Affective Disorders, Anxiety disorders & Personality 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
How can mood disorders present and what are they often associated with?
Disordered mood can present as a primary problem or as a consequence of other disorder or illness, e.g. stroke, dementia, drug misuse or medical treatment (steroids)
Often associated with anxiety symptoms and anxiety disorders
What mood disorders are classified in ICD 11 that you should be aware of?
Depressive disorder – mild/mod/severe – with/without psychosis
Bipolar I
Bipolar II
Cyclothymia
Substance induced
Secondary mood disorders
What is the difference between depression as a symptom and as a syndrome?
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
- typically considered as a form of sadness, not just an absence of happiness
Syndrome=A constellation of symptoms and signs
- Single episode / Recurrent illness
When does depression become abnormal (what psychiatrists place emphasis on)?
- persistence of symptoms
- pervasiveness of symptoms
- degree of impairment
- presence of specific symptoms or signs
How long do depressive symptoms (e.g. low mood or reduced interest/pleasure) have to last before it can be classified as depression?
Most of the day, nearly everyday and lasts for at least 2 weeks
What is seen in depression and what might psychotic symptoms make you consider?
Significant functional impairment
No hypomanic or manic episodes in lifetime
Not attributable to psychoactive substance use or organic mental disorder
If psychotic symptoms then likely severe depression with psychotic symptoms (but can be moderate)
What are the differences between mild, moderate and severe depression?
MILD
The individual is usually distressed by the symptoms to a mild extent
Some difficulty in continuing to function in one or more domains
There are no delusions or hallucinations during the episode.
MODERATE
several symptoms of a depressive episode are present to a marked degree or a large number of depressive symptoms of lesser severity are present overall
The individual typically has considerable difficulty functioning in multiple domains
Can be with/without psychotic sx
SEVERE
many or most symptoms of a Depressive Episode are present to a marked degree
or a smaller number of symptoms are present and manifest to an intense degree
The individual has serious difficulty continuing to function in most domains
With/without psychosis
Domains=personal, family, social, educational, occupational, or other important domains
When does post natal depression occur and what does it increase the risk of?
Often within a month or two of giving birth
Can start several months postpartum
A third of cases begin in pregnancy and persist
Increased risk of psychiatric admission in the 30 days following childbirth
How common is blues and how common is puerperal psychosis?
75% of women experience ‘blues’ within 2 weeks
‘puerperal psychosis’ - 1 in 1000 deliveries with a risk of recurrence with subsequent deliveries
What treatments are available for depression?
Antidepressants:
Selective Serotonin Reuptake Inhibitors SSRIs
Serotonin and norepinephrine reuptake inhibitors SNRIs
Tricyclic antidepressants TCAs
Monamine Oxidase Inhibitors MAOIs
Other antidepressants eg Mirtazapine
Antipsychotics
Mood stabilisers
Psychological Treatments
CBT, IPT, Individual dynamic psychotherapy
Physical Treatments – severe or treatment resistant
ECT, Psychosurgery, ketamine
What are some measurement tools available to assess 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 manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention
What are the symptoms and signs of mania?
- euphoria, irritability, increased activity, increased energy
- rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behaviour, and rapid changes among different mood states (i.e., mood lability).
- Delusions of grandeur /religious delusions can be present
What is hypomania?
Hypomania indicates a less severe episode with minimal functional impairment, no hospitalisation, no psychosis
What is a mixed affective state and when do symptoms present?
A mixed episode is characterised by the presence of several prominent manic and several prominent depressive symptoms, which either occur simultaneously or alternate very rapidly (from day to day or within the same day).
Symptoms are present most of the day, nearly every day, during a period of at least 2 weeks, unless shortened by a treatment intervention.
What is the difference between Bipolar I & II
I
At least one Manic or Mixed Episode
With/without psychosis
typical course of the disorder is characterized by recurrent Depressive and Manic or Mixed Episodes
Although some episodes may be Hypomanic, there must be a history of at least one Manic or Mixed Episode.
II
One or more hypomanic episodes
At least one depressive episode
No hx manic/mixed episodes
What is cyclothymia and what symptoms are present?
Persistent instability of mood over a period of at least 2 years
Numerous periods of hypomania
Depressive symptoms that are present during more of the time than not
The depressive symptomatology has never been sufficiently severe or prolonged to meet the diagnostic requirements for a depressive episode
What tools can be used to measure symptoms of bipolar?
SCID
SCAN
Young Mania Rating Scale (YMRS)
What medications can be used to treat Bipolar?
Benzodiazepines
Antipsychotics:
Olanzapine
Risperidone
Quetiapine
Mood Stabilisers:
Sodium Valproate
Lithium
ECT
Is the rate of bipolar different for males and females?
No its equal
What is the mean age of onset of bipolar disorder?
21 (unusual >30)
Early onset (15-19) is usually present with a positive what?
Usually with positive FH
Prevalence consistently increased in 1st degree relatives
Are the rates of depression higher in females or males?
