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Affective disorders Flashcards

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1
Q

List 3 affective disorders

A

Depression
Mania
Bipolar

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2
Q

name 1 example of genetic susceptibility to stress?

A

The serotonin transporter gene

Its promoter region has two versions: an S (short) allele and an L (long) allele.

If someone with the S allele suffers three or more life events, their risk of depression trebles,

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3
Q

list 5 life events in order of degree of stressfulness?

A
  1. Death of spouse.
  2. Divorce.
  3. Marital separation.
  4. Jail term.
  5. Death of a close relative.
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4
Q

what does the Holmes–Rahe Social Adjustment Scale outline?

A

life events in order of degree of stressfulness

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5
Q

waht did the Brown and Harris study of women in Camberwell, London show?

A

showed that life events did not always precipitate depression, but were more likely to do so if other vulnerability factors were already present

  • three or more children under the age of 14 at home
  • not working outside the home
  • lack of a confidante
  • loss of mother before the age of 11.
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6
Q

list the vulnerability factors increasing depressoin risk according to brown and Harris?

A

unemployment,
lack of a confiding relation- ship,
lower socio-economic status,
social isolation

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7
Q

list physical/organic causes of depression?

A

Cushing’s syndrome, hypo- thyroidism, stroke, Parkinson’s disease, multiple sclerosis, and hyperparathyroidism, dementia

aneaemia/vit d deficiency - can cause low energy = low mood

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8
Q

list drug causes of depression?

A

Some medications (e.g. beta-blockers and antihypertensives)

as can illicit drugs such as stimulants (e.g. cocaine).

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9
Q

What are the main theories of affective disorders?

A

Behavioural and cognitive theories:

  1. Seligman’s studies led to the learned helplessness model of depression. feel helpless so give up trying.
  2. Becks negative cognitive triad; negative views of self and world leads to depressed mood, causing vicious cycle.

Psycoanalytical theories:
1. early experience, particularly the quality of early relationships, determines the risk of later depression

personality traits - more pessimistic view on life = inc risk

Neurochemical theories:
1. The monoamine hypothesis -> depression is the result of a deficiency in brain monoamine neurotransmitters.

  1. Mania may be related to dopamine overactivity.
  2. Cortisol may cause depression - observed failure to suppress - also in mania and schizoids
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10
Q

list the 3 monoamaines and their role

A

Noradrenaline (NA):
– affects mood and energy.

• Serotonin (5-hydroxytryptamine, 5-HT):
– affects sleep, appetite, memory, and mood.

• Dopamine (DA):
– affects psychomotor activity.

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11
Q

what is the mode of action of SSRIs and TCAs?

A

SSRI - BLOCK serotonin/5HT reuptake presynaptic terminal

TCA - INCREASE serotonin/5HT reuptake AND NA reuptake

MAOIs - inhibit MAO enzymes thus preventing inactivation of moa’s

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12
Q

what are the core depression symptoms?

A

The core symptoms of depression are:
• low mood
• anergia
• anhedonia

for more than 2 weeks

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13
Q

what are the most worrying depression symptoms?

A
  1. Suicidality
  2. psychotic symptoms
  3. severe self neglect
  4. not eating/drinking
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14
Q

list psychotic symtoms in depression ?

A
  1. Auditory hallucinations - unpleasant derogatory (critical) voices. mood congruent
  2. Rarely, visual hallucinations of scenes of destruction or evil spirits may be seen.
  3. Delusions - nihilistic or persecutory.
    Nihilistic delusions follow the theme of ‘nothingness’—e.g. the world has ended; the patient is dead; their organs are blocked or decomposing.

persecutory delusions - deserve persecution or punishment - Guilt - may progress to a delusional level

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15
Q

list differentials for depression?

