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First Aid for Psych Clerkship > Chapter 4: Mood Disorders > Flashcards

Chapter 4: Mood Disorders Flashcards

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1
Q

mood

A

internal emotional state

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2
Q

mood episodes

A

distinct periods of time in which some abnormal mood is present. Include depression, mania, and hypomania

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3
Q

Mood disorders

A

defined by their patterns of mood episodes. Include major depressive disorder (MDD), bipolar I, II, persistent depressive disorder, cyclothymic disorder. Some may have psychotic features

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4
Q

psychotic features

A

delusions or hallucinations

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5
Q

mood congruent

A

when delusions and hallucinations are due to underlying mood disorders, they’re usually congruent with the mood.

Example: depression–> paranoia and worthlessness

mania-> themes of grandiosity and invincibility

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6
Q

Major depressive episode:

A

5 of following symptoms including 1 or 2:

  1. depressed mood most of hte time
  2. anhedonia
  3. change in appetite or weight
  4. feelings of worthlessness or excessive guilt
  5. insomnia or hypersomnia
  6. diminished concentration
  7. psychomotor agitation or retardation
  8. fatigue or loss of energy
  9. recurrent thoughts of death or suicide

not attributable to effects of a substance or other medical condition; must cause clinically significant distress or social/ occupational impairment

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7
Q

mnemonic for symptoms of major depression

A

SIG E CAPS

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor activity
Suicidal ideation
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8
Q

Manic episode

A

distinct period of abnormally and persistently elevated, expansive or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week (or any duration if hospitalization is necessary) and including at least 3 of the following (4 if mood is only irritable):

  1. distractibility
  2. Inflated self-esteem or grandiosity
  3. Increase in goal-directed activity or psychomotor agitation
  4. decreased need for sleep
  5. flight of ideas or racing thoughts
  6. more talkative than usual or pressured speech
  7. excessive involvement in pleasurable activities that have a high risk of negative consequences (shopping sprees, sexual indiscretion, etc.)

Symptos not due to substance or othe rmed condition, and must cause clinically significant distress or social/occupational impairment. > 50% of manic patients have psychotic symptoms

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9
Q

hypomanic episode

A

distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-direted activity or energy, lasting at least 4 consecutive days; includes at least 3 of symptoms for manic episode (four if mood only irritable).

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10
Q

differences between mania and hypomania

A

mania- >/= 7 days, severe impairment, may need hospitalization, may have psychotic features

hypomania: >/= 4 days, no marked impairment, no hospitalization, no psychotic features

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11
Q

mixed features

A

criteria met for manic or hypomanic episode and at least 3 symptoms of a major depressive episode are present for majority of the time. Nearly every day for at least 1 week.

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12
Q

mood disorders- wards tip

A

irritability often the predominant mood state

poorer response to lithium

anticonvulsants such as valproic acid may be more helpful

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13
Q

mood disorders

A

often chronic
marked by relapses with normal functioning between episodes
may be caused by med condition or drug; always investigate.

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14
Q

medical causes of depressive episode

A 
cerebrovascular disease (stroke, MI)
endocrinopathies (diabetes mellitus, Cushing, Addison, hypoglycemia, hyper/ hypothyroidism, hyper/ hypocalcemia)
Parkinson's
viral illnesses
Carcinoid syndrome
Cancer (esp lymphyoma and pancreatic)
Collagen vascular disease (lupus, etc)
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15
Q

medical causes of a manic episode

A

metabolic (hyperthyroidism)
neurologic disorders (temporal lobe seizures, MS)
Neoplasms
HIV infection

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16
Q

stroke and depression

A

stroke patients increased risk of depression

–> poorer outcome

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17
Q

substance/ med induced depressive disorder

A 
ETOH
antihypertensives
barbiturates
corticosteroids
levodopa
sedative-hypnotics
anticonvulsants
antipsychotics
diuretics
sulfonamides
withdrawal from stiulants (cocaine, amphetamines)
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18
Q

substance/ med induced bipolar

A 
antidepressants
sympathomimetics
dopamine
corticosteroids
levodopa
bronchodilators
cocaine
amphetamines
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19
Q

most common disorder among those who commit suicide

A

major depressive disorder

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20
Q

major depressive disorder

A

marked by episodes of depressed mood associated with loss of interest in daily activities. Pts may not acknowledge their depressed mood or may express vague, somatic complaints (fatigue, headache, abdominal pain, muscle tension, etc.)

