Exam 2 Mood disorders Flashcards
What are the various mood disorders
- Depression: Major Depressive Disorder (MDD); Dysthymia
- Bipolar disorder: Type 1, Type 2, Cyclothymia
- Adjustment Disorder:
- with depressed mood
- with anxiety
- with mixed anxiety and depressed mood
- with disturbance in conduct
- with mixed disturbance of emotion and conduct
- unspecified
S/sx of MDD
- persistent low mood, depressed mood, anhedonia
- loss of interest and enjoyment
- neurovegetative disturbance (slowed down)
- Reduced energy, poor concentration
- social and occupational dysfunction
- weight, libido and sleep changes
- Psychomotor problems
- excessive guild, suicidal ideation
DSM criteria for MDD… LONG LONG LONG
[A]. Presence of Major depressive episode (single or recurrent)
1) Sx present of at least TWO WEEKS. at least one of the sx is either DEPRESSED mood OR LOSS OF INTEREST or pleasure:
- (a) depressed mood most of the day, nearly every day. Children/adolescent can be irritable mood
- (b) markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day
- (c) sig wt loss/gain or increase or decrease in appetite
- (d) Insomnia or hypersomnia nearly every d
- (e) psychomotor agitation or retardation
- (f) fatigue or loss of energy nearly every d
- (g) feelings of worthlessness or excessive or inappropriate guilt
- (h) Diminished ability to think or concentrate or indecisiveness
- (I) recurrent thought of death (not just fear of dying), recurrent suicidal ideation w/o a specific plan or a suicide attempt or a specific plan for committing suicide
2) Not mixed episode
3) Clinically sig impairment
4) not due to drug or GMC
5) NOT BEREAVEMENT
[B] not attributed to schizoaffective disorder or superimposed on other psychotic disorder
[C] no hx of manic, mixed or hypomanic episodes
ways to remember MDD sx ( remember, must have been present at least 2 wks everyday and one being depressed mood or loss of interest/pleasure )
SIG E CAPs
Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor changes, Suicide
*write for (SIG) some Energy (E) Capsules (CAPs)
MDD specifiers re. psychotic features
Mild, moderate, severe with or Severe without psychotic features
MDD specifiers re. time/chronic
*chronic: >2yr continuous
MDD specifiers re. catatonic features
*with CATATONIC features: immobility, echolalia, echopraxia
MDD specifiers re. melancholic features
with MELANCHOLIC features (anhedonia, or no rxn to pleasure, worse in AM, early AM awakening, marked psych changes, sig wt loss, guilt) (usually older pt)
MDD specifiers re. atypical features
MOOD REACTIVITY, wt gain, hypersomnia, LEADEN PARALYSIS, interpersonal rejection sensitivity leading to sox/oxx impairment (usually younger pt)
MDD specifiers re. postpartum/preg features
With postpartum onset (within 4 weeks)
MDD specifiers re. seasonality
With seasonal pattern (ie winter depression)
*think seattle and maine
What ways can you screen for MDD/depression
PRIME-MD (primary care evaluation of mental disorders)
Patient Health Questionnaire (PHQ-9)
Edinburg Depression Score for Postpartum Depressions
Based off the Patient health questionnaire (PHQ-9), what criteria qualify for MDD
Checked #s 1 or 2 at level of “nearly every day” AND:
- 5 items from #s 3-9 checked at level of “for more than half” or “nearly every day”
- SI (suicidal ideation?) always counted if + response regardless of severity
*Cannot make MDD dx until it is confirmed that pt is w/o hx of hypomanic or manic episode, underlying med condition or drug causing sx and situation of “normal bereavement”
