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Affective/Mood disorders Flashcards

1
Q

Affective disorders general

A

Main feature is excessively high or low mood
Run a relapsing and remitting course
Unipolar or bipolar

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2
Q

Aetiology

A

Genetics - runs in fams, combo of genes, some specific e.g. serotonin transporter gene
Childhood and life experiences - adverse experiences via impact on confidence/trust/self-esteem (abuse, criticism, parent loss). adult vulnerabiliity factors impact resilience (unemploy, relationship, socio-econ, soc isolation)
Life events - Holmes-Rahe Social Adjustment scale - deaths, divorce, jail, physical illness. Postnatal, sleep depr, across time zones can triggermanic eps.
Physical causes - chronic pain, illnesses that directly cause, drugs (b-blockers, antiHTN, cocaine)

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3
Q

Physical illnesses that directly cause depression

A

Cushings syndrome
Hypothyroidism
Parkinson’s disease

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4
Q

Physical disorders that can cause mania

A 
Cushings syndrome
Head injury
MS
Steroids
Antidepressants
Stimulants
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5
Q

Theories of affective disorders

A

Behavioural and cognitive - Beck’s model: Bases of CBT; early adverse events+negative thought of self/world+life events -> cognitive distortions/negative thoughts - cycle of negative thoughts, low mood (guilty,discouraged,inadequate) and reduced behaviour (less active, avoid ppl/situations)

Psychoanalytical - Early experience, quality of early relationships determines risk of later depression

Neurochemical - Monoamine hypothesis: depression from deficiency in NTs - NA (mood, energy), Serotonin (sleep, appetite, memory, mood), Dopamine (psychomotor activity). Drugs that deplete -> depression., low NT metabolites in CSF suicide, drugs that increase monamine levels can precipitate mania, antipsychotics can treat mania

Endocrine abnormalities - cortisol maybe links stressful life events and depression ?damage to hippocampal neurones

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6
Q

Depression symptoms

A

Clinically low in mood with physical+psychological associated Sx which distort thinking and reduce motivation

> 2 weeks

Core:

  • Anhedonia - loss of pleasure in activities they previously enjoyed
  • Anergia - tired all the time
  • Low mood - Pervasively low, irritability, anxiety, tearfulness

Others:

  • Cognitive Sx - low confidence, low self esteem, ideas of guilt and unworthiness, bleak/pessimistic view of future, poor concentration and memory, self harm/suicide ideation
  • Biological Sx - disturbed sleep, diminished appetite/sex drive, physical Sx (constipation, aches/pains, dysmenorrhoea)

Psychotic: in SEVERE; unpleasant derogatory audio halluc; destruction/evil spirit visual halluc.; nihilistic/persecutaory delusions

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7
Q

Classification of depression

A

Mild - 2 core + 2 others.

Moderate - 2 core, 5-6 total Sx

Severe - 3 core, 7 total OR psychotic OR self-harm/self-neglect/suicidal. Marked functional impairment.

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8
Q

Differentials for depression

A

Organic causes

  • hypothyroid
  • hyperCa
  • Cushings
  • Addisons
  • Head injury
  • Cancer
  • Chronic disease

Adjustment disorder - unpleasant but mild; following life event

Normal sadness/bereavement

BPAD/schizoaffective disorder/schizophrenia

Substance misuse - Alcohol/drugs as cause of depression or form of self-medication

Postnatal depression

Dementia

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9
Q

Subtypes of depression

A

SAD - low mood in winter; usually biological Sx of sleeping and eating

Atypical depression -

Agitated depression - with psychomotor agitation (instead o retardation) i.e. restlessness, pacing, hand-wringing

Depressive stupor - Psychomotor retardation so severe that the person grinds to a halt. Becomes mute, stops eating/drinking/moving

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10
Q

Ix for depression

A

Collateral Hx
Physical exam
Bloods - TFTs, FBC (anaemia->fatigue?), HbA1c (diabetes->fatigue?), Vit D, B12, Ca
Rating scale to measure/monitor severity/Tx response
CT/MRI - not routine, but can rule out suspected cerebral pathology

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11
Q

NICE management of depression: first step

A

Step 1:

  • Thorough assessment
  • Support
  • Psychoeducation: advice on sleep hygiene, physical exercise
  • Active monitoring - further assessment WITHIN 2 WEEKS!!
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12
Q

NICE management of depression: For subthreshold Sx/mild-moderate depression

A

Step 2: For subthreshold Sx/mild-moderate depression

  • Low intensity psychosocial intervention - self/e- guided CBT principles, structure d group physical activity, 6-8 sessions
  • Psychological interventions
  • Medication not routinely used in subthreshold/mild/moderate
  • Active monitoring - further assess in 2 weeks
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13
Q

NICE management of depression: For subthreshold/mild-moderate with inadequate response to initial Tx OR moderate/severe depression