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21
Q

Dx of MDD

A

at least one major depressive episode

no history of manic or hypomanic episode

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22
Q

epidemiology of MDD

A

lifetime prevvalence: 12% worldwide
onset at any age, but the age of onset peaks in the 20s
1.5-2 tiems as prevalent in women than men during reproductive years
no ethnic or socioeconomic differences
lifetime prevalence in the elderly: less than 10%
Depression can increase mortality for patients with other comorbidities such as diabetes, stroke, and cardiovascular disease

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23
Q

Sleep problems associated with MDD

A

multiple awakenings
initial and terminal insomnia (hard to fall asleep and early morning awakenings)
hypersomnia (excessive sleepiness) is less common
rapid eye movement sleep shifted arlier in the night and for a greater duration, with reduced stages 3 and 4 (slow wave) sleep

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24
Q

Etiology of MDD

A
  • neurotransitter abnormalities- decreased serotonin
  • increased sensitivity of beta-adrenergic receptors
  • high cortisol
  • abnormal thyroid axis
  • GABA, glutamate, endogenous opiates
  • psychosocial/ life events
  • genetics- 1st degree relatives 2-4x as likely
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25
Q

MDD course and prognosis

A

untreated- self-limiting 6-12 months. More frequently as disorder progresses.
60% respond to antidepressants

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26
Q

when is hospitalization indicated for MDD?

A

if at risk for suicide, homicide, or unable to care for self

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27
Q

SSRIs (and others) for MDD

A

safer and better tolerated than other antidepressants
side effects: headache, GI, sex dysfunction, rebound anxiety
SNRIs (venlafaxine and duloxetine),
alpha2 adrenergic receptor antagonis mirtazapine
dopamine-norepinephrine reuptake inhibitor: bupropion

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28
Q

TCAs and MDD

A

Most lethal in overdose (cardiac arrhythmias
side effects: sedation, weight gain, orthostatic hypotension, anticholinergic effects. Can aggravate prolonged QTc syndrome

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29
Q

MAOIs and MDD

A

Monoamine oxidase inhibitors
older meds; occasionally used for refractory depression
risk hypertensive crisis with sympathomimetics or tyramine-rich foods (wine, beer, aged cheeses, liver, smoked meats)
risk of serotonin syndrome with SSRIs
Most common side effect: hypotension

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30
Q

comparative effectiveness of antidepressants

A

all antidepressant meds are equally effective but differ in side effect profiles. Meds usually take 4-6 weeks to fully work

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31
Q

adjunct meds for MDD

A

atypical (2nd gen) antipsychotics with antidepressants are first-line treatment in pts iwith MDD with psychotic features. Also for resistant/ refractory MDD without psychotic features

Triiodothyronine (T3), levothyroxine (T4) and lithium- some benefit when augmenting antidepressants in refractory MDD

stimluants (methylphenidate) may be used in some (terminally ill, eg), but limited efficacy, small trials

32
Q

Serotonin syndrome

A

autonomic instability, hyperthermia, hyperreflexia (including myoclonus), and seizures. Coma or death may result.

33
Q

when do we use adjunctive treatment for MDD?

A

after multiple 1st-line treatment failures

34
Q

Psychotherapy for MDD

A

Cognitive behavioral therapy, interpersonal psychotherapy, supportive therapy, psychodynamic psychotherapy, problem-solving therapy, and family/ couples therapy have all demonstrated some benefit in treating MDD (primarily CBT or interpersonal psychotherapy)

May be used alone or in conjunction with pharmacotherapy

35
Q

ECT

A

Electroconvulsive therapy

  • if unresponsive to drugs, cannot tolerate, or rapid reduction of symptoms is desired (e.g. immediate suicide risk, refusal to eat/ drink, catatonia)
  • extremely safe (primary risk is from anesthesia), may be used alone or with drugs
  • premedicate with atropine, followed by general anesthesia, administration of a muscle relaxant (typically succinylcholine). Generalized seizure is induced by passing a current of electricity across the brain (generally bilateral, less commonly unilateral); the seizure should last between 30 and 60 seconds, and no longer than 90 seconds
  • 6-12 (average of 7) treatments administered over a 2-3 week period; significant improvement sometimes after first treatment
  • retrograde and anterograde amnesia are common side effects, usually resolve within 6 months.
  • common but transient side effects: headache, nausea, muscle soreness
36
Q

MDD specifier: melancholic features

A

in 25-30% of patients
more likely in severely ill inpatients
anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, anorexia

37
Q

MDD specifier: atypical features

A

hypersomnia, hyperphagia, reactive mood, leaden aralysis, hypersensitivity to interpersonal rejection

38
Q

MDD specifier: mixed features

A

manic/ hypomanic symptoms present during majority of days during MDE: elevated mood, grandiosity, talkativeness/ pressured speech, flight of ideas/ racing thoughts, increased energy/ goal-directed activity, excessive involvement in dangerous activities, decreased need for sleep

