Affective Disorders Flashcards
What are mood disorders?
Disorders of mental status and function where altered mood is the (or a) core feature
They are the most common group of mental disorders
What is mania?
A term referring to states of depression and of elevated mood
A term referring to states of depression and of elevated mood?
Mania
What disorders/symptoms are often associated with mood disorders?
Anxiety
What are the causes of mood disorders?
Disordered mood can present as a primary problem or as a consequence of other disorder or illness, e.g. cancer, dementia, drug misuse or medical treatment (steroids)
How are mood disorder classified?
Using the
ICD-10 (International Classification of Disease 10th Edition – World Health Organisation)
or
DSM-5 (Diagnostic and Statistical Manual of Mental Disorders 5th Edition – American Psychiatric Association)
What is depression?
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
In terms of depression what emphasis does psychiatry place emphasis on?
Psychiatry places emphasis on:
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
Which three spheres can symptoms of depression fall under?
1) Psychological
2) Physical
3) Social
Which three spheres can symptoms of depression fall under - Psychological?
CHANGE IN MOOD:
1) DEPRESSION - May find diurnal variation
2) ANXIETY - inability to relax
3) PERPLEXITY - particularly in Puerperal illness
4) ANHEDONIA
CHANGE IN THOUGHT CONTENT: 1) GUILT
2) HOPELESSNESS
3) WORTHLESSNESS
4) ANY NEUROTIC SYMPOMATOLOGY e.g.. Hypochondriasis, agoraphobia, obsessions & compulsions, panic attacks.
5) IDEAS OF REFERENCE
6) DELUSIONS AND HALLUCINATIONS if severe
Which three spheres can symptoms of depression fall under - Physical?
CHANGE IN BODILY FUNCTION
1) ENERGY - Fatigue
2) SLEEP
3) APPETITE - weight loss
4) LIBIDO
5) CONSTIPATION
6) PAIN
CHANGE IN PSYCHOMOTOR FUNCTIONING:
1) AGITATION
2) RETARDATION
Which three spheres can symptoms of depression fall under - Social?
1) LOSS OF INTERESTS
2) IRRITABILITY
3) APATHY
4) WITHDRAWAL, LOSS OF CONFIDENCE, INDECISIVE
5) LOSS OF CONCENTRATION, REGISTRATION & MEMORY
Definition of symptoms - Agitation?
A state of restless overactivity, aimless or ineffective
Definition of symptoms - Anhedonia?
Loss of ability to derive pleasure from experience
Definition of symptoms - Apathy?
Loss of interest in own surroundings
Definition of symptoms - Anxiety?
An unpleasant emotion in which thoughts of apprehension or fear predominate
Definition of symptoms - Depression?
An unpleasant emotion in which sadness or unhappiness predominates
Definition of symptoms - Retardation?
A slowing of motor responses including speech
Definition of symptoms - 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
General criteria for depression - ICD10?
1) Last for at least 2 weeks
2) No hypomanic or manic episodes in lifetime
3) Not attributable to psychoactive substance use or organic mental disorder
4) If psychotic symptoms or stupor then severe depression with psychotic symptoms
> Need to exclude other psychotic illnesses first like schizophrenia
General criteria for depression, somatic syndrome - ICD10?
1) Marked loss of interest or pleasure in activities that are
normally pleasurable
2) Lack of emotional reactions to events or activities that normally produce an emotional response
3) Waking 2 hrs before the normal time
4) Depression worse in the morning
5) Objective evidence of psychomotor agitation or retardation
6) Marked loss of appetite
7) Weight loss (5%+ of body weight in a month)
8) Marked loss of libido
Criteria for mild depression - ICD10?
General criteria
At least two of:
1) Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
2) Loss of interest or pleasure
3) Decreased energy or increased fatigability
Additional from this list to give at least 4
1) Loss of confidence or self esteem
2) Unreasonable feelings of guilt or self reproach or excessive guilt
3) Recurrent thoughts of death by suicide or any suicidal behaviour
4) Decreased concentration
5) Agitation or retardation
6) Sleep disturbance of any sort
7) Change in appetite
Criteria for moderate depression - ICD10?