Score of 15-19 = moderately severe, initiate psychopharmacotherapy and/or refer for psychotherapy
Interpreting PHQ-9 results (MDD)
0-4 = none/minimal depression –> no tx
5-9 = mild depression –> watch/wait/reevaluate
10-14 = moderate –> consider referral for psych meds and/or therapy
15-19 = moderate/severe –> initiate pscyh meds and/or refer for therapy
20-27 = severe –> initiate psych meds, may expedite therapy referral
DSM dx criteria for dysthymia
A) depressed mood for most of the day for more days than not as indicated by self or others for at least TWO YEARS
B) Presence while depressed, of TWO OR MORE:
(1) poor appetite or overeating
(2) insomnia or hypersomnia
(3) Low energy or fatigue
(4) Low self-esteem
(5) poor concentration or difficulty making decisions
(6) feelings of hopelessness
{{Eat, sleep, energy, esteem, concentration/decisions, hopelessness}}
[C] during the TWO YEAR PEROID (ONE if child/adoles), the person has never been without the sx in Criteria A and B for >2mth at a time
[D] No MD episode during first 2 yr disturbance
[E] never a manic episode
[F] does not occur during course of psychotic disorder
[G} not due to GMC or substance
[H} sx cause clinically sig distress or impairment
Tx of mild/moderate dysthymia//MDD
Antidepressants (SSRI/SNRI)
Psychotherapy (CBT, IPT)
*IPT = interpersonal threapy
Tx of severe dysthymia/MDD
Antidepressants: SSRI/SNRI, mirtazapine (alpha 2 antagonist, good for older bc wt gain), TCA (cardiotoxic)
Psychotherapy: CBT
Reasonable Alt: ECT
Citalopram, escitalopram, fluoxetine, fluvoxamine CR, Paroxetine CR, Sertraline… class
SSRI
venlaxafine, duloxetine, milnacipran … class of med
SNRI
Atypical anti depressants
Bupropion, Mirtazapine
What is Bipolar affective disorder:
Manic Depression
Abnormally elevated or irritable mood, with increased goal directed activity
Disruptive sx > 1 WEEK
- distractibility
- indiscretions (sexual or financial)
- Grandiosity
- flight of ideas
- Hyperactivity
- decreased need for sleep
- talkativeness
Definition: flight of ideas
*corresponding disorder?
Bipolar affective disorder
- rapid continuous play on words produce constant shift from one idea to another
Pressured speech? associated disorder?
Tendency to speak rapidly and frenziedly as if motivated by an urgency not apparent to the listener
_ associated with bipolar affective disorder
Characteristics of Bipolar Type 1
“Manic Depressive Psychosis”
- distinct period of abnormally and persistently elevated, expansive or irritable mood lasting AT LEAST 1 WK
- Major Depressive episode NOT REQURED for diagnosis
Characteristics of Bipolar Type II
Hypomanic period lasts MIN of 4 DAYS
- must include hx major depressive episode
- no marked impairment in social or occupational function
- less severity/shorter duration
Characteristics of Cyclothymia (class of bipolar affective disorder)
Alt periods hypomania and mild depression
- does NOT meet criteria for major depressive episode
- sx present at least 2 YEARS
dx criteria BAD type I (Manic depressive psychosis)
[A] currently or recently in Manic episode (see criteria)
[B] at least 1 previous MDD, Manic or mixed episode
[c} not better explained by other disorder
criteria for manic episode (part of BAD type I dx) (7 possible)
[1] At least one week of abnormally and persistently elevated, expansive or irritable mood
[2] during period of mood disturbance, 3 or more of the follow (4 if mood only irritable) - *think DIGFAST
– inflated self esteem/grandiosity
