Affective Disorders Flashcards
What are mood disorders?
- disorders of mental status and function where altered mood is the (or a) core feature
- a term referring to states of depression and of elevated mood - mania
- the commonest group of mental disorders
- recognition and management forms a large component of activities for GPs, psychiatrists and clinical psychologists
What are the classification systems for mood disorders?
ICD-10
- International Classification of Disease 10th Edition – World Health Organisation
DSM-5
- Diagnostic and Statistical Manual of Mental Disorders 5th Edition – American Psychiatric Association
What is depression?
Symptom
- An emotion within the range of normal experience
- describe a state of feeling, or mood, that can range from normal experience to severe, life-threatening illness
- a ‘systemic’ symptom (complaint) with similarities to fatigue and pain
- typically considered as a form of sadness, not just an absence of happiness
Syndrome
- A constellation of symptoms and signs
Recurrent illness
- Recurrent depressive disorder
When does depression become a problem?
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
What are the psychological symptoms of depression?
CHANGE IN MOOD
- DEPRESSION May find diurnal variation
- ANXIETY inability to relax
- PERPLEXITY particularly in Puerperal illness
- ANHEDONIA pleasure in no activities
CHANGE IN THOUGHT CONTENT
- GUILT
- HOPELESSNESS
- WORTHLESSNESS
- ANY NEUROTIC SYMPOMATOLOGY e.g.. Hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks.
- IDEAS OF REFERENCE
- DELUSIONS AND HALLUCINATIONS if severe
What are the physical symptoms of depression?
CHANGE IN BODILY FUNCTION
- ENERGY Fatigue
- SLEEP
- APPETITE weight loss
- LIBIDO
- CONSTIPATION
- PAIN
CHANGE IN PSYCHOMOTOR FUNCTIONING
- AGITATION
- RETARDATION
What are the social symptoms of depression?
- LOSS OF INTERESTS
- IRRITABILITY
- APATHY
- WITHDRAWAL, LOSS OF CONFIDENCE, INDECISIVE
- LOSS OF CONCENTRATION, REGISTRATION & MEMORY
What is agitation?
a state of restless overactivity, aimless or ineffective
What is anhedonia?
loss of ability to derive please from experience
What is apathy?
loss of interest in own surroundings
What is anxiety?
An unpleasant emotion in which thoughts of apprehension or fear predominate
What is depression?
An unpleasant emotion in which sadness or unhappiness predominates
What is retardation?
A slowing of motor responses including speech
What is stupor?
A state of extreme retardation in which consciousness is intact. \
The patient stops moving, speaking, eating and drinking.
On recovery can describe clearly events which occurred whilst stuporose.
According to the ICD 10;
how long must a depressive episode last at least to be classed as depression?
2 weeks
According to the ICD 10;
How many manic or hypomanic episodes can a patient have for a classification of depression?
No manic or hypomanic episodes ever in their lifetime
According to the ICD 10;
Can depression be attributed to psychoactive substances?
No; it for the ICD 10
depression is not at
Not attributable to psychoactive substance use or organic mental disorder
According to the ICD 10;
Can depression be attributed to psychoactive substances?
No; it for the ICD 10
depression is not at
Not attributable to psychoactive substance use or organic mental disorder
According to the ICD 10;
if there are psychotic symptoms or stupor then what level of depression is it?
What do you need to exclude?
Severe depression
Need to exclude other psychotic illnesses like schizophrenia
According to the ICD 10;
What are the somatic syndromes of depression?
- Marked loss of interest or pleasure in activities that are normally pleasurable
- lack of emotional reactions to events or activities that normally produce an emotional response
- waking 2 hrs 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
According to the ICD 10;
What are the criteria for mild depression?
At least 2 of:
- Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
- Loss of interest or pleasure
- Decreased energy or increased fatigability
Addition from this list to give at least 4:
- Loss of confidence or self-esteem
- Unreasonable feelings of guilt or 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
According to the ICD 10;
What are the criteria for moderate depression?
At least 2 of:
- Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
- Loss of interest or pleasure
- Decreased energy or increased fatigability
Addition from this list to give at least 6:
- Loss of confidence or self-esteem
- Unreasonable feelings of guilt or 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
According to the ICD 10;
What are the criteria for severe depression?
All 3:
- Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
- Loss of interest or pleasure
- Decreased energy or increased fatigability
Addition from this list to give at least 8:
- Loss of confidence or self-esteem
- Unreasonable feelings of guilt or 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
What is postnatal depression?
- increased risk of psychiatric admission in the 30 days following childbirth (risk for 24m)
- 75% of women experience ‘blues’ within 2 weeks
- 10% of women develop MDD within 3-6 months
- ‘puerperal psychosis’ - 1 in 500 deliveries with a risk of recurrence of 1-3 with subsequent deliveries
- despite intuitive appeal - no association with hormonal changes has ever been demonstrated
What is the differential diagnosis of depression?
- Normal reaction to life event
- SAD
- Dysthymia
- Cyclothymia
- Bipolar
- Stroke, tumour, dementia
- Hypothyroidism, Addison’s, Hyperparathyroidism
- Infections – Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
- Drugs
What are the antidepressant treatments for depression?
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Tricyclic antidepressants (TCAs)
- Monamine Oxidase Inhibitors
- Other antidepressants
What are the psychological treatments for depression?
- CBT
- IPT
- Individual dynamic psychotherapy
- family therapy
What are the physical treatments for depression?
- ECT
- Psychosurgery
- DBS
- VNS
What are the measurement tools for depression?