A
  1. Physical causes, e.g. hypothyroidism, head injury, cancer, ‘quiet’ delirium.
  2. Adjustment disorder: unpleasant but mild affective symptoms follow a life event, but do not reach the severity needed to diagnose depression.
  3. Normal sadness: try not to medicalize; people are allowed to be sad sometimes.
  4. Bereavement: normal grief should not be diagnosed as depression.
  5. BPAD/schizoaffective disorder/schizophrenia: look for previous manic or psychotic features.
  6. Substance misuse:
  7. Postnatal depression/puerperal illness
  8. Dementia: depression can affect memory so badly
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16
Q

what is a normal vs abnormal greif response?

A 
normal:
Numbness
• Pining
• Depression
• Recovery

abnormal:
Extremely intense (reaching the level for depression; dis- abling the person)
• Prolonged (>6 months) without relief or
• Delayed (no sign of an emotional response).

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17
Q

list some subtypes of depression and their presentation?

A
  1. Seasonal affective disorder (SAD) - predictably with low mood in the winter. reversed biological symptoms of overeating and oversleeping.
  2. Atypical depression has no seasonal variation, but again shows reversed biological symptoms and may retain mood reactivity.
  3. Agitated depression is depression with psychomotor agitation (instead of retardation), e.g. restlessness, pacing, hand-wringing.
  4. Depressive stupor is when psychomotor retardation is so profound that the person grinds to a halt. They become mute and stop eating, drinking, or moving.
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18
Q

what is meant by a biological symptom?

A

Sleep - difficulty getting sleep
Appetite - reduced; food + sex

other sx: GI, menses etc

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19
Q

Rx for mild depression?

A

STEPPED CARE MODEL
goes spontaneously -watchful waiting
Advice on sleep hygiene, exercise, and self-help

Otherwise, 1st line:
self help/ group/ computerised CBT or counselling,

Moderate:
Self refer to IAPT
1-1 CBT
Interpersonal therapy - deal with underlying issues
Psychodynamic psychotherapy - put words to patient feelings ?

address stressors - eg time off work

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20
Q

name these common thinking errors:
1• ‘I always mess everything up’.
2• ‘I only passed that exam by chance.
It doesn’t mean I’m good enough’.

A

1• Generalization—‘I always mess everything up’.

2• Minimization—‘I only passed that exam by chance.

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21
Q

what is thought to account for the 4–6 week delay in antidepressant effects?

A

Antidepressants increase the overall level of monoamines at the synapse

Over time, the serotonin and central beta-adrenergic receptors become downregulated

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22
Q

Rx for moderate to severe depression ?

A

STEPPED CARE MODEL

  1. SSRI
    + psychotherapy
    + anti-psychotic if psychotic symptoms

continue till no longer depressed + 6 months after.
if reccurent depression : 2yrs+ therapy

  1. Non drug options
    - ECT; severe/psychotic cases
    - Light therapy; seasonal affective disorder
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23
Q

Side effects of all antidepressants?

A

hyponatraemia

sexual dysfunction

most - Lower seizure threshold - careful in epilepsy

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24
Q

what advise to give when prescribing antidepressants?

A

explain delayed onset of action and side effects

NO alcohol
NO driving if feeling drowsy

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25
Q

when are anti-depressants contraindicated?

A

Mania

Hypomania

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26
Q

which anti-depressants to avoid in suicide risk and why?

A

TCA

bcos lethal in overdose due to cardiotoxicity

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27
Q

why are MOAIs not used much?

A

risk of hyperetensive crisis / cheese reaction:

when eating tyramine rich foods* - NA builds up causing blood vessels to constrict by activating alpha-1 adrenergic receptors. Ordinarily, MAO-A would destroy the excess NE but is inhibited.

*i.e. cheese, alcohol, liver

dont combine with other anti-depressants

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28
Q

problems with st johns wort?

A

can induce metabolising enzymes = drugs e.g. COCPs dont work!

known interaction with MOAI in particular!

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29
Q

what to worry about if someone is ‘responding too well’ to anti-depressants?

A

all anti-depressants can swithc bipolar patients into MANIA!

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30
Q

what happens when anti-depressants are stopped?

A

NO withdrawal

BUT discontinuation symptoms!

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31
Q

how to discountinue anti-depressants?