A

Step 3: For above with inadequate response to initial Tx OR moderate/severe depression

  • Persistent subthreshold/mild-mod: SSRI OR psych intervention
  • Moderate-severe: SSRI (First-line usually sertraline) AND psych intervention
  • High-intensity psychological interventions: CBT, interpersonal therapy, behavioural activation, behavioural couples therapy; 16-20 sessions over 3-4 months
  • Combined treatments and collaborative care
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14
Q

NICE management of depression: For severe and complex depression; risk to life; severe self-neglect

A

Step 4: Severe and complex depression; risk to life; severe self-neglect

  • Medication
  • High intensity psychological interventions
  • Crisis service - crisis resolution and home treatment teams
  • Crisis plan to identify triggers and manage
  • Combines Tx
  • Multi-professional and inpatient care
  • Consider ECT for acute Tx for severe depression and when a rapid response is required
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15
Q

Biopsychosocial approach to depression

A

Biological: Anti-depressants
Psychological: CBT, psychodynamic psychotherapy, interpersonal therapy,
Social: Housing, substance misuse/support groups

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16
Q

ECT indications, effects, side effects and contraindications

A

Electroconvulsive therapy indications: treatment resistant depression, catatonic schizophrenia and severe mania

Electrodes to produce generalised tonic-clonic seizure while the pt is anaesthetised. Can be fast, life-saving Tx in severe or psychotic depression e.g. stopped eating/drinking

Short term SI: headache, nausea, memory impairment/loss, arrhythmias; may get long term memory issue

If on antidepressant - reduce safely to minimum dose

Absolute contraindications: phaeochromocytoma, raised ICP
Relative: recent MI/stroke, raised ICP/SOL, arterial HTN, narcotic intolerance, acte glaucome, cerebral aneurysm/angioma
Pregnancy/pacemaker ok

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17
Q

What is discontinuation syndrome, Sx, onset, how to prevent

A

Occurs following discontinuation of an antidepressant

Sx: flu-like, sleep trouble, N&V, diarrhoea, abdo cramping, poor balance, anxiety, dizziness, electric shock sensations in the hands and legs

Begin within 3 days and can last months

Prevent by tapering drug over 4 weeks

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18
Q

What is serotonin syndrome, triggers, symptoms and management

A

Uncommon, but potentially serious high levels of synaptic serotonin

Triggered usually by use of 2+ serotonergic drugs. Others: St John’s wort, opioids, amphetamins, MDMA
MAOi associated with severe serotonin syndrome

Sx: confusion, agitation, shivering, D&V, hyperthermia, HTN, tremor, rigidity, hyperreflexia, + Babinski, clonus,
Severe: seizures, arrhythmia, unconsciousness

Management: Stop seratonergic drugs, supportive care, sedation with benzos, short-acting agents to manage autonomic instability, hyperthermia Tx, if severe: cyproheptadine (antidote therapy)

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19
Q

What is catch up phenomenon

A

Pt recovers from depression due to Tx, then stopped Tx, suddenly -> will relapse into depression that is worse

To prevent: advise pt to take anti-depress for advised time, even if feel better

20
Q

Antidepressant problems/things to look out for

A

Stopping and swapping
Poor response/resistance
Hyponatraemia - esp elderly; SSRIs can cause SIADH
SSRI - May be initial worsening of Sx in 1st 2wks, continue at least 6/12, review every 1-2 wks
When switching from fluoxetine/paroxetine/MAOi - start new at lower dose/2week washout period

21
Q

SSRIs in pregnancy

A

Use in 1st trimester - small risk of congenital heart defects (paroxetine esp high risk congenital malformations in 1st/3). In 3rd - risk of persistent pulmonary HTN of newborn

22
Q

Types of psychological treatment for depression and what they are

A

CBT - evidence base for anxiety and depression; cognitive and behavioural intervention coupled; goal oriented to challenge distorted perceptions and encourage positive behaviours; challenge your NATs

Psychodynamic psychotherapy - good relationship with pt necessary; pt applies unconscious template from past to new situation; distorted perceptions known as transferences; recognising these hidden beliefs and re-evaluating in current reality

Interpersonal therapy - Focus on main themes- unresolved loss, psychosocial transitions, relationship conflict and social skill deficit; focus on pts relationship with other ppl

23
Q

What are the key/core symptoms of mania + cognitive, biological and psychotic Sx

A

Constant elation or euphoria (change in affect) and observable hyperactivity

Elevated mood - may be elation/excitement or aggression/irritability; or labile mood
Boundless energy and overactive
Increased enjoyment and interest - may indulge in new activities

Cognitive: inflated self-esteem and confidence (believes are gifted), pressured speech, topics change rapidly (flight of ideas)

Biological: reduced sleep; voracious appetite for food and sex, but also can forget/be busy to eat; reckless disinhibited behaviour (excessive spending, gambling, reckless driving)

Psychotic: grandiose delusions of an important mission, fame or special powers; persecutory delusions; auditory hallucinations may reflect elevated mood

24
Q

Differentials for mania

A

Physical/organic:

  • drug induced e.g. amphetamines, cocaine
  • dementia
  • frontal lobe disease
  • delerium
  • cerebral HIV
  • Myxoedema maddness (extreme hypoT4)

Schizophrenia/schizoaffective disorder - psychotic Sx precede and outweigh affective Sx.

