Affective Disorders Flashcards
1
Q
What is an affective disorder?
A
They are a set of psychiatric disorders aka mood disorders, the main disorders include: depression, bipolar and anxiety.
- Can present as a primary disorder for many
- Or secondary as a result of another illness
2
Q
What two classification systems do we have for affective disorders?
A
- 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
3
Q
What is depression: symptom?
A
- 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
4
Q
What is depression: syndrome?
A
A constellation of symptoms and signs.
5
Q
When does depression become abnormal?
A
(the consensus is often a matter of perspective)
Psychiatry focuses on:
- persistence of symptoms (how long)
- pervasiveness of symptoms (widely impact of symptoms)
- degree of impairment
- presence of specific symptoms or signs
6
Q
What three spheres do the symptoms of depression exist in?
A
- Psychological
- Physical
- Social
7
Q
Explain the psychological sphere of depressive symptoms:
A
Change in mood
- DEPRESSION May find diurnal variation (sometimes worse in the morning)
- ANXIETY inability to relax
- PERPLEXITY particularly in Puerperal illness
- ANHEDONIA - not being able to experience pleasure in what you normally enjoy.
Change in thought content
- GUILT
- HOPELESSNESS
- WORTHLESSNESS
- ANY NEUROTIC SYMPTOMATOLOGY e.g.. Hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks.
- IDEAS OF REFERENCE - “such as thinking random people laughing, are in fact, laughing at you”
- DELUSIONS AND HALLUCINATIONS if severe
8
Q
Explain the physical sphere of depressive symptoms:
A
Change in bodily function:
- ENERGY Fatigue
- SLEEP - waking early seen in Severe Depression
- APPETITE weight loss
- LIBIDO
- CONSTIPATION
- PAIN
Change in psychomotor functioning:
- AGITATION
- RETARDATION
9
Q
Explain the social sphere of depressive symptoms:
A
- LOSS OF INTERESTS
- IRRITABILITY
- APATHY
- WITHDRAWAL, LOSS OF CONFIDENCE, INDECISIVE
- LOSS OF CONCENTRATION, REGISTRATION & MEMORY
10
Q
What is the classification of depression in ICD-10?
A
- Last for at least 2 weeks
- 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 with psychotic symptoms
- Need to exclude other psychotic illnesses first like schizophrenia
11
Q
What is the criteria of depression as a somatic syndrome? [characterised by physical symptoms more commonly]
A
- 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
12
Q
Criteria for mild depression (ICD-10)?
A
At least two 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
And 2 from list below:
- 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
13
Q
Criteria for moderate depression (ICD-10):
A
At least two 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
And from this list to make up to 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
14
Q
Criteria for severe depression (ICD-10):
A
All of below:
- 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 fatiguability
Additional from this list to make up 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
15
Q
Explain briefly post natal depression:
A
- 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
16
Q
List some DDx for depression:
A
- Normal reaction to life event
- SAD
- Dysthymia
- Cyclothymia
- Bipolar
- Stroke, tumour, dementia
- Hypothyroidism, Addison’s, Hyperparathyroidism
- Infections – Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
- Drugs
17
Q
What antidepressants are available for depression?
A
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- Tricyclic antidepressants (TCAs)
- Monamine Oxidase Inhibitors
- Other antidepressants
18
Q
What psychological treatments are available for depression?
A
- CBT, IPT, Individual dynamic psychotherapy, family therapy
19
Q
What physical treatments are available for depression?
A
- ECT, Psychosurgery, DBS, VNS
20
Q
What are some of the measurement tools used to assess depression, mania?
A
- SCID (Structured Clinical Interview for DSM disorders)
- SCAN (Schedules for Clinical Assessment in Neuropsychiatry)
For mania add:
- Young Mania Rating Scale (YMRS)
21
Q
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
22
Q
Psychiatric view of mania?
A
- Concencus is problematic (because psychiatry is a pseudoscience)
But emphasis on:
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
23
Q
What types of mania does ICD-10 classify:
A
- 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.
24
Q
What is the criteria of hypomania?
A
- 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
25
What is the criteria of 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.
26
What are some DDx for mania?
Psychiatric:
* Mixed affective state
* Schizoaffective disorder
* Schizophrenia
* Cyclothymia
* ADHD
* Drugs and Alcohol
Medical
* Stroke, MS, Tumour, epilepsy, AIDS, Neurosyphilis
* Endocrine – Cushing’s, hyperthyroidism
* SLE
27
Management for mania?
* Antipsychotics
* Olanzapine
* Risperidone
* Quetiapine
* Mood Stabilisers
* Sodium Valproate
* Lamotrigene
* Carbamazepine
* Lithium
* ECT
28
What is ICD-10 description of Bipolar disorder?
* Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
* If no mania or 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.)
29
What is the epidemiology of bipolar?
* 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
30
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
31
What is a typical clinical course 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
32
What is a typical clinical course of bipolar/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
