Bipolar, Depression & Anxiety Flashcards
Define Delirium
An acute and fluctuating disturbance in level of consciousness, attention and global cognition
How is delirium investigated?
Bloods: U&E, FBC, WCC, LFTs, TFTs, glucose AMTS Confusion Assessment Method ECG CXT Urinalysis
What is the epidemiology of delirium?
Most common: Elderly & very young
50% of hip fractures & terminal illness
10% >65 on hospital admission
50% after hospital admission
What are the signs & symptoms of delirium?
Recent onset of fluctuating awareness!!
1) Inattention
2) Impaired global cognitive functions (inc memory-confabulation)
3) Disorganised thinking- Delusions (Dr is poisoning me)
4) Perceptual disturbances
5) Inc/dec psychomotor activity (Hyper/hypoactive)
6) Disturbed sleep wake cycle (insomnia, day sleeping, difficult to distinguish between dreams & reality)
Other:
Reduced level of consciousness
Disorientation (time/place/person)
Illusions/hallucinations
Altered personality
Mood disturbance
Speech disorders (slurred/aphasia/chaotic pattern)
Lack of insight
In delirium are the symptoms stable or changing?
Fluctuate over the course of the day and tend to be worse at night.
Patients may show signs of hyperactivity (typically in withdrawal states) or lethargy (common in hepatic encephalopathy).
What are the common causes of delirium?
S- Sepsis, Substrate (hyper/hypoG)
M- Meningitis, mental illness
A- Alcohol (toxic/withdrawal)
S- Seizure, STROKE
H- Hyper (thyroid, parathyroid, thermia, carbia), Hypo (thyroid, thermia, tension, hypoxia)
E- Encephalopathy, Electrolytes (hyper/hypoNa, hyperCa), Embolism
D- Drugs: anticholinergics, antiemetics, opiates, corticosteroids, digoxin, levodopa, benzos (intoxication & withdrawal)
What are the main differences between delirium & dementia?
Delirium: Sudden onset, fluctuating, days-weeks, varying level of consciousness, inattention, psychomotor changes, reversible
Dementia: Gradual onset, slowly progressive, months-years, consciousness unimpaired, attention preserved, psychomotor normal, degenerative
What are the main types of affective disorders?
Bipolar
Depression
Mania
How is bipolar diagnosed?
> 2 episodes of mood & activity disturbance
One episode MUST be mania or hypomania
What are the risk factors for bipolar?
Early age of mood disorder <20 Family history Prev Hx of depression Stressful life events Sunstance abuse Comorbid anxiety
How is bipolar investigated?
Hx: If prev overactivity/disinhibited behaviour >4days referral for specialist mental health assessment considered
PHQ-9: Depression screen
PRIME-MD: Mental health screen
Self-rating scale= Mood disorder questionnaire: mania/hypomania
Bipolarity index
How is bipolar managed?
1) CBT or IPT
1st manic episode: Seen 1/w for 6w then every 4w for 3m,
ACUTE manic: Antipsychotic (Haloperidol, Olanzapine, Risperidone)
Ineffective inc dose/change drug
Ineffective add Lithium (CI = Valproate)
STOP antidepressants
ECT if all else fails
ACUTE depressive: mild= monitor, mod-severe= Fluoxetine w/Olanzapine +/- CBT
Ineffective Lamotrigine alone
Review = 4weeks of episode
ONGOING: Lithium (only if more than 1 episode)
(if ineffective +) Valproate
Long-term= 2years but may last 5
What are the complications of bipolar?
Drug abuse Suicide/Self-harm Cognitive dysfunction Lithium hypothyroid/nephrotoxicity Rapid cycling - >4 cycles of depression & mania a year, with no intervening asymptomatic episodes (10-20%)
Define depression
Persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical, and behavioural symptoms.
What is the pathophysiology of depression?
What conditions can cause depression?
Monoamine-deficiency theory= A depletion of neurotransmitters serotonin, norE or dopamine in the CNS Chronic health conditions including pain Hypothyroidism Genetic predisposition Female Elderly Substance abuse
What are the core symptoms of depression?
Anhedonia- loss of interest/pleasure
Low mood
Loss of energy/fatigue
Other: Loss of appetite
Poor conc/attention
Lack of emotional reactivity
Insomnia
What are symptoms of atypical depression?
Reactive mood Increased appetite Weight gain Excessive sleepiness Sensitivity to rejection Usually seen in SAD
How does NICE diagnose depression?
Either 2 core symptoms present most days, most of the time for at least 2/52.
NOT: Secondary to effects of drugs/OH-, organic illness, bereavement
Ask about appetite, fatigue, energy, insomnia, suicide
MUST have 1 or more core condition & 5/9 of the other symptoms
How is SAD diagnosed?
Episodes of depression occurring annually at the same time each year with remission in between
How is depression investigated?
Mental state Exam PHQ-9: Self-report questionnaire mild:5-9, Severe 20-27 Geriatric depression scale Suicide & self harm Rule out organic causes: Bloods, imaging
What medications can be given to treat depression?
