Affective disorders Flashcards
Two types of affective disorder
Depressive and manic state
Criteria of depressive episode (DSM V - 9 criteria)
1) Depressed mood
2) Loss of interest or pleasure (anhedonia)
3) Significant weight loss or weight gain
4) Insomnia, or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue, or loss of energy
7) Feeling of worthlessness, or excessive or inappropriate guilt
8) Diminished ability to think or concentrate, or indecisiveness
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
Psychopathological symptoms in depression
- Hypoprosexia
- Monoideism
- Self-accusation
- Loss of perspective
- Feeling of worthlessness
- Anhedonia
- Dysthymia
- Dysphoria
- Irritability
- Anxiety
- Hypobulia
- Anergia
- Retarded psychomotorium
- Agitation
- Psychotic symptoms
- Holothym delusions
- Hallucinations
- Suicidal thoughts
Hypoprosexia
Defective fixing of attention
Monoideism
State of prolonged absorption in a single idea
Anhedonia
Loss of interest/pleasure
Dysthymia word meaning
Depressed mood
Hypobulia
Lowered ability to make decisions or to act
“-thymia”
Emotion, mood or state of mind
Holothym delusions
Delusions connected with emotional state
Somatic symptoms of depression
- Sleep disorder
- Weight loss
- Sexual dysfunction
2 main types of depression, based on behavioural symptoms
1) Melancolic type
2) Agitated type
Diagnostic criterias of manic episode (DSM V - 8 criteria)
- Hyperthymia or irritability (one of them is necessary for the diagnosis)
+ 3 or more of: - Inflated self-esteem or gradiosity
- Decreased need for sleep
- More talkative than ususal or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increase in goal-directed or psychomotor agitation
- Excessive involvement in pleasurable activities that have a high potential for painful consequences
Psychopathological symptoms in manic episode
- Hyperthymia
- Irritability
- Logorrhea
- Flight of ideas
- Secunder incherentia
- Grandiosity
- Delusions
- Accelerated psychomotorium
- Agitation
- Hyperbulia
- Loss of critical sense
- Hyperprosexia
- Loss of insight
Bipolar I definition
- There are manic and depressive phases
- Between them, in most cases are euthym episodes
Bipolar II definition
There are hypomanic and depressive epoisodes in the anamnesis
Cyclothymia definition
- Intensive affective fluctuation and change in the activity
- Affective changes doesn’t reach clinical level
Unipolar depression definition
Only depressive episodes, no mania
Dysthymia definition
- In most cases, affective symptoms doesn’t reach the criteria of depression
- In many cases, dysthymia is based on personality disorder
How can we classify affective disorders?
Based on suspected etiology: endogenous, reactive, organic
Based on the progress: bipolar-unipolar, the disease takes place in phases, or is persistent
Bases on intensity: minor, major
Differential diagnosis of depressive symptoms
1) Somatic diseases and drug effect
2) Psychiatric disorder
- Bipolar disorder
- Dysthymia
- Anxiety disorders
- Drug, or alcohol abuse
- Schizoaffective disorder
- Schizophrenia
Differential diagnosis of manic symptoms
1) Somatic diseases and drug effect
2) Psychiatric disorders
- Bipolar disorder
- Schizoaffective disorder
- Drug, or alcohol abuse
- Schizophrenia
Therapy of a depressive episode
1) Every depressive episode should be treated
2) Mild depressive episode: psychotherapy
3) Moderate and severe: antidepressant medication
Antidepressant medication principles
- Affecting serotonin, NE, DA systems of CNS
- Effect builds up in 2-4 weeks
- Continue treatment for at least 6-12 months after recovery
- In recurrent depression, profylactic antidepressive therapy is needed long-term
SSRIs advantages (3)
- Well tolerated
- Low toxicity
- Effective also in anxiety disorders
SSRIs SEs (5)
- Nausea, vomiting
- Diarrhea
- Headache
- Sleep disorder
- Sexual disorder
SSRIs names