– decreased sleep need
– talkative
– flight of ideas, racing thoughts
– distractibility
– increase goal directed activity or psychomotor agitation
– excessive involvement in pleasurable activities that have high potential for painful consequences
[3] marked functional impairment or required hospitalization to prevent harm to self/others or psychosis
[4] not due to drug or GMC
mnemonic to help remember mania dx (7 possible)
((at least 1 wk elevated/expansive/irritable with 3 or more (4 if just irritable) of the following:))
DIGFAST
distractibility, impulsivity, grandiosity, flight of ideas, activity (increased goal directed), sleep (decreased), talkative
Dx criteria for BAD type II
[A] presence/hx of 1+ major depressive episode
[B] presence/hx of 1+ hypomanic episode
(a) persistently elevated/expansive/irritable mood lasting FOUR DAYS, clearly different from usual
(b) Three+ (4+ if irritable) of the following present:
–> self/esteem/grandiosity
–> decreased sleep needs
–> talkative
–> flight of ideas/ racing thoughts
–> distractibility
–> increase in goal directed activity
–> excessive involvement in pleasurable activities with high potential for consequence (impulsivity)
(c) clear change in functioning, uncharacteristic of person
(d) change in mood and functioning observable by others
(e) not severe enough to cause marked impairment in social or occupational functioning or to require hospitalization; no psychosis
(f) not due to drug or GMC
[C] no hx of manic or mixed episode
[D] not other d/o
[E] clinically sig distress/impairment
Complete criteria (including manic episode criteria) for BAD Type 1
[A] currently or recently in Manic episode (see criteria below)
[B] at least 1 previous MDD, Manic or mixed episode
[c} not better explained by other disorder
——————————
Manic episode criteria:
[1] At least ONE WEEK of abnormally and persistently elevated, expansive or irritable mood
[2] during period of mood disturbance, 3 or more of the follow (4 if mood only irritable) - *think DIGFAST
– inflated self esteem/grandiosity
– decreased sleep need
– talkative
– flight of ideas, racing thoughts
– distractibility
– increase goal directed activity or psychomotor agitation
– excessive involvement in pleasurable activities that have high potential for painful consequences
[3] marked functional impairment or required hospitalization to prevent harm to self/others or psychosis
[4] not due to drug or GMC
—————————————–
diagnostic criteria for hypomanic episode (part of BAD type II dx)
(a) persistently elevated/expansive/irritable mood lasting FOUR DAYS, clearly different from usual
(b) Three+ (4+ if irritable) of the following present:
- -> self/esteem/grandiosity
- -> decreased sleep needs
- -> talkative
- -> flight of ideas/ racing thoughts
- -> distractibility
- -> increase in goal directed activity
- -> excessive involvement in pleasurable activities with high potential for consequence (impulsivity)
MAIN distinction bw hypomanic episode and manic episode
manic = at least one week of persistently elevated/ expansive or irritable mood
Hypomanic = at least 4 days
What is the mood disorder questionnaire? what does a positive screen reveal, and recommendations?
MDQ screens for Bipolar spectrum Disorder (Bipolar I, Bipolar II and Bipolar NOS)
Postivie Screen
- YES to at least 7/13 items in #1
- YES to #2
- MOD or SERIOUS to #3
- -> positive screen should be followed by comprehensive medical eval for bipolar spectrum disorder
BAD I and II comorbidity?