F:M=2:1
What age is at highest risk of depression developing?
Highest risk from age 18-44 (median 25)
Onset during old age is not unusual
What is depression (first episode) associated with?
Excess of adverse life events
‘exit events’=seperations, losses
How long does a typical episode of major depression last and what % have further episodes?
Typical episode lasts 4-6 months
80+% have further episodes
Bipolar disorder/Mania: How long is a typical manic episode?
1-3 months
90% have further episodes
What is crucial to know about affective disorders?
Affective disorders can be classified and symptoms measured
Affective disorders are recurrent and disabling
All have effective treatments
What is unipolar depression?
Only have depression
(can be primary or secondary)
What is dysthymia?
Chronic form of depression-rumbling on low mood-hard to treat
What are the first lines for depression in primary and secondary care?
- SSRI=1st line
- SNRI=1st line in 2ndary care
What treatment for depression has the best evidence?
- Best evidence is for a psych treatment with an antidepressant
- Some peoples is treatment resistant-so can use physical treatments
What is the psychological (Transactional) model of stress?
Interactive
An individual’s reaction to stress will depend on a balance between their cognitive processing of any perceived threat and perceived ability to cope
What are the 2 ways of coping with stress (e.g. interview or exams)?
Problem focussed
Where efforts are directed toward modifying stressor. Preparation, studying or interview practice
Emotion focussed
Modify emotional reaction. Mental defence mechanisms eg Denial. Relaxation training
Take a sedative drug.
There are human physiological and psychological reactions to stress: What happens in anxiety disorders?
Normal pathways are not functioning correctly
What symptom groups are present in flight or fight response and in anxiety?
Psychological arousal
Autonomic Arousal
Muscle Tension
Hyperventilation
Sleep Disturbance
What does the Yerkes Dodson curve show?
Empirical relationship between stress and performance
What are signs of psychological arousal?
Fearful Anticipation
Irritability
Sensitivity to noise
Poor concentration
Worrying Thoughts
What are some signs of autonomic arousal (system based)?
Gastrointestinal
Dry Mouth
Swallowing difficulties
Dyspepsia, nausea and wind
Frequent loose motions
Respiratory
Tight chest, difficulty inhaling
Cardiovascular
Palpitations/Missed beats
Chest pain
Genitourinary
Frequency/urgency of micturition
Amenorrhoea/ Dysmenorrhoea
Erectile failure
CNS
Dizziness and sweating
Symptoms-reactions to stress
Muscle Tension
Tremor
Headache
Muscle pain
Hyperventilation
Causing CO2 deficit hypocapnia
Numbness tingling in extremities may lead to carpopedal spasm
Breathlessness
Sleep Disturbance
Initial insomnia
Frequent waking
Nightmares and night terrors
What is the difference between phobic anxiety disorders & GAD?
Both these sets of disorders have same core anxiety symptoms but they EITHER occur in particular circumstances:
PHOBIAS
Agoraphobia
Social phobia
Specific (Isolated) Phobias
OR Occur persistently
GENERALISED ANXIETY DISORDER (GAD)
What is GAD?
Persistent (several months) symptoms not confined to a situation or object.
All the symptoms of human anxiety mentioned earlier can occur
Psychological arousal
Autonomic Arousal
Muscle Tension
Hyperventilation
Sleep Disturbance
What are some physical conditions that are differential diagnosis for anxiety disorders?
Thyrotoxicosis
Phaeochromoctoma
Hypoglycaemia
Asthma and or Arrhythmias
What is the aetiology of GAD?
No clear line between “normal” anxiety and the anxiety disorders they differ in extent of symptoms and duration.
“In general terms GAD for instance is caused by a stressor acting on a personality predisposed to the disorder by a combination of genetic factors and environmental influences in childhood.”
How is GAD managed?
Counselling-
Clear Plan of Management
Explanation and education
Advice re caffeine, alcohol, exercise etc.
Relaxation training-
Group or individual
DVDs, tapes or clinician led
Medication-
Sedatives have high risk dependency
Antidepressants SSRI or TCA
Cognitive Behavioural Therapy
What are some key features of phobic anxiety disorders?
Same core features as GAD
ONLY in specific circumstances
Person behaves to avoid these circumstances “phobic avoidance”
Sufferer also experiences anxiety if there is a perceived threat of encountering the feared object or situation “anticipatory anxiety”
What are the 3 clinically important syndromes in phobic anxiety disorders?
- Specific phobias
- Social phobia
- Agoraphobia
What is social phobia?
Inappropriate anxiety in situation where person feels observed or could be criticised (ICD-11 thinks about fleeing being difficult)
Restaurants
Shops or any queues
Public speaking
Symptoms are any of the anxiety cluster mentioned above but blushing and tremor predominate
How is social phobia managed
CBT addressing the groundless fear of criticism.
CBT challenges
Negative views of self
“Safety barriers”
Unrealistically high standards
Excessive self monitoring
Education and advice
Medication SSRI antidepressants
What are the core features of OCD?
