Depressive/Bipolar/Related disorders Flashcards
Major Depressive Disorder
EDC: must experience at least 1 major depressive episode, can’t have a history of mania or hypomania, must be unipolar depression
-usually incidence in 20’s persist 6-12 months likely recurrent and some develop mania
ASSOCIATED- anxiety, substance abuse, increased mortality and morbidity
-if going through berevement, use clinical judgement
Depressive episode
at least two weeks of 5 or more of
Affective-depressed mood anhedona, Neruovegetative-significant weight change, insomnia/hypersomnia, loss of energy,Cognitive- psychomotor changes, feeling guilty/worthless, decreased concentration, suicidal ideation.
SIG ECAPS
Sleep change, interest loss, guilt, Energy problem, concentration, Appetite change, Pyschomotor changes, Suicidal ideation.
MDD- melancholic
severe anhedonia, lack of mood reactivity, profound depondency and guilt. depression worse in the mornings, early morning awakenings, significant appetite loss
MDD-atypical features
mood reactivity, weight and sleep increase, leaden paralysis
MDD- Psychotic Features
Hallucinations or delusions
- mood incongruent- content of Hal/Del does not involve typical depressive themes
- Mood congruent- content is conssitent with depressive themes
MDD with catatonia
waxy flexibility, stereotypes, odd posturing
MDD anxious distress
MDE with feeling tense, restelss and fearful
MDD with peripartum onset
MDE during pregenancy or post delivery (4 weeks)
MDD with seasonal pattern
consistentwith temporal relationship between time of year and MDE
Normal Grief vs MDE
Normal- emptiness loss, decreases over time and occurs in waves, preoccupied with memories of deceased, Self esteem preserved, less likely to have ruminations of death and if present want to reunite with deceased, unlikely to have an MDE
MDE- Persistent depressed mood with inability to anticipate happiness pleasure, persistent intensity without waves, self critical/loathing pessimism. want to end life because of undeserving worthless, likely to have another MDE
Etiology of MDE
10% general , 20% if 1st degree relative, 30% if MZ cotwin.
has environmental stressors as triggers, with neuroendocrine dysfunction and decreased monoamines.
HPA axis
normal- stressor–>amygdala–> hypothalamus–> ant Pit–> Adrenal Glands–> cortisol–> hippocampus (glucocoritcoid receptor)–> stops production of CRH
Depressed- Cortisol toxicity damages FR’s in teh hippocampus and hypothalamus continues production of CRH failure of suppression of the HA axis
Dexamethasone Supression test
MDD show non supression of cortisol on the DST which shows impaired negative feedback.
effects of Chronic HPA activation
Anxiety, Depressive symptoms(affecuts neurons in raphe n. and locus ceruleus which decreases monoamines), immune dysregulation.
treatment for MDD
pyschotherapy- talk therapies to help address symptoms
antidepressant drugs to help increase monoamines and serotonin levels( take 3-4 weeks to show effects, min duration of 6-12 months, slightly above placembo for mild and notable for moe severe)
ECT- electrical induction of a generalize seizure, pretreated with muscle relaxant and anesthetic to reduce consciousness- used to treat acute depression.
Transcranial magnetic Stimulation- magnetic pulses are generated and used to stimulate a patients cortex
Vagus Nerve Stimulation- intermittent electrical stimulation of the vagus nerve, FDA approved for treatment resistant MDD- risks of surgery implantation mild effects of stimulation.
Antidepressants
SSRIs inhibits uptake of serotonin-
SNRI inhibits uptake of serotonin and norepinephrine
TCAs- Tricyclic antidepressants- Monoamine reputake inhibitors, have cardiac side effects(postural hypotension and tachycardia
MAOIs- monoamine oxidase inhibitors- diet restrictions to avoid tyramine induced hypertention
Black box on ads
could cause suicide
Serotonin syndrome
hyperthermia tachycardia, hypertension and delirium. ADs are switched without adequate washout period.
MOA of ECT
multiple indiscrimante CNS effects, no mechanism identified, used with treatment resistant of depression, severe depression or preganant depressed.
Contraindications of ECT
vascular disease, can cause initial side effects of cardiac arrhythmias, headache and confusion, some memory loss for recent long term memory and some encoding deicculties surrounding sessions
Persistent depressive disorder
DC depressed mood for longer than 2 years with at least two of the following.