39
Q

MDD specifier: catatonia

A

features inclue catalepsy (immobility), purposeless motor activity, extreme negativism or mutism, bizarre postures, and echolalia. Esp responsive to ECT

40
Q

MDD specifier: psychotic features

A

delusions/ hallucinations

24-54% of older, hospitalized patients with MDD

41
Q

MDD specifier: anxious distress

A

feeling keyed up/ tense, restless, difficulty concntrating, fears of something bad happening, feelings of loss of control

42
Q

MDD specifier: peripartum onset

A

occurs during pregnancy or 4 weeks following delivery

43
Q

MDD specifier: seasonal pattern

A

temporal relationship etween onset of MDD and particular time of the year (most commonly the winter but may occur in any season). SAD (seasonal affective disorder) often respond to light therapy.

44
Q

Bereavement

A

= simple grief
rxn to a major loss, usually of a loved one.
not a mental illness.
symptoms usually self-limited, several months. But if an individual meets creteria for a depressive episode, he/ she would be dxed with MDD. Normal bereavement should not include gross psychotic symptoms, disorganization or actve suicidality

45
Q

how do we treat MDD with psychotic features?

A

combination of antidepressant and antipsychotic or ECT

46
Q

Bipolar I disorder involves

A

episodes of mania and major depression

however, episodes of major depression are NOT required for the dx. Also known as manic-depression

47
Q

DX of Bipolar I - DSM criteria

A

only requirement is occurrence of a manic episode (5% of pts only experience manic episodes). Between manic episodes, there may be interspersed euthymia, major depressive episodes, or hypomanic episodes, but none of these are required for the dx

48
Q

Epidemiology of Bipolar I

A

lifetime prevalence 1-2%
women and men equally affected
no ethnic differeces.
high income 2x rate
onset usually before age 30, mean age of first mood episode is 18
frequently misdiagnosed and thereby inappropriately or inadequately treated

49
Q

Etiology of bipolar I

A

biological, environmental, psychosocial, and genetic factors
first-degree relatives of pts with bipolar disorder are 10x more likely to develop the illness
highest genetic link of all major psychiatric disorders

50
Q

Course and prognosis of bipolar I

A

untreated manic episodes generally last several months
course is usually chronic with relapses; as disease progresses, episodes may occur more frequently
90% of individuals after one manic episode will have a repeat mood episode within 5 years
Bipolar has poorer prognosis than MDD
maintenance treatment with mood stabilizing meds between episodes helps reduce risk of relapse
25-50% of people with bipolar attempt suicide

51
Q

Pharmacotherapy of Bipolar I

A

Lithium- mood stabilizer -> partial reduction of mania. Reduces suicide risk. Acute overdose can be fatal (low therapeutic index)

Anticonvulsants: carbamazepine, valproic acid- mood stabilizers. Particularly useful for rapid cycling bipolar disorder and those with mixed features.

Atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone) are effective as both monotherapy and adjunct therapy for acute mania. In fact, many patients (especially with severe mania and/or with psychotic features) are treated with a combination of a mood stabilizer and antipsychotic; studies have shown a greater and faster response with combination therapy.

Antidepressants are discouraged as monotherapy due to concerns of activating mania or hypomania. Occasionally used to treat depressive episodes when patients concurrently

52
Q

ECT and bipolar

A

works well in treatment of manic episodes
some require more treatments (up to 20) than for depression
esp. effective for refractory or life-threatening acutemania or depression

53
Q

Bipolar II is also called

A

recurrent major depressive episodes with hypomania

54
Q

DX and DSM-5 criteria of bipolar II

A

History of one or more major depressive episodes and at least one HYPOMANIC episode. Rember: if there has been a full manic episode, even in the past, then the dx is bipolar I NOT bipolar II disorder.

55
Q

Side effects of lithium

A 
Weight gain
tremor
GI
fatigue
Cardiac arrhythmias
seizures
goiter/ hypothyroidism
leukocytosis (benign)
coma (in toxic doses)
polyuria (nephrogenic diabtes insipidus)
polydipsia
alopecia
metallic taste
56
Q

best treatment for pregnant woman having a manic episode?

A

ECT

relatively safe in all 3 trimesters

57
Q

Treatment fo bipolar disorder- drugs

A

lithium, valproic acid, carbamazepine (for rapid cyclers), or 2nd gen antipsychotics. Lithium remains the gold standard, particularly due to demonstrated reduction in suicide risk.