- SCID (Structured Clinical Interview for DSM disorders)
- SCAN (Schedules for Clinical Assessment in Neuropsychiatry)
- HDRS (Hamilton Depression Rating Scale)
- BDI-II (Beck Depression Inventory II)
- HADS (Hospital Anxiety and Depression Scale)
- PHQ-9 (Patient Health Questionnaire 9)
What is mania?
- a term to describe a state of feeling, or mood, that can range from near-normal experience to severe, life-threatening illness
- rarely a symptom, often associated with grandiose ideas, disinhibition, loss of judgment; with similarities to the mental effects of stimulant drugs (AMPH, cocaine)
- typically considered as a form of pathological, inappropriate elevated mood
According to the ICD 10;
mania is rarely a symptom, often associated with grandiose ideas, disinhibition, loss of judgment; with similarities to the mental effects of stimulant drugs (AMPH, cocaine)
typically considered as a form of pathological, inappropriate elevated mood
Which 4 factors does psychiatry place emphasis on?
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
According to the ICD 10;
What are the different types of mania?
- F30.0 Hypomania
- F30.1 Mania without psychotic symptoms
- F30.2 Mania with psychotic symptoms
- F30.8 Other Manic episodes
- F30.8 Manic episode, unspecified.
According to the ICD 10;
There are different types of mania
- F30.0 Hypomania
- F30.1 Mania without psychotic symptoms
- F30.2 Mania with psychotic symptoms
- F30.8 Other Manic episodes
- F30.8 Manic episode, unspecified.
What is 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
According to the ICD 10;
There are different types of mania
- F30.0 Hypomania
- F30.1 Mania without psychotic symptoms
- F30.2 Mania with psychotic symptoms
- F30.8 Other Manic episodes
- F30.8 Manic episode, unspecified.
What is 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
According to the ICD 10;
There are different types of mania
- F30.0 Hypomania
- F30.1 Mania without psychotic symptoms
- F30.2 Mania with psychotic symptoms
- F30.8 Other Manic episodes
- F30.8 Manic episode, unspecified.
What is mania?
- 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.
What is the psychiatric differential for mania?
- Mixed affective state
- Schizoaffective disorder
- Schizophrenia
- Cyclothymia
- ADHD
- Drugs and Alcohol
What is the medical differential for mania?
- Stroke
- MS
- Tumour
- epilepsy
- AIDS
- Neurosyphilis
- Endocrine – Cushing’s, hyperthyroidism
- SLE
What are the tools to measure symptom of mania?
- SCID
- SCAN
- Young Mania Rating Scale (YMRS)
What are the 4 broad treatments for mania?
- Antipsychotics
- Mood stabilisers
- Lithium
- ECT
The 4 broad treatments for mania are;
- Antipsychotics
- Mood stabilisers
- Lithium
- ECT
What are some antipsychotics?
- Olanzapine
- Risperidone
- Quetiapine
The 4 broad treatments for mania are;
- Antipsychotics
- Mood stabilisers
- Lithium
- ECT
What are some mood stabilisers?
- Sodium Valproate
- Lamotrigene
- Carbamazepine
According to the ICD-10;
What is bipolar affective disorder?
Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
According to the ICD-10;
Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
If there is no mania, what is the diagnosis?
Recurrent depression
According to the ICD-10;
Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
If there is no depression, then what is the diagnosis?
- If no depression the diagnosis is hypomania or bipolar disorder
- (In DSM-5 a single episode of mania is sufficient to diagnose bipolar disorder.)
What is the epidemiology of mood disorders?
- studies hindered by differences in diagnostic classification
- greatest agreement for most severe forms
- with improved case definition and funding for large scale community surveys - greater agreement
- ‘state of the art’ - structured, standardised interview schedules
What is the epidemiology of bipolar disorder?
- lifetime prevalence rate (n per 100) : 0.7 - 1.6
- point prevalence rate of mania : 0.08 - 0.8
- industrialised nations = non-industrialised
- rates for males = rates for females
- mean age of onset = 21 (unusual >30)
- some studies - 1/3 onset < 20
- early onset (15-19) usually with positive FH
- no differential prevalence according to income, occupation or educational status
- prevalence consistently increased in 1st0 relatives
- other forms of depression also more common
What is the epidemiology of depression?
- lifetime prevalence rate (n per 100): 2.9 - 12
- point prevalence rate of depression: 3.7 - 7.7
- lifetime risk for less severe manifestations - 20
- rates for females exceed rates for males - 2:1
- highest risk from age 18-44 (median 25)
- mean age of onset = 27
- onset during old age is not unusual
- no overall association with socioeconomic status
- MDD less common in those employed
- MDD less common in those financially independent (N.B. - direction of effect)
- association with lower educational attainment
- stable marriage negatively associated with MDD
- increased risk in 1st0 relatives where proband has MDD (3x) or BPD (2x)
- twin studies: MZ ‘v’ DZ = 27% ‘v’ 12%
- onset of depression (first episode) associated with excess of adverse life events
- ‘exit events’ - separations, losses
What is the clinical outcome of major depression?
- typical episode lasts 4-6 months
- 54% recovered at 26 weeks
- 12% fail to recover
- 80+% have further episodes
- 15% die by suicide
What is the clinical outcome of bipolar disorder/ mania?
- typical manic episode lasts 1-3 months
- 60% recovered at 10 weeks
- 5% fail to recover
- 90% have further episodes
- 1/3 have poor outcome
- 1/3-1/4 have good outcome
- 10% die by suicide
