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
- disordered mood can present as a ______ problem or as a __________ of other disorder or illness, e.g. cancer, dementia, drug misuse or medical treatment (steroids)
- often associated with ______ symptoms and _____ disorders. focus on the depressive disorders
primary
consequence
anxiety
anxiety
(If anxiety and depression then treat depression first as often the treatment of the depressive disorder helps with the anxiety symptoms)
what classification systems are avalible?
- 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
- A leading cause of disability worldwide
- A common condition
When does depression become abnormal?
•no clear and convenient division. consensus problematic, often a matter of perspective
psychiatry places emphasis on:
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
SYMPTOMS OF DEPRESSIVE ILLNESS occurs in 3 spheres which are what?
PSYCHOLOGICAL
PHYSICAL
SOCIAL
what are depressive symptoms that may be present in the psychological sphere?
CHANGE IN MOOD:
DEPRESSION - May find diurnal variation
ANXIETY - inability to relax
PERPLEXITY - particularly in Puerperal illness
ANHEDONIA
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 (psychotic symptoms)
what are depressive symptoms that may be present in the physical sphere?
CHANGE IN BODILY FUNCTION:
ENERGY - Fatigue
SLEEP
APPETITE - weight loss
LIBIDO
CONSTIPATION
PAIN
CHANGE IN PSYCHOMOTOR FUNCTIONING:
AGITATION (restlass anxiety)
RETARDATION (thoughts, speech and movement slowed)
what are depressive symptoms that may be present in the social sphere?
LOSS OF INTERESTS
IRRITABILITY
APATHY
WITHDRAWAL, LOSS OF CONFIDENCE, INDECISIVE
LOSS OF CONCENTRATION, REGISTRATION & MEMORY
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
Depression – ICD-10
what is their definition of depression?
- Last for at least 2 weeks
- No hypomanic or manic episodes in lifetime
- Not attributable to psychoactive substance use or organic mental disorder (some symptoms of depression may overlap with those)
- If psychotic symptoms or stupor then severe depression with psychotic symptoms - Need to exclude other psychotic illnesses first like schizophrenia
Depression – ICD-10 – Somatic Syndrome:
One diagnosis within the depressive disorders is somatic syndrome - what is classed as somatic syndrome?
- 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
Mild Depression – ICD-10
what is classed as mild depression?
Left is core symptoms - at least 2 of 3
Then a further 2 form the list on the right
Moderate Depression – ICD-10
what is classed as moderate depression?
Same 2 lists
But 4 symptoms from the left
Severe Depression – ICD-10
what is classed as severe depression?
All 3 of core symptoms
Then at least 5 from right hand list
how common is Post-natal Depression?
- increased risk of psychiatric admission in the 30 days following childbirth (risk for 24m)
- 75% of women experience ‘blues’ within 2 weeks (passes quickly)
- 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 are some differential diagnosis you should consider in a depressive disorder?
- Normal reaction to life event
- Seasonal Affective Disorder
- Dysthymia
- Cyclothymia
- Bipolar
- Stroke, tumour, dementia
- Hypothyroidism, Addison’s, Hyperparathyroidism
- Infections – Influenza, infectious mononucleosis, hepatitis, HIV/AIDS
- Drugs
what are the main evidence based treatments for depression?
- Antidepressants - Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclic antidepressants (TCAs), Monamine Oxidase Inhibitors, Other antidepressants
- Psychological Treatments - CBT, IPT, Individual dynamic psychotherapy, family therapy
- Physical Treatments - ECT, Psychosurgery, DBS, VNS
how do you measure and diagnose depressive disorders?
- SCID (Structured Clinical Interview for DSM disorders)
- SCAN (Schedules for Clinical Assessment in Neuropsychiatry) (aligns with ICD-10)
- HDRS (Hamilton Depression Rating Scale)
- BDI-II (Beck Depression Inventory II)
- HADS (Hospital Anxiety and Depression Scale)
- PHQ-9 (Patient Health Questionnaire 9)
Summary:
- Affective disorders are ________, _______ and ________
- Depression is a leading cause of morbidity _______
- All have effective __________
- Depressive disorders can be classified and symptoms _________
common
recurrent
disabling
globally
treatments
measured
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 (unlike depression), 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
how do you classify someone as having mania?
- no clear and convenient division. consensus problematic, often a matter of judgment of deviation from ‘normal self’
- psychiatry places emphasis on: (Same 4 emphasis as depressive disorders)
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
how does ICD-10 classify 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
how does ICD-10 classify 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 (speak rapidly and difficult to follow), decreased need for sleep
- Disinhibition (behaving in a way they wouldn’t normally)
- Grandiosity (elevated sense of yourself)
- Alteration of senses
- Extravagant spending
- Can be irritable rather than elated
whata re some differential diagnosis of hypomania and 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
whata re some Tools to Measure
Symptoms?
SCID
SCAN
Young Mania Rating Scale (YMRS) - used to measure changes in severity of symptoms, track over time how someone’s symptoms are
what treatment is avalible for mania?
- Antipsychotics - Olanzapine, Risperidone, Quetiapine
- Mood Stabilisers - Sodium Valproate, Lamotrigene, Carbamazepine
- Lithium
- ECT
what are the different types of bipolar disorders?
Different phases, depending on if they are manic or hypomanic, weather they have psychotic symptoms or not, weather they are in a depressive episode with or without psychotic symptoms, can be in remission or not
What is ICD-10 definition for the diagnosis 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.)
Very unlikely to have a one of manic episode without the other side
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 (suggesting there is probably a genetic link)
- 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 Course and Outcome of major depression?
- typical episode lasts 4-6 months
- 54% recovered at 26 weeks
- 12% fail to recover
- 80+% have further episodes (Depression recurrence is actually about 40%)
- 15% die by suicide
What is the Clinical Course and 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
Summary:
- Affective disorders can be _______ and symptoms _________
- Affective disorders are ________ and ________
- Mania less common than _______ disorder (which again is less common than depressive disorders)
- All have effective _________
classified
measured
recurrent
disabling
bipolar
treatments