- Fluoxetine
- FLuvoxamine
- Sertraline
- Citalopram
- Escitalopram
- Paroxetine
Dual action antidepressants examples
- SSNRIs: Venlafaxine, duloxetine
- NA+DA: Buproprion
- Alpha 2 R inhibitor + serotonin antagonist: Mirtazapine
SSNRIs advantaged use
- Good when there´s psychomotor retardation and anergia
- Duloxetine can be useful in depression with psychosomatic symptoms
Bupropion when extra effective
- Anhedonia
- Psychomotor retardation
Bupropion serious SEs
- Can intensify psychotic symptoms
- Can provocate epileptic seizure
Mirtazapine when extra effective + 2 common SE
When anxiety and insomnia symptoms are present
- SE: weight gain, sedation
Tricyclic and tetracyclic antidepressants
- Both serotonergic and NA
- Rarely used due to SEs and toxicity
- Clomipramine (tricyclic), Mianserine (tetracyclic)
Tricyclic and tetracyclic SEs
AntiACh: dry mouth, accomodation problems, glaucoma, tachycardia, urine retention, obstipation, delirium, memory
Anti-histamine: sedation, weight gain
Alpha-1 R inhibition: orthostatic hypotonia, reflex tachycardia, sedation
Trazodone
- Serotonin reuptake inhibitor and atg of 5-HT2A/2C
- Beneficial when insomnia, agitation and anxiety symptoms
Moclobemid
- RIMA (reversible MAO-A inh)
- Used in atypical depression
- SE: serotonin SY
Reboxetine
- Selective NA reuptake inhibitor
- Used when anergia, psychomotor retardation are present
Agomelatin
- Agonist on melatonin R´s, atg on 5-HT2C R´s
- Effective when insomnia
Tianeptin
- Helps serotonin reuptake
- Effective when anxiety and ethyl abuse / dependency present
Most common psychotherapeutic approaches in depression
- Cognitive-behavioural therapy
- Person-centered therapy
- Short dynamic therapy
- Interpersonal therapy
Indications electroconvulsive therapy
- Therapy-resistant depression
- Severe retarded psychomotorium
- Stupor
- Nutrition negativism
- High suicide risk
- Bad somatic state
Electroconvulsion safe?
It is safe during pregnancy and in elderly
How often do we commonly use ECT?
2-3 times a week, 6-10 times totally
Advantages ECT
- Shorter therapy
- Also effective in therapy-resistant depressions
Other possible therapies of depression
- Sleep deprivation
- Light therapy
- Augmenting medication
Main principles bipolar disorder therapy
- All patients need sustained drug therapy
- Base of therapy is mood stabilizers
- Need both acute phase therapy and phase-prophylactic therapy (classic mood stabilizers and SGAs)
Can antidepressants be used in depression in bipolar disorder?
Yes, but only combined with mood stabilizers
Therapy of manic episode in bipolar disorder
- Continue mood stabilizers (lithium, valproate, lamotrigine, carbamazepine)
- First line: SGAs (olanzapine, quetiapine, aripiprazole)
- If agitation: add benzo´s (clonazepam)
- *Antidepressants are CI!
Mood stabilizers
- Lithium
- Valproate
- Carbamazepine
- Lamotrigine
Lithium function
- Mood stabilizer
- Antimanic and phase-prophylactic effect
- Narrow TI
- Eliminated only through kidney
- SE: tremor, weight gai, hypothyreosis, diabetes insipidus
Lithium TI + toxic effects
Blood level 0,6 - 1,0 mmol/l
- Loss of consciousness, tremor, diarrhea, nausea and kidney failure
Valproate functions
- Mood stabilizer + antimanic effect
- CI in age of pregnancy
Carbamazepine functions
- Mood stabilizer + antimanic effect
- Inductor of cytochrome system (drug interactions)
Lamotrigine
- Mood stabilizer + effective in preventing depressive episodes (esp. bipolar II)
- Fast dose-elevation can cause SJS
45 year old bipolar patient with symptoms: tremor, diarrhea, anxiety. First 2 steps?
1) Estimate suicidal risk and find out if overdosed on some medication
2) Urgent Lithium blood level control
30 year old bipolar patient with depressive symptoms. Talks about acoustic hallucinations and guilt delusions. Possible treatment?
- Antipsychotics
- Phase-prophylactics
- Anxiolytics
- Antidepressants