Mild-mod: Consider watch & wait & review in 2weeks, exercise, low intensity psychological interventions (self-help CBT) NOT meds
Mod-severe: Combined SSRI (consider PPI) & HIPT/CBT
Life-threatening: ECT
REVIEW: Suicidal/<30 =1week, no suicide= 2weeks
What are the core symptoms in the ICD-10 assessment for diagnosis of depression?
Low/depressed mood Loss of interest & enjoyment Lack of energy Sleep disturbance Change in appetite Reduced concentration Reduced sex drive Loss of confidence Guilt feelings Suicidal thoughts
What are the levels of severity of depression according to the ICD 10 criteria?
Mild= 2core + 2other Mod= 2core + 3other Severe= 3core + 4other
How is a manic episode in Bipolar classed by ICD 10?
Elated/irritable/labile mood Increased energy/overactive Distractibility/ reduced conc/ constant change of plans Reduced need for sleep Inflated self esteem/ grandiosity Overfamiliarity/ disinhibition Reckless behaviour/ overspending Inc sex drive Psychotic symptoms Racing thoughts/ flight of ideas
What is anxiety?
Evolutionary response to a threatening situation
Associated ↑ HR, ↑BP, ↑RR, nausea, muscle tingling
Fight or flight response
When does anxiety become problematic?
Out of proportion to threat
More prolonged
Occurs without a threat
Interferes with daily life
What is a panic attack?
Discrete episode(s) of intense fear or discomfort
Starts abruptly/unpredictable
Reaches max within mins & lasts mins
4 symptoms of anxiety: Palpitations, chest pain, feelings of unreality, choking sensation, dizziness
What are the signs & symptoms of anxiety?
Headaches/ lightheaded Tiredness Choking sensation SOB Tension Dry mouth Sweating Nausea Flushing/chills Stomach pains Chest pain/palpitations Butterflies Jelly legs/ shakiness/trembling Loss of appetite
What are the different types of anxiety disorders?
Phobic
Other: Panic, GAD
OCD
Dissociative/conversion: Amnesia, stupor, motor, sensory loss, trance & possession states
Somatoform: Hypochondriacal, somatisation
Reactions to s. stress: PTSD, acute stress reaction, adjustment disorder
What is an adjustment disorder? What are the signs?
Abnormal and excessive reaction to an identifiable life stressor. The reaction is more severe than normally expected and can result in signif impairment in social or occupational
Signs: Depression, anxiety, inability to cope, physical complaints, withdrawal, conduct disturbance (truancy)
How is delirium diagnosed?
DSM-IV Criteria:
- Disturbance of consciousness: Poor attention, focus, lack of awareness
- Change in cognition: disorientated, memory deficit, language/visual disturbance
- Develops over a short time period: Fluctuating over course of the day
How is delirium managed?
Conservative: Orientate the patient, clear communication, hearing aids/glasses
Treat underlying cause
Aggression & Agitation: Haloperidol 0.5-1mg PO/IM
What are the signs & symptoms of Bipolar disorder?
Manic: Pressure of speech, Grandiose ideas, Excessive energy, Overactivity, Flight of ideas, Needing little sleep, easily distracted, Inc sex drive, Inc spending, unusual clothing +/- delusions & hallucinations
Hypomanic: Persistent mild elevation of mood, energy, without delusions or hallucinations no significant effect on functional ability
Depressive: Low mood-worse am, reduced energy, anhedonia, guilt, despair, low self-esteem, reduced appetite, altered sleep
Psychosocial functioning: Difficulties with work/ relationships
What symptoms are indicative of mania? How many symptoms are needed for a diagnosis?
3 of the following: Grandiosity/inflated self-esteem. Decreased sleep. Pressured speech. Flight of ideas Distractibility. Psychomotor agitation. Excessive involvement in pleasurable activities without thought for consequences (spending spree resulting in excessive debts).
What are the abnormal signs of bereavement?
Prolonged grieving
Severe reactive depression with/without suicidal ideation
Excessive feelings of guilt
Converting emotional conflicts into psychosomatic symptoms.
Searching for the deceased
Sometimes mild auditory/visual hallucinations (e.g seeing the deceased face in a crowd)
Self-neglect
Impulse of radical changes (suddenly moving house)
Denial of the death
What medications can increase someone’s risk of depression?
Beta blockers Steroids Anticonvulsants Benzos Opiates Antipsychotics NSAIDs
What are the risk factors for delirium?
Age Cognitive impairement Prev delirium Depression Sensory impairment Falls
What is inattention?
Unable to generate, sustain or shift attention, easily distracted
Disorientated: Time/place
Bedside test: Serial 7’s, months backwards
What are the signs of psychomotor disorder in delirium?
Hyper: Restless, Pressured speech, Laughing/crying, Repetitive movements
Hypo: Lethargy and sedation, respond slowly to questioning, and show little spontaneous movement.
In what condition is caution needed with Haloperidol?
Parkinson’s
Haloperidol: Can worsen parkinsonian symptoms
Use Lorazepam instead