Cyclothymia - persistent mood instability with many episodes of mild low mood/mild elation; none eps sufficient for mild depression/hypomania criteria

Puerperal disorders

25
BPAD diagnosis and subtypes
Two episodes of mania necessary for BPAD Dx; 1 ep is single episode mania Type I BPAD: manic episodes interspersed with depressive episodes Type II BPAD: mainly recurrent depressive episodes with less prominent hypomanic episodes Rapid cycling BPAD: >4 affective eps in 1 yr; more common in women; may respond better to sodium valproate
26
Mania vs hypomania
Mania Sx are more severe and effect functionality; Sx usually last >1wk; Generally psychotic Sx present - hallucinations/delusional beliefs Hypomania Sx less severe, not affecting function; can present as thoughts, energy, confidence, overflow, creativity; Sx <7days
27
Investigations for BPAD
``` Collateral Hx Physical exam Blood tests - FBC, TFTs, CRP, others if indicated Urine drug screen CT/MRI brain if indicated ```
28
Pharmacological Tx for BPAD
Mood stabilisers: stabilise extremes highs of mania (mainly) and profound lows of depression 3 main drugs: lithium, sodium valproate, carbamazepine Others: atypical antipsychotics e.g. olanzapine, other anticonvulsants e.g. Lamotrigine for type II BPAD prophylaxis
29
What is Lithium toxicity, presentation, triggers and management
Life threatening; level >1.2mmol/L Nausea, D&V, nystagmus, coarse tremor, polyuria/polydipsia, sluggishness, giddiness, ataxia, nystagmus, fits, renal failure, seizures Triggers: salt balance changes from diet, dehydration, D&V; drugs affecting excretion: NSAIDS, diuretics, ACEis; Accidental/deliberate overdose Management: check level, stop lithium + monitor mental status, transfer for med care (hydration, osmotic diuresis), if severe overdose, may need gastric lavage or dialysis
30
Lithium therapeutic range, monitoring and adverse effects
Range: 0.6 - 1.0 mmol/L Must check: 12hr post dose, lithium levels a week after starting/changing dose + monitor weekly until steady, then every 3 months U&Es + TFTs every 3-6 months as can cause renal impairment Be careful if switching from lithium citrate to lithium carbonate as contain diff doses of lithium Adverse effects: N&V, weight gain, renal impairment, hypothyroidism, metallic taste in mouth, fine tremor, polydipsia/polyuria (causes nephrogenic DI), oedema, benign leucocytosis, hyperPTH and resultant hyperCa, flattened/inverted T wave on ECG.
31
Sodium valproate
Anticonvulsant that can treat acute mania and provide prophylaxis in BPAD Valproic acid is active drug; sodium/semi-sodium salt given to lessen adverse effects Dose-related toxicity not an issue, no monitoring of plasma levels necessary.
32
Carbamazepine
Anticonvulsant Causes toxicity at high doses (induces metabolic liver enzymes); monitor levels and check for drug interactions when prescribing Less effective than lithium
33
Mood stabilisers and pregnancy
Are teratogenic: individual risk of relapse - may continue w/ monitoring&obs, may stop prior to conception, may stop 1st trimester only Risk of relapse in perinatal period is high Lithium: Ebstein's anomaly - atrialisation of R side of heart -> tricuspid valve issue; lithium may be expressed in breast milk Valproate/carbamazepine: spina bifida (if used give high dose folate) Valproate not given to premeno women; if special circumstance - advise contraception and prescribe folate supplement Do not offer lithium or sodium valproate to pregnant/planning, unless antipsychotics have not been effective If becomes pregnant: taper drugs over 4 weeks, consider switch to antipsychotic (safe in preg/breastfeed except clozapine) Monitor in preg - every 4 weeks, weekly from week 36, deliver in hospital
34
Psychological treatment
CBT - Psychoeducation is essential: identify relapse indicators (insomnia, high energy) - Establish strategies to avert (routine, good sleep, avoid excess stimulation/stress, avoid substance misuse, unsure drug compliance - CBT reduces relapse rates, shortens relapse and decreased hospitalisations Psychodynamic psychotherapy - sometimes useful when mood is stabilised
35
Social interventions
Family support Aiding return to work Therapy
36
NICE management of BPAD: first presentation/Sx in primary care
Refer to confirm Dx, treat acute ep, establish care plan - Sx hypomania - routine referral to CMHT - Sx mania/severe depression - urgent referral to CMHT Risk assessment If needs admission persuade to go voluntarily or section 2/3/4 Advise patient against driving during acute illness
37
NICE management of BPAD: acute manic episode in secondary care
