this age.
A 45-year-old woman is taken to see a GP by her husband. He mentions that
his wife has been irritable for the past 2 weeks. She is not sleeping well and on
examination she has pressure of speech and mild elation. She is not hallucinating
and there is no evidence of delusional thinking. What is the most likely diagnosis?
A. Hypomania
B. Mania
C. Cyclothymia
D. Agitated depression
E. Bipolar affective disorder
A. Hypomania
Hypomania (A) is associated with elevated mood (elation) and/or irritability
which interferes with activities of daily living but is not severely disruptive
or associated with psychotic symptoms. Mania (B) occurs over a time-course
of at least a week and is defined by a significantly elevated mood which
has a noticeable effect on work and social activities and is often associated
with psychotic features (mood-congruent delusions and/or hallucinations).
Cyclothymia (C) is persistent instability of mood, not a discrete episode.
Agitated depression (D) may present with an irritable mood and anxiety,
but not elation. A diagnosis of bipolar affective disorder (E) can be made
if there has been a history of two more affective episodes at least one of
which must include elevated mood.
A 25-year-old man with bipolar disorder is seen on the psychiatric ward by a
medical student. Taking a history is not easy, as the patient continually wants to
speak. The patient is difficult to interrupt. What feature of mania is demonstrated
by this patient?
A. Elevated mood
B. Poor concentration
C. Flight of ideas
D. Pressure of speech
E. Impaired judgement
D. Pressure of speech
Pressure of speech (D) in mania is the result of pressure of thought.
The speech of a patient become increasingly difficult to interrupt as the
patient wants to portray all of his/her thoughts. Speech is rapid and is
worse with increased severity of mania. Manic patients may have an
elevated mood (A) which may manifest as being over-cheerful or irritable.
Manic patients find it difficult to maintain focus on one thing which
leads to poor concentration (B). Flight of ideas (C) occurs when patients
thoughts move from topic to topic, although there is usually a connection
between the ideas. Mania often leads to impaired judgement (E).
A 25-year-old man is seen in accident and emergency with an elevated mood and
mild signs of meningism. He has a low grade fever and a bulls eye rash is seen on
his left lower arm. What is the most likely diagnosis?
A. HIV
B. Lyme disease
C. Encephalitis
D. Neurosyphilis
E. Meningococcal septicaemia
B. Lyme disease
Lyme disease (B) is an infectious disease caused by bacteria belonging
to the genus Borrelia, transmitted to humans via tick bites. Early
symptoms will include fever, headache, fatigue and mood changes.
An expanding rash known as erythema chronicum migrans (bulls eye
rash) appears at the site of the tick bite and is strongly suggestive
of the diagnosis. People with HIV (A) infection may develop manic
symptoms. Symptoms of encephalitis (C) may include headache, fever
and confusion, hallucinations, cognitive decline and mania. Neurosyphilis
(D) is a sexually transmitted disease, associated with several psychiatric
conditions including psychosis, mania and depression. People with
meningococcal septicaemia (E) are acutely unwell and have a generalized
erythematous rash.
According to the International Classification of Diseases, which of the following is
a core feature of depression?
A. Anergia
B. Diurnal variation of mood
C. Loss of appetite
D. Suicidal ideation
E. Waking early
A. Anergia
The three core features of depression are anergia (loss of energy) (A)
anhedonia (loss of enjoyment) and low mood. At least one feature must
be present for at least 2 weeks. Biological features include change in
appetite (C) and weight, change in sleep pattern (classically waking early
(E)), loss of libido and diurnal variation of mood (B), where the mood
is worse in the morning. Psychological features of depression include
feelings of guilt, hopelessness, and suicidal ideation (D).
Which of the following antidepressants is not a serotonin specific reuptake
inhibitor (SSRI)?
A. Citalopram
B. Fluoxetine
C. Mirtazapine
D. Paroxetine
E. Sertraline
C. Mirtazapine
Mirtazapine (c) is a noradrenergic and specific serotinergic antidepressant
with a tetracyclic structure. Mirtazapine is often used second line. It
differs from SSRIs (A, B, D, E) in that it does not usually cause nausea or
weight loss and induces sleep.
Which of the following is a significant risk factor for depression?
A. Education to degree level
B. Male gender
C. Obesity
D. Older age
E. Social isolation
E. Social isolation
Risk factors for depression include having a family history, female gender
(B), childhood abuse, poverty and social isolation (E). Being older (D) does
not increase risk of depression and higher education may be protective
(A). Obesity (C) is a risk factor for dementia but not depression as such.
Which of the following statements is most consistent with a diagnosis of psychotic
depression?
A. The bank has said I’m bankrupt and are going to sell all my clothes
B. I have developed a special computer program which will cure people of
depression
C. The Queen is hiding in the police station and controls my movements
through the radio
D. I’m worried I have got cancer and will die soon
E. The prime minister was on the radio last night and told the country
how much he was in love with me
A. The bank has said I’m bankrupt and are going to sell all my clothes
Psychosis is an infrequent complication of depression although may be
seen quite commonly in psychiatric settings. Delusions in depression
are usually ‘mood congruent’, i.e. are understandable in the context of
being depressed. Examples include delusions of poverty or low self-worth
(A). Delusions in mania are frequently grandiose (B). Bizarre delusions,
especially with passivity (C) or thought alienation, are suggestive of
schizophrenia. Option (E) is suggestive of de Clérembault’s syndrome
which usually occurs in mania or schizophrenia, rarely depression. It
is important to distinguish delusions from non-delusional ideation (D)
which is not held with subjective certainty.