Experience of recurrent obsessional thoughts &/or compulsive acts
- Ideas, images or impulses
- Occurring repeatedly not willed
- Unpleasant & distressing (often antithesis of personality type)
- Recognised as the individuals own thoughts
- Usual key anxiety symptoms arise because of distress of the thoughts or attempts to resist
Compulsive acts or rituals: What are they and how are they viewed?
Stereotypical behaviours repeated again and again
Not enjoyable
Not helpful i.e. do not result in useful activity
Often viewed by sufferer as
preventing some harm to self or others; “magical undoing”
Viewed as pointless and resisted with key anxiety symptoms accompanying resistance
Does OCD equally affect men and women and and what is the aetiological theory for it?
Equally affects men and women
Aetiological Theory
- Genetic e.g. gene coding for 5HT receptors
- 5 HT function abnormalities
How is OCD managed?
- Good Hx & MSE exclude treatable depressive illness
- Serotonergic drugs
SSRI e.g. Fluoxetine
Clomipramine - CBT-Exposure & response prevention, exam of evidence to weaken convictions
- Psychosurgery
What is PTSD defined as?
“Delayed and or protracted reaction to a stressor of exceptional severity” (would distress anyone)
Combat
Natural or human-caused disaster
Rape
Assault
Torture
Witnessing any of the above
In PTSD what are 3 key elements to reaction?
Hyperarousal
Re-experiencing phenomena
Avoidance of reminders
What are symptoms of hyperarousal in PTSD?
Persistent anxiety
Irritability
Insomnia
Poor concentration
What occurs with re-experiencing phenomena in PTSD?
Intense intrusive images
- Flashbacks when awake
- Nightmares during sleep
What occurs with re-experiencing phenomena in PTSD?
Intense intrusive images
- Flashbacks when awake
- Nightmares during sleep
How is avoidance seen in PTSD?
Emotional numbness
Cue avoidance
Recall difficulties
Diminishes interests
What is the aetiology of PTSD?
Nature of stressor
Life threatening and degree of exposure generally confers greater risk however
Vulnerability factors:
Mood disorder
Previous trauma especially as child
Lack of social support
Female
Protective factors (examples)
Higher education and social group
Good paternal relationship
Susceptibility partly genetic
How is PTSD managed?
Survivors of disasters screened at one month
Mild symptoms “watchful waiting” and review further month
Trauma-focused CBT if more severe symptoms
Eye Movement Desensitisation and Reprocessing
Risk of dependence with any sedatives but patient may prefer medication SSRI or TCA
What is disorganised attachment often associated with?
The development of BPD
What is a personality disorder?
- Problems in functioning of aspects of the self &/or interpersonal dysfunction
- Extended period of time
- Extends across a range of personal and social situations
Can be classed as mild, moderate or severe
What is negative affectivity in personality disorder?
Experiencing a broad range of negative emotions with a frequency and intensity out of proportion to the situation.
Emotional lability and poor emotion regulation.
Negativistic attitudes.
Low self-esteem and self-confidence.
Mistrustfulness.
What kinds of detachment can be present in personality disorder?
Social detachment.
- avoidance of social interactions, lack of friendships, and avoidance of intimacy.
- They have few to no friends or even casual acquaintances. Their interactions with family members tend to be minimal and superficial. They rarely engage in any intimate relationships and are not particularly interested in sexual relations.
Emotional detachment.
- reserve, aloofness, and limited emotional expression and experience.
- keep to themselves to the extent possible, even in obligatory social situations. They are typically aloof and respond to direct attempts at social engagement only briefly and in ways that discourage further conversation.
- do not talk about their feelings and it is difficult to discern what they might be feeling from their behaviours. In extreme cases, there is a lack of emotional experience itself and they are non-reactive to either negative or positive events
What dissociality can present in personality disorder?
- Self Centeredness
- Lack of empathy
What disinhibition is present in personality disorder?
Impulsivity.
Distractibility.
Irresponsibility.
Recklessness.
Lack of planning
What is anankastia in personality disorder?
Perfectionism
Emotional & behavioural constraint
What is exhibited in BPD?
Frantic efforts to avoid real or imagined abandonment.
A pattern of unstable and intense interpersonal relationships
Identity disturbance, manifested in markedly and persistently unstable self-image or sense of self.
Recurrent episodes of self-harm
Emotional instability due to marked reactivity of mood.
Chronic feelings of emptiness.
Inappropriate intense anger or difficulty controlling anger manifested in frequent displays of temper
Transient dissociative symptoms or psychotic-like features (e.g., brief hallucinations, paranoia) in situations of high affective arousal.
How are personality disorders managed?
Biopsychosocial approach
Assessment for full diagnostic picture, including co-occurring mood and addictive disorders
Diagnostic formulation, risk management planning, and setting of treatment goals and realistic ways of meeting them
Judicious use of medication
Specific psychological treatments
Social interventions