Stop all meds that may induce Sx: anti-depressants, drugs or abuse, steroids, dopamine agonist; monitor oral intake (dehydration risk in mania) Therapeutic trial of 1 oral antipsychotic: haliperidol, olanzapine, quetiapine or risperidon; if not tolerated/effective try a diff one of them If 2nd line not effective: maybe add lithium or sodium valproate (not youngF); if already on- check dose and compliance Taper and discontinue antidepressants May need short course of benzos in acute manic episode (e.g. diazepam)
38
NICE management of BPAD: long term
Plan made by secondary care four weeks after acute episode resolved To prevent relapse: continue Tx options for mania - lithium or add valproate (if lith not effec) or valproate/olanzapine alone (if lith poorly tolerated) Psychological therapies: CBT (identify relapse indicators and prevention strategies), psychodynamic psychotherapy Social interventions: family support and therapy, aiding return to work or education Monitor physical and mental health and effects of drugs for at least first 12 months
39
NICE management of BPAD: depression
Difficult as may switch to mania; antidepressants should only be given with a mood stabiliser or antipsychotic - 1st line: fluoxitine + olanzapine/quietiapine - 2nd line: lamotrigine Monitor signs of mania closely and stop antidepressants if signs present Cautiously withdraw is pt is Sx-free for sustained period
40
Suicide vs self harm and examples
Suicide: act to deliberately bring about ones own death Self-harm: act intentionally causing physical injury to the body, but not resulting in death (included attempted suicide, also some with little or no suicidal intent) Methods of self harm: self-cutting(most common), burning, poisoning (overdose)
41
Causes of suicide
Social causes - life events and stress - social class - social isolation - occupation Mental health causes - previous suicide attempt - strongest predictor of eventual suicide - previous self harm - depression - particularly if older, single, prev self harm, recurrent suicidal thoughts, insomnia, weight changes, extreme feelings of hopeless, worthless or guilt - schizophrenia - particularly in young ambitious patients with insight; tends to occur after acute psychosis - substance misuse - personality disorders
42
Suicide: risk factors
Male sex Hx deliberate self harm Alcohol/drug misuse Hx mental illness (depression, schizophrenia) Hx of chronic disease Advancing age Unemployed or social isolation/living alone Being unmarried, divorced or widowed Prev suicide attempt with factors associated with increased risk - isolation at time of act, efforts to avoid discovery, planning, leaving a note, final acts e.g. finances, violent method, definite intent to die, believing to be lethal, ongoing wish to die
43
Suicide: protective factos
Family support Having children at home Religious beliefs
44
Self harm reasoning and associations
Must distinguish between self harm and attempted suicide Often performed to release tension that builds up as emotions build and patients feel a sense of pressure Reasons for self harm: - avoiding more dangerous self harm or suicide - self punishment - suicide attempt - substituting psychological stress with physical pain - overcoming numbness - to change intolerable situations (often relationship issues) More common in children and adolescents Associated with affective disorder and personality disorder Patients who has a traumatic/abusive childhood may find difficult to reflect and think through emotional experiences and can only deal through actions
45
Overdose treatments
Activated charcoal - decreases intestinal absorption of some substances (e.g. antidepressants); must be used within 1 hr Antidotes: N-acetylcysteine for paracetamol Naloxone for opioid Activated charcoal for most poisons Atropine for organophosphates and carbamates Digoxin immune fab Dimercaprol for arsenic, gold or inorganic mercury poisoning Flumazenil for benzodiazepine overdose Pralidoxime for poisoning by anti-cholinesterase nerve agents
46
Laceration treatment
Superficial cuts: sutures of steristrips Plastic surgery for deep cuts Adequate analgesia should be given
47
Management
Treat overdose, laceration etc. RISK ASSESS Assess risk factor features and specific Hx features If attempting to leave - assess capacity Immediate interventions: - if high risk suicide+lack capacity - admit - lower risk if home circumstance ok - manage at home - crisis plan should be made for future ideation or self harm thoughts Follow up interventions: - within 1 week of self harm or inpatient discharge - could be community MH, OPD, GP, counsellor - treat any underlying disorders (e.g. depression) - psychological therapies - CBT/DBT, metallisation-based Tx, transference-focused psychotherapy Coping strategies: - distraction techniques - mood-raising activities (e.g. exercise, writing) - strategies to decrease or avoid self harming (triggers/opportunity avoidance, being somewhere/someone safe)

Y5 Psych (11 decks)

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