MOST have at least 1
- substance abuse, anxiety, ADHD, PD (BPD, NPD)
Tx recommendations for BAD I and II: manic phase
a) antimanic agent: Lithium (Lithobid) or Valproate
AND
B) 1st gen or atypical neuroleptic:
- aripiprazole (abilify)
- risperidone (Risperdal)
- Olanzapine (zyprexa)
- Quetiapine (Seroquel)
Tx recommendations for BAD I&II depressed phase
a) antimanic agent and/or anticonvulsant
And/or
c) Atypical neuroleptic
And/or
d) antidepressant combo (olanzapine/fluoxetine (symbyaz), omega 3 FA, ECT
Tx recommendations for BAD I&II maintenance phase (*note, whatever is used to treat manic phase is usually what is used for maintenance)
- Antimanic agent (lithim)
- Anticonvulsant (valproate, lamotrigine (Lamictal))
- Atypical neuroleptic (Risperidone/Risperdal)
Lithium (lithobid) PK, SE, monitoring, toxicity
(tx for BAD I, II (antimanic))*
Kidney metab; steady state in 5 days, once daily dosing
*monitor Lithium level (0.6-1.2), TSH, BMP, CBC, Pregnancy test (risk congenital anomalies)
SE: abrupt decrease –> mania, suicidal ideation, decrease future response to lithium; tremor, wt gain, ND, leukocytosis, hypothyroid, nephrogenic DI, interstitial nephritis
Toxicity: NVD, muscle fasiculations, DELIRIUM, EKG changes, SEIZURE, KIDNEY FAILURE, DEATH
Interactions: NSAIDS, ACEI, cox2 inhibitors, ASA, Plavix
Lithium side effects/ toxicity (tx for BAD I, II (antimanic))
abrupt decrease can cause mania, suicidal thoughts, and reduce future response to lithium
SE: tremor, weight gain, Nausea, diarrhea, hypothyroid, nephrogenic DI, interstitial nephritis
Toxicity: Delirium, EKG changes, muscle fasiculations, kidney failure, seizure, death
drug interactions with lithium (tx for BAD I, II (antimanic))
NSAIDS, ACEI, Plavix, cox 2 inhibitors, ASA
Valproate (Depakote) PK, monitoring, warnings, SE
*anticonvulsant used in BAD I, II and maintenance as antimanic
PK: metab in liver (CI if hepatic dysfunction) , steady state in 3 days
Monitor: CBC, CMP & valproic acid level (therapeutic 50-125) *if LFT>3x normal, STOP; if elevated but <3x normal, monitor weekly
Black box: HEPATOTOXIC, pancreatitis, teratogenicity
SE: pancytopenia, GI upset, sedation, alopecia, hirsutism, PCOS
Warnings and SE of Valproate (Depakote)
anticonvulsant used in BAD I, II and maintenance as antimanic
Black box: hepatotoxic, pancreatitis, teratogenicity (neural tube defects)
SE: wt gain, GI upset, sedation, pancytopenia, alopecia, hirsutism, PCOS
Lamotrigine (Lamictal) use, warning, metab, SE, interactions
ONLY approved for BAD Maintenance (not an antimanic)
Black box: aseptic meningitis
Metab: liver, risk SJS, dose to decrease risk (slow titration)
SE: GI, HA, dizzy, SI, rash, SJS
Int: decreased by OCs
What is Cyclothymic disorder
- Chronic fluctuating mood disturbance with numerous periods of hypomanic and depressed sx, does not meet critera for BAD or MDD
- onset adolescence or early adult (later onset could suggest GMC (MS))
- 15-50% risk developing BAD I or II
DSM criteria for cyclothymia dx
[A] at least 2 yr of numerous periods w hypomanic sx & numerous pd w depressive sx
[B] not sx free >2 consecutive mth
[C] No MD, manic or mixed episode present in 1st 2 yr
[D] not better accounted for by other psych d/o
[E] not due to drug or GMC
[F] clinically sig distress/ impairment
Tx of cyclothymia
Less evidence
first line: mood stabilizers
*could consider antidepressants with caution
What is the essential feature of adjustment disorders
psychological response to an identifiable stressor(2) resulting in clinically sig emotional or behavioral sx
what are the criteria for adjustment disoder dx
a) sx develop w/in 3mth
b) sig impairment in social/ occupation
c) criteria not met for another axis I disorder
d) r/o bereavement
e) must resolve w/in 6 mth
what are the subtypes of adjustment disorder
a) with depressed mood
b) with anxiety
c) with mixed anxiety and depressed mood
d) with disturbance in conduct
e) with mixed disturbance of emotion and conduct
f) unspecified
If adjustment d/o sx continue after stressor removed and there are difficulties in sleep, appetite, concentration and energy.. ddx?
MDD
other potential: Mood d/o rom substances or GMC; PTSD, bereavement
Tx of adjustment disorder
Psychosocial tx
- designed to have impact on whatever habits, conflicts, developmental inadequacies or disturbing social sx are thought to be the source of the pt problem