General criteria
At least two of:
1) Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
2) Loss of interest or pleasure
3) Decreased energy or increased fatigability
Additional from this list to give at least 6:
1) Loss of confidence or self esteem
2) Unreasonable feelings of guilt or self reproach or excessive guilt
3) Recurrent thoughts of death by suicide or any suicidal behaviour
4) Decreased concentration
5) Agitation or retardation
6) Sleep disturbance of any sort
7) Change in appetite
Criteria for severe depression - ICD10?
General criteria
All of:
1) Depressed mood that is abnormal for most of the day almost everyday for the past two weeks, largely uninfluenced by circumstances
2) Loss of interest or pleasure
3) Decreased energy or increased fatigability
Additional from this list to give at least 8:
1) Loss of confidence or self esteem
2) Unreasonable feelings of guilt or self reproach or excessive guilt
3) Recurrent thoughts of death by suicide or any suicidal behaviour
4) Decreased concentration
5) Agitation or retardation
6) Sleep disturbance of any sort
7) Change in appetite
Post-natal Depression - Percentage of women who experience “blues” within 2 weeks?
75%
Post-natal Depression - Percentage of women who experience MDD within 3-6 months?
10%
Post-natal Depression - Percentage of women who experience puerperal psychosis?
1 in 500 deliveries with a risk of recurrence of 1-3 with subsequent deliveries
Differential diagnosis to 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
Treatments for depression?
1) Antidepressants
2) Psychological treatments
3) Physical treatments
Treatments for depression - anti-depressants?
1) Selective Serotonin Reuptake Inhibitors (SSRIs)
3) Tricyclic antidepressants (TCAs)
4) Monamine Oxidase Inhibitors
5) Other antidepressants
Treatments for depression - Psychological treatments?
1) CBT (Cognitive behavioural therapy)
2) IPT (Interpersonal therapy)
3) Individual dynamic psychotherapy
4) Family therapy
Treatments for depression - Physical treatments?
1) ECT (Electroconvulsive therapy)
2) Psychosurgery
3) DBS (Deep brain stimulation)
4) VNS (Vagus nerve stimulation)
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
What does psychiatry place an emphasis on within mania?
Psychiatry places emphasis on
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
Classes of mania by ICD-10?
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.
Classification of 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
Classification of Mania (with or without psychosis)
> 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
Tools to measure mania?
SCID
SCAN
Young Mania Rating Scale (YMRS)
Treatment of mania?
1) Antipsychotics
> Olanzapine
> Risperidone
> Quetiapine
2) Mood Stabilisers
> Sodium Valproate
> Lamotrigene
> Carbamazepine
3) Lithium
4) ECT (Electroconvulsive therapy)
ICD-10 Classification of mania?
F31.0 BAD, currently hypomanic
F31.1 BAD, current manic without psychosis
F31.2 BAD, current manic with psychosis
F31.3 BAD, Current mild/mod depression
F31.4 BAD, current severe depression without psychosis
F31.5 BAD, current severe depression with psychosis
F31.6 BAD, current episode mixed
F31.7 BAD, current episode in remission
F31.8 Other bipolar affective disorders
F31.9 Bipolar affective disorder, unspecified
ICD-10 and diagnosis of bipolar disorder?
1) Bipolar Affective Disorder consists of repeated (2+) episodes of depression and mania or hypomania.
2) If no mania or hypomania then diagnosis is recurrent depression.
3) If no depression the diagnosis is hypomania or bipolar disorder
(In DSM-5 a single episode of mania is sufficient to diagnose bipolar disorder.)
Epidemiology of
Mood Disorder?
> 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
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 1st degree relatives
> Other forms of depression also more common
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 1st degree 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
Clinical Course
and Outcome - 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
Clinical Course
and Outcome - 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