A

over a few weeks

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32
Q

patient presents to A&E with restlessness and sweating, myo- clonus, confusion, and fits.
pmhx : depression

what is happening?

treatment?

A

Serotonin syndrome - too much 5HT
- from 2 SSRIs

rx: supportive. self resolving.
benzo for agitation if needed

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33
Q

what is treatment resistance in depression?

how to treat this?

A

failure to respond to 2 adequate trials of different classes of antidepressants at adequate doses and for a period of 6–8 weeks

solution:
Augmentation strategies:
• Lithium
• Tri-iodothyronine (T3) or levothyroxine (T4)
• Buspirone (an anxiolytic drug that acts on 5HT1a receptors) + SSRI

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34
Q

average length of depression episode on vs off treatment?

A

off treatment: 8-9 months

on treatment: 2-3 months

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35
Q

list examples of SSRIs?

A

Fluoxetine Sertraline Paroxetine Fluvoxamine Citalopram Escitalopram

36
Q

list examples of SNRIs?

A

Venlafaxine

Duloxitine

37
Q

List examples of TCAs?

A

Amitriptyline Clomipramine Imipramine Lofepramine Dosulepin

38
Q

List examples of MAOIs?

A

Phenelzine Tranylcypromine

39
Q

Moclobemide is what type of drug?

A

Reversible inhibitors of monoamine oxidase A (RIMAs)

40
Q

which anti-depressant is associated with weight gain and sedation ?

A

TCA

NASSAs - mirtazipine

41
Q

which anti-depressant is associated with insomnia, tremor, dizziness ?

A

SSRIs

possible MAOIs too - not tremor

42
Q

which anti-depressant is associated with drowsiness ?

A

MAOIs

43
Q

list the core symptoms of mania?

A

raised mood - can be irritable, aggresive, labile
raised energy - overactive, restless, talkative
raised enjoyment - new activities

symptoms should last for at least a week and prevent work and ordinary social activities.

44
Q

difference between mania and hypomania?

A

hypomania - not entirely disrupt the patient’s ability to function - they can be productive

45
Q

list the cognitive symptoms of mania?

A
  1. Inflated self-esteem and confidence lead the person to believe that they are gifted, attractive etc
  2. Optimism makes the future
  3. thoughts race, concentration dissolves etc
  4. Speech becomes pressured and topics change rapidly (flight of ideas)
46
Q

list biological symptoms of mania?

A
  1. Sleep is reduced, up all night without feeling tired.
  2. Voracious appetites for food and sex - may forget to eat
  3. Disinhibited and reckless Behaviour
  4. spend excessively, drive recklessly, or gamble their money away (didnt do it before)
  5. Drugs or alcohol can become new interests
47
Q

list psychotic symptoms of mania?

A

in severe mania;

  1. Grandiose delusions optimism develops into grandiose delusions - important mission, fame, or special powers.
  2. Persecutory delusions - may believe that others are jealous of them.
  3. Auditory hallucinations may reflect the elevated mood, e.g. prime ministers or saints talking to the patient.
48
Q

ddx for mania?

A
  1. organic causes; dementia, drugs
    Myxoedema madness’ (paradoxically, a state of frenzied activity in extreme hypothyroidism).
  2. schizophrenia/ affective disorder
  3. clyclothymia - peristent mood instability but not severe enough to be mild depression or mania
  4. puerperal disorders
49
Q

what ivx would you do for mania in order?

A
  1. Collateral history.

1a. Young mania rating scale,
- > MSE, AMTS, MMSE - consideering other ddx

  1. Physical examination.
  2. Blood tests: FBC, TFTs, CRP to exclude infection or thyroid problems; other tests as indicated.
  3. Urine drug screen.
  4. CT/MRI brain to exclude organic causes, if indicated.
50
Q

what are the different types of BPAD - bipolar affective disorder?

A

Type I BPAD
– Manic episodes interspersed with depressive episodes. (at least 1)
- Depressive episodes are common but are NOT necessary to make the diagnosis

• Type II BPAD
AT leat one of:
– Mainly recurrent MAJOR depressive episodes, with less pro-
minent hypomanic episodes.

