Depressive/Anxiety Disorders and Bipolar with related disorders

Question 1

If a patient comes in with loss of interest in things they used to enjoy (anhedonia) what should you think first?

Answer 1

Depression

Question 2

How do dopamine levels differ in mania vs. depression

Answer 2

Dopamine decreases in depression and increases in mania

Question 3

How are serotonin levels in depression? what drugs are effective anti-depressants that help with this?

Answer 3

Decreased, SSRIs

Question 4

What was the main example he gave as a life event that can precede the first mood episode?

Answer 4

• death of a family member (think caregiver- could be a parent, grandparent) before age 11
• the death of a child may also be the case

Question 5

How do you classify Major Depressive Episode?

Answer 5

At least five of the following for a 2-week period with at least one either (1) depressed mood or (2) Loss of interest (anhedonia)

• depressed mood
• diminished interest
• weight loss or gain
• insomnia or hypersomnia
• psychomotor agitation or retardation
• fatigue or loss of energy
• fellings of worthlessness
• diminished thinking/concentration
• recurrent thought of death or suicide

Question 6

How do we classify Major Depressive Disorder?

Answer 6

Diagnosis requires the presence of one or more major depressive episodes and the absence of any manic, hypomanic, or mixed episodes

• Associated features

psychotic, anxious, melancholic, Catatonic (shock them), peripartum onset, mixed features

Question 7

What are somatic therapies used for Major Depressive Disorders?

Answer 7

TCAs - Hill used nortriptyline

MAOIs

SSRIs

Triazolopyridines - trazadone (priapism)

buproprion (seizure risk)

SNRIs

Mirtazapine

Question 8

What is ECT and what is it used for?

Answer 8

Electroconvulsive therapy - used for resistant depression and has great efficacy

75-80% treatment response

Question 9

(Exam) - how do we classify Persistent Depressive Disorder

Answer 9

• Depressed mood for most of the day (at least 2 years in duration for adults and 1 year for children) that has not been severe enough to meet criteria for major depressive episode
• During 2 years, cannot be w/o sx for 2>months at a time should be continuous

Question 10

What is depression with seasonal pattern? what are some of its characteristics?

Answer 10

Essential feature is the onset and remission of major depressive episodes at charcteristic times of the year (fall/winter)

Question 11

What is premenstrual dysphoric disorder (PMDD)?

Answer 11

• Mood instability with anxiety, depression, irritability and will occur the week before menstruation.
• Tx: SSRIs, exercise, diet, relaxation therapy

Question 12

How do we classify a manic episode?

Answer 12

Abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week with at least three of the following:

During the mood disturbance and increased energy, three of the following:

• inflated self esteem (grandiosity)
• Decreased need for sleep
• more talkative (pressured/push of speech)
• flight of ideas and racing thoughts
• distractibility
• increased Goal-oriented behavior
• excessive involvement in pleasurable activities

Question 13

What is a hypomanic episode?

Answer 13

• Similar to manic episode but is less severe, episode only need to last 4 days and must not include psychotic features
• unlike manic episode there is no social/occupational impairment

Question 14

What is Bipolar 1 Disorder?

Answer 14

• Single manic episode is necessary to diagnose. (patient only needs on “pole” of the bipolar for this diagnosis)

Question 15

How does Bipolar 1 Disorder usually present first?

Answer 15

Major depressive episode, note: that you do not have to have depression for diagnosis

Question 16

How do we classify/diagnose Bipolar 2 disorder?

Answer 16

Patients have had at least one major depressive episode and one hypomanic episode in the absence of any manic or mixed episodes

Note: this is more prevalent than Bipolar 1

Question 17

What is the treatment for Bipolar Disorders?

Answer 17

Mood stabilizers

• lithium
• Valproic acid

Carbamazepine

SGAs

Lamotrigine - Side effect SJS-TEN rash up the neck and is life threatening

Question 18

What is Cyclothymic Disorder?

Answer 18

• characterized as dysthymic disorder with intermittent hypomanic periods.
• Patient who, over the last 2 years (1 year for children), experiences repeated episodes of hypomania and depression (not severe enough to meet criteria for major depressive disorder)

Question 19

How do we classify Panic Disorder?

Answer 19

1 - Reccurent unexpected panic attacks

2 - At least one attack followed by 1 month or more of one or more:

• persisten concern about additional attacks
• worry about the implications of the attack or its consequences
• significant change in behavior related to the attacks

Question 20

How do we classify panic attacks?

Answer 20

A discrete period of intense fear or discomfort, in which four or more of the following developed abruptly and reached peak within 10 minutes and usually last <25 minutes: now specific as “unexpected and expected” panic attacks.

• palpitations, sweating, trembling, SOB, chest pain, dizzy, fear of losing control or going crazy/death, paresthesias, chills or hot flashes

Question 21

What is the average of onset for panic disorder and which gender is more affected?

Answer 21

2-3x more prevelant in females, average age of onset is 25

Question 22

What is Generalized Anxiety Disorder?

Answer 22

• Excessive worry and anxiety (apprehensive expectation), occuring more days than not or at least 6 months, for most of day, about a number of events or activities
• It is difficult control the worry
• The anxiety and worry are associated with at least three persisting for more days than not of the past 6 months:
• restlessness or on edge
• easily fatigued
• difficulty concentrating
• irritability
• muscle tension
• sleep disturbances

Question 23

How do we classify obsessions?

Answer 23

• recurrent or persistent thought, impulses, or images experienced as intrusive and inappropriate and causing marked anxiety or distress
• person attempts to ignore or suppress thoughts

Question 24

How do we classify compulsions?

What is the goal of the compulsions?

Answer 24

• repetitive behaviors or mental acts that the person feels drive to perform.
• Aimed at preventing or reducing distress or preventing some dreaded event/situation

Question 25

How do obsessions and compulsions effect patients life?

Answer 25

marked distress consuming > 1hour per day and interferes with functioning.

Question 26

Depression Mnemonic - SIG E CAPS what does it stand for?

Answer 26

S - sleep-lack of

I - Interest lack of (anhedonia)

G - Guilt

E - Energy lack of

C - concentration lack of

A - appetite changes

P - psychomotor (catatonic)

S - Suicidal ideation

Question 27

Mnemonic for Manic - DIG FAST

Answer 27

D - Distractibility

I - inflated self-esteem, impulsive

G - grandiosity

F - Flight of ideas

A - Activity (increased) / agitation

S - Speech - pressured or pushed

T - Thoughtlessness

Question 28

Dysthymic Mnemonic - CHASES

Answer 28

C - Concentration - poor

H - Hopelessness

A - Appetite - poor

S - sleep (insomnia)

E - energy low

S - self esteem low