58
Q

what to do with pt with history of postpartum mania

A

high risk of relapse with future deliveries
treat with mood stabilizing agents as prophylaxis
some meds may be contraindicated in breastfeeding

59
Q

Mnemonic for symptoms of persistent depressive disorder (dysthymia)

A

2 or more of CHASES

poor Concentration
feelings of Hopelessness
poor Appetite or overeating
inSomnia or hypersomnia
low Energy or fatigue
low Self-esteem
60
Q

difference between MDD and persistent depressive disorder

A

MDD is episodic

persistent depressive disorder is pervasive

61
Q

Persistent depressive disorder

A

= dysthymia
chronic depression most of the time
discrete major depressive episodes

62
Q

Persistent depressive disorder Mnemonic

A

DD-2Ds
2 years of depression, 2 listed criteria
never asymptomatic for >2 months

63
Q

Dx and DSM-5 criteria for persistent depressive disorder

A

Depressed mood for the majority of time most days for at least 2 years (in children or adolescents for at least 1 year

At least 2 of the following: poor concentration or difficulty making decisions, feelings of hopelessness, poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem

During the 2 year period: the person has not been without the above symptoms for > 2 months at a time

Never manic or hypomanic

64
Q

Persistent depressive disorder course and prognosis

A

early and insidious onset, with a chronic course. Depressive symptoms much less likely to resolve than in MDD

65
Q

treatment of persistent depressive disorder

A

combo of psychotherapy and pharm most efficacious

Cognitive therapy, interpersonal therapy, insight-oriented psychotherapy are most effective

antidepressants include SSRIs, TCAs, and MAOIs

66
Q

Cyclothymic disorder

A

alternating periods of hypomania and periods with mild-to-moderate depressive symptoms

67
Q

dx and DSM-5 criteria of cyclothymic disorder

A
  • numerous periods with hypomanic symptoms (but not a full hypomanic episode) and periods with depressive symptoms (but not full MDE) for at least 2 years
  • the person must never have been symptom free for >2 months during those 2 years
  • no history of major depressive episode, hypomania, or manic episode
68
Q

course and prognosis of cyclothymic disorder

A

chronic

most –> bipolar I/II

69
Q

treatment of cyclothymic disorder

A

antimanic agents (mood stabilizers or 2nd generation antipsychotics) as used to treat bipolar disorder

70
Q

Premenstrual dysphoric disorder

A

mood lability, irritability, dysphoria, and anxiety that occur repeatedly during the prementrual phase of the cycle

71
Q

dx and DSM-5 criteria for premenstrual dysphoric disorder

A

In most cycles, at least 5 symptoms in final week before menses, improve within a few days after menses, minimal/ absent in the week postmenses (confirm by daily ratings for at least 2 cycles)

  • At least one of: affective lability, irritability/ anger, depressedmood, anxiety/ tension
  • at least one: anhedonia, problems concentrating, anergia, appetite changes/ food cravings, hypersomnia/ insomnia, feeling overwhelmed/ out of control, physical symptoms (e.g. breast tenderness/ swelling, joint/ muscle pain, bloating, weight gain)

Symptoms cause distress/ impairment

not exacerbation of another disorder

not due to a substance or other med condition

72
Q

course/ prognosis of premenstrual dysphoric disorder

A

symptoms may worsen prior to menopause but cease after menopause

73
Q

Treatment of premenstrual dysphoric disorder

A

SSRIs first-line: daily or luteal phase only (day 14, stop on menses or shortly thereafter)
oral contraceptives may reduce symptoms
GnRH agonists have also been used and, in rare cases, bilateral oophorectomy with hysterectomy will resolve symptoms

74
Q

Disruptive mood dysregulation disorder (DMDD) definition

A

chronic, severe, persistent irritability occuring in childhood and adolescence

75
Q

DX and DSM-5 criteria for Disruptive Mood Dysregulation Disorder

A

Severe recurrent verbal and/or physical outbursts out of proportion to situation
more than 3 per week, inconsistent with deelopmental level
between outbursts persistently angry/ irritable most of the day nearly every day, observed by others
at least 1 year, no more than 3 months without symptoms
in at least 2 settings
start before age 10 but dx can be made from age 6-18
no episodes meeting full criteria for manic/ hypomanic episode lasting longer than 1 day
do not occur during MDD and not better explained by another disorder (can’t coexist with ODD, IED- intermittent explosive disorder, or bipolar)
symptoms not due to a substance (medication or drug) or other conditions

76
Q

Treatment of Disruptive Mood Dysregulation Disorder

A

New disorder; no consensus on evidence-based treatments. Psychotherapy, parent management training
meds for comorbid disorders
stimulants, SSRIs, mood stailizers, and 2nd gen antipsychotics have all been used to treat the primary symptoms of DMDD

77
Q

Other disorders of mood in DSM-5

A

Mood disorder due to another medical condition
Substance/ Medication-induced mood disorder
Specified depressive/ bipolar disorder (meets criteria for MDE or bipolar except shorter duration or too few symptoms)
Unspecified depressive/ bipolar disorder

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