• Rapid cycling BPAD / cyclothymia
– Four or more affective episodes in a year.
History of hypomanic episodes with periods of depression that
do not meet the criteria for major depressive disorder

– More common in women.
– May respond better to sodium valproate.

51
Q

how is a diagnosis of bipolar reached?

A

made when a patient has suffered a manic episode and

+ other affective episode, whether depressed, hypomanic, manic, or mixed (elements of both depression and mania at once).

52
Q

what is the target of anti-convulsants?

A

Na and GABA channels in the CNS

53
Q

How do we treat mania?

A

stop all mania inducing meds i.e. antidepressants, steroids etc.

check food and fluid intake

  1. Drugs:
    A. Mood stabilisers
    - used in longterm treatment too
    - Lithium 0.6-1 mmol/l ; monitor levels

B. Antipsychotics - atypicals - olanzapine

C. Anticonvulsants

  • Valproate
  • Carbamezapine ; monitor levels
  • short course only

D. combine 2 drugs if severe

  1. ECT
    - if unresponsive to meds
  2. Psychological:
    A. CBT
    B. psychodynamic therapy
  3. Social:
    - family support, going back to work etc
54
Q

which drug is used as use in prophylaxis after mood settling in mania?

A

Lithium mainly

if frequent relapse or impairment;

Valproate or
Antipsychotics - atypicals - olanzapine

55
Q

purpose of CBT in mania?

A

identify relapse factors so patients can work to avert them

56
Q

list some relapse prevention strategies in cbt?

A
  • Developing routine
  • Ensuring good-quality sleep
  • Promoting a healthy lifestyle

• Avoiding excessive stimulation/stress (often easier
said than done)
• Addressing substance misuse
• Ensuring drug compliance

57
Q

patient on rc for mania presents with ;

Presents with gastrointestinal disturbance, sluggishness, giddiness, ataxia, gross tremor, fits, and renal failure

diagnosis?
suggest possible reasons for these symptoms?

A

lithium toxicity

– salt balance changes - diarrhoea, or vomiting
– Drugs interfering with lithium excretion, e.g. NSAIDs, diuretics, ACE inhibitors
– Accidental or deliberate overdose

58
Q

what is the management for lithium toxicity?

A

stop lithium and transfer for medical care (rehydration, osmotic diuresis)

59
Q

why is lithium as a medication so dangerous?

how to make sure patient is safe?

A

narrow therapeutic index, becoming toxic from
1.2mmol/L.

Lithium levels are taken 12 hours post-dose.

Lithium levels must be checked 1 week after starting or changing the dose,

monitored weekly until a steady therapeutic level has been achieved, and then every 3 months.

U&Es and TFTs should be monitored every 3–6 months, since lithium can cause renal impairment and hypothyroidism.

60
Q

how long can benzo’s be given for in acute mania/hypomania?

A

short course only - a few days

i.e. to help them regain sleep

61
Q

rx in bipolar?

A

anti-depressant +
mood stabiliser or antipsychotic

otherwise will slip into mania

1st line: fluoxetine + olanzapine/quetiapine

62
Q

whats the icd-10 criteria for bipolar diagnosis?

A

at least 2 episodes

1: manic, hypomanic or mixed
2: low mood

with complete recovery in-between

63
Q

Liver failure
Thrombocytopenia
Hair loss
are the side effects of which drug?

A

valproate

64
Q 
Polyuria,
 polydipsia
 Arrhythmia
Hypothyroidism
are the side effects of which drug?
A

lithium

65
Q

Rash
Leucopenia
ataxia
Enzyme induction may decrease levels of other drugs, making them ineffective (e.g. OCP)

are the side effects of which drug?

A

carbamazepine

66
Q

Arthralgia and back pain
Skin rashes which may be life-threatening

what is this rash?
are the side effects of which drug?

A

lamotrigine

rash: SJS - steven johnson (rare side effect)

67
Q

can mood stabilisers eg lithium be used in pregnancy?