- Poor appetite or overeating
- insomnia/hypersomnia
- low energy
- low self esteem
- trouble concentrating or making decisions
- feelings of hopelessness
- No MDE and is subthreshold- pure dysthymic syndrome
- MDE then diagnose PDD with persistent MDE or intermittent MDE
PDD with pure Dysthymic syndrome
low self image, brooding sullen, pessimistic, appetite sleep and energy have always been low
treatment of PDD
same as MDD treatments, more invasive MDD treatments may be used for PDDs that involve MDEs
PMDD
present in the week before menses onset, improve a few days after mensesand minimized in the weeks post menses
-mood lability, irritability, dysphoria and anxiety symptoms
-anhedonia, problems concentration, lethargy, appetite and sleep change, physical symptoms. (breast tenderness and weight gain)
MUST CAUSE SIGNIFICANT DISTRESS or FUNCTIONAL IMPAIRMENT.
Treatment of PMDD
SSRI’s taken intermittently or continuously, also birth control pills, nutritional supplements, diet and lifestyle changes, no caffeine and carbohydrate rich diets.)
DMDD
DC- severe temper outbursts at least 3x/week
- Sad, irritable or angry mood almost every day
- reaction is disproportionate to situation
- symptoms are present in at least 2 settings.
- symptoms begin before age 10, don’t diagnose before 6 years or after 18.
difference between bipolar and DMDD
bipolar irritability is episodic
-DMDD kids are more at risk for generalized anxiety or MDD as an adult, not bipolar.
Bipolar I Disorder (Manic Depression)
DC- must experience at least 1 Manic Episode
- Most also experience MDE but not necessary for diagnosis
- mean age of onset is 18,
- mania usually occurs directly before MDE and lasts about 3 months
- rule out another medical condition and substance intoxication
- although the genes are unknown, BPI is highly heritable, more genetically controlled than MDD, Manic episodes involve increased monaminergic activity
Manic Episode
abnormally elevated mood or irritability PLUS increased energy. Must have 3 symptoms.
- inflated self esteem/grandiosity
- decreased need for sleep
- pressured speech
- flight of ideas
- distractibility
- increased goal directed energy or psychomotor agitation
- excessive involvement in risky activities
- symptoms last at least a week, marked ipairment in functioning
Bipolar Specifiers
mixed features- MDE symptoms occur throughout the same time period as mania
rapid cycling- patient experiences greater than 4 mood episodes/year
psychotic features- delusions or hallucinations are present
Treatment for BP I
mood stabilizers- lithium, anticonvulsants, antipsychotics
Antidepressants- are used off label and mood stabilizer is added.
Antipsychotics- the only FDA approved drugs for BP depression fall in this class and are different from those used to treat mania.
ECT- improves both manic and depressive states
Pyschotherapy- used for secondary issues but not to treat the primary symptoms. `
BP II
a person experiences at least 1 MDE and at least 1 hypomanic episode.
-more disruptive problem is depressed state
treatment is same as for BP I in using bipolar depressive drugs.
Hypomanic episode
Hypomania includes the same symptoms of mania but different in severity,
- doesn’t cause marked impairment.
- change in mood must be unequivicoal and uncharacteristic of person.
- hypomania must last at least 4 days
Cyclothymic Disorder
DC: for greater than two years, a person experiences periods of hypomanic symptoms that fluctuate with periods of depressive symptoms
- must not meet criteria for MDE. Similar to Bipolar I but the mood shifts are not as extreme.
- can change diagnosis to BP I
- Treatment- Mood stabilizers (as For BP I)
Distinguishing Bipolar from Uniolar MDE’s
Bipolar disorders, MDE may be the patients first major mood episode prior to a manic or hypomanic episodes
-Because of treatment implications, it’s important to determine whether a MDE reflects MDD or a bipolar disorder.
BP vs MDD
Family History-1.BP almost uniform, 2.MDD sometimes
First MDE episode less than 25- 1.Very common, 2. sometimes
MDE frequency- 1.Frequent 2. Less Frequent
MDE duration less than 3 months- 1.Suggestive 2 Unusual
Atypical Features- 1.Common 2. Occasional
EMAs and Insomnia- 1.More likely 2. Less Likely
Psychotic Features- 1.highly perdictive 2. Uncommon
Postpartum onset 1. Very Common 2. Sometimes