A

are teratogenic - weigh out costs and benefits

but yes

monitor foetus well

68
Q

side effect of using the following in pregnancy are what:

  1. lithium
  2. valproate + carbamazepine

how to prevent these effects?

A

Lithium - Ebsteins anomaly: cardiac effect

Valproate + carba - spina bifida

69
Q

how long are manic episodes compared to depression?

A

abrupt start - 5 months

so shorter episodes

70
Q

what is the difference betweene flight of ideas and loosening of associations? which condition is each seen in

A

loosening of association, or Knight’s move thinking, a formal thought disorder observed in psychosis where there are no clear links between successive thoughts. - schizophrenia

In flight of ideas links are evident from thought to thought despite the topic regularly changing. It is more commonly seen in mania.

71
Q

What are the PHQ tests and how should they be used?

A

When screening for depression the Patient Health Questionnaire (PHQ-2) can be used first (it has a 97% sensitivity and a 67% specificity).

If this is positive, the PHQ-9 can then be used. It is not a screening tool for depression but it is used to monitor the severity of depression and response to treatment.

72
Q

which drugs are associated with dose-dependent QT interval prolongation?

A

citalopram and escitalopram

73
Q

what is the aetiology of bipolar disorder?

A

Genetic: heterogeneity, no single gene implicated

Environmental;
childhood abuse
recent life events - precipitant
sleep deprivation - precipitant

Neurological:
1. bipolar disorder may occur when the ventral system - emotional perception - is overactivated and the dorsal system - emotional regulation - is underactivated

2.Dopamine, a neurotransmitter responsible for mood cycling, has increased transmission during the manic phase.
decreased in depressive phase

74
Q

what is a clang association?

give an example

what condition is it found in?

A

Clang associations are groupings of words, usually rhyming words, that are based on similar-sounding sounds, even though the words themselves don’t have any logical reason to be grouped together.

eg: I wrote the boat overload showed my goat float tote.
- > Bipolar ; mania

75
Q

what is cotard syndrome?

A

Cotard’s delusion, also known as walking corpse syndrome

is a rare mental disorder in which the affected person holds the delusional belief that they have lost their blood or internal organs or they are rotting.

76
Q

define Psychomotor retardation

A

Psychomotor retardation involves a slowing-down of thought and a reduction of physical movements in an individual.

Psychomotor retardation can cause a visible slowing of physical and emotional reactions, including speech and affect.

77
Q

in which conditions may you see Psychomotor retardation?

A

schizophrenia, severe depression, bipolar disorder, etc.

eating disorders, mood disorders, anxiety disorders, etc.

Psychiatric medicines (if taken improperly, overdosed, or mixed with alcohol)

Parkinson’s disease

78
Q

epidemiology of depression?

A

15% lifetime prevalence 5% point prevalence

F:M 2:1

peak age; 40s women
60-70 men

79
Q

What are the componenets of becks triad?

A

WORTHLESSNESS - i am useless

HOPLESSNESS -

HELPLESSNESS

80
Q

what are atypical biological symptoms?

A

over eating over sleeping

usually its under doing it

81
Q

What is the prognodis of depression

A

depression can go for 2 years without treatment
review treatment after 6 months

80% likely to get another episode

10% chronic

males 7% suicide rate (more violent methods), female 1%

82
Q

what is the course of BPAD?

A

1 or 2 cycles year

rapid cycling cases - change over weeks, NEVER over days

83
Q

epidemiology of BPAD?

A

1:1
M:F

84
Q

If a patient comes in with depression what other condition MUST you probe for?

A

mania/ hypomania symptoms

85
Q

What drugs should be used in the ACUTE treatment of mania?

A

ROQ:
Respiridone
Olanzipine
Quetiapine

Mood stabilisers are mainly for long term prophylaxis i.e. to prevent relapse.

86
Q

list some discontinuation symptoms?

A

These vary with the drug, but include ‘flu-like

symptoms, ‘electric shock’ sensations, headaches, vertigo, or irritability.

A- Psych (24 decks)

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