Module 3 - Affect Disorders Flashcards
How do you diagnose bipolar disorder?
A distinct period of abnormally and persistently elevated, expansive, and irritable mood for >1week (or admission) +/- grandiose delusions + A distinct period of abnormally and persistently elevated, expansive, and irritable mood for >2 weeks +/- nihilistic delusions.
3 symptoms (or 4 if irritable):
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Talkative or pressure of speech
- Flight of ideas or racing thoughts
- Distractibility
- Psychomotor agitation or increase in
activity (socially, work, sexually)
- excessive involvement in pleasurable
activities with potential neg. conseq.
5 symptoms of:
- depressed mood most of the day
- diminished pleasure in activities
- significant weight loss (>5% /month), or change in appetite
- insomnia or hypersomnia
- psychomotor agitation or retardation
- fatigue or loss of energy
- feelings of worthlessness or guilt
- diminished ability to think, concentrate, or indecisiveness
- recurrent thoughts of death or suicide.
BP-I = mania/mixed +/- depression
BP-II = hypomania + depression
Cyclothymic = hypomania + subdepressive
Young Mania Rating Scale - 12 catergories, points out of 4 or 8 and then >20 is likely to be a manic episode and <12 is in remission.
The Hamilton Rating Scale for Depression - 21 categories out of 2 or 4, 8-13 is mild depression, 19-22 is severe depression.
Symptoms present 50% time, depressive:manic = 3:1, presence sybthreshold 1/3 time, functional impairment in 1/3 cases.
What is the epidemiology?
£2 billion annual cost to UK, 10% NHS use, 4% non-health-care and 86% indirect sots. Lifetime prevalence 1-2%, subthreshold forms of bipolar 5.1%.
10-30yo onset, 50% adults report childhood/adolescent onset. Increase in diagnosis in adolescents (400%) and children (500%) But often diagnosed 10 years late, because heterogeneity, no clear definition episodes.
What are the risk factors for bipolar disorder?
75% heritable, if 2 affected 1st degree relatives. Cross-Disorder Group of PGC 2013
exhaustion, drugs (abuse and medication), seasons, pregnancy, insomnia , family conflict, high grades (15 year olds with A grades 4-fold increased risk, those with poorest grades have double risk)
What is the kindling hypothesis?
Initial episodes are triggered by life stressors but successive episodes may occur autonomously. Possibly changes in receptors, ion channels, sprouting, etc. which causes reorganisations in neuronal circuitry and increased excitability. Found this with epilepsy in mice (amygdala-kindled seizures and then spontaneous). Eg. maybe cocaine increases psychomotor activity and then there’s tolerance and then reverse tolerance which causes sensitisation of brain tissue and neural activity that leads to functional and structural changes.
What is the social rhythm disruption theory?
Episodes are triggered by loss of regular social rhythms and circadian activity patterns.
Life events cause changes in social cues and changes in social rhythms (eg. sleeping patterns, etc.) which and change internal biological rhythms (eg. melatonin, cortisol) and then somatic symptoms (eg. headaches, insomnia) and then an episode.
What is the Behavioural Approach System Dysregulation?
BAS= psychobiological system implicated in facilitating approach to rewards in the environment
(explain reward-related risky behaviours)
Vulnerability/High BAS sensitivity leads to BAS activation or deactivation relevent event (stress) which leads to excessive BAS activation or deactivation and then a manic or depressive episode. Allay 2010
What is the Response Inhibition deficits mechanism?
(hypo)manic risk-taking reflects a
general failure to inhibit behavioral responses regardless of the reward context
Abnormalities in prefrontal and anterior cingulate cortices: involved in cognitive control needed for response inhibition may have a role in the aetiology of BD. Dis Bora 2009
What is Disruptive Mood Dysregulation Disorder?
- Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.
- The temper outbursts are inconsistent with developmental level (e.g., the child is older than you would expect to be having a temper tantrum).
- The temper outbursts occur, on average, three or more times per week.
- The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, friends).
- The above criteria have been present for 1 year or more, without a relief period of longer than 3 months. The above criteria must also be present in two or more settings (e.g., at home and school), and are severe in at least one of these settings.
- The diagnosis should not be made for the first time before age 6 years or after age 18. Age of onset of these symptoms must be before 10 years old.
- There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.
- The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder.
LONG TERM FOLLOW UP SHOWS HIGH RATE OF DEPRESSION AND ANXIETY DISORDER AND NOT BP
What is the prognosis of BP?
Rapid cycling (4 episodes/year), more in women, 16%, less treatment response, 30-40% cases previous exposure antidepressants.
Recurrence - 37% at 1 year, 61% at 4 years.
Polarity - 50-65% start with depressive episode (initial episode presentation is more predominant symptom) and depressive episode has worse prognosis (suicidality increase, earlier onset, rapid cycling, mixed symptoms). Manic polarity is associated with cognitive deterioration.
Bipolar patients have the highest rate of suicide of all psychiatric disorders. (Highest early in illness, male, previous self harm, alcohol and drug use disorders, previous criminality, hopelessness). Non-fatal suicidal behaviour 30%.
Risk of violent (8% in males) and non-violent crime (18% in males) in firs 5 years
BP-II more likely to have hospital admissions and outpatient treatment.
Life expectancy - die 9 years earlier - 2-fold physical illness risk (COPD, pneumonia, CV, cancer) and 10-fold suicide risk women, 8-fold men.
Other comorbidities: OCD 10-fold, substance use disorder 4-fold, anxiety disorder 7-fold, ADHD 7-fold, pathological gambling 2-fold.
What is the pathophysiology of bipolar disorder?
Primary deficit in serotoninergic transmission (mood, memory, sleep, cognition) with catecholamine (DA, NA, A) changes over the top (excessive -> mania, deficit -> depressive)
What is the treatment for bipolar disorder?
Non-pharmacological: Psychoeducation for patient, family, school
CBT, InterPersonal and Social Rhythm Therapy, Family-focused therapy.
Pharmacological: Atypical antipsychotics, mood stabilisers, antidepressants
Manic episode: If a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser, offer haloperidol, olanzapine, quetiapine or risperidone
aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder
Depressive episode: offer fluoxetine +/- olanzapine, or quetiapine on its own, or (second-line: lamotrigine)
Long term: Lithium, second-line: + valproate (not girls of reproductive age), if lithium poorly tolerated: consider valproate or olanzapine instead or, if it has been effective during an episode of mania or bipolar depression, quetiapine.
Lithium and divalproex possibly neuroprotective, increase neurotrophic factors and decrease apoptosis.
What is the epidemiology of depression?
4-10% MDD, 2.5-5% Dysthymia DALYS: -> 1990, 4th most common -> 2020 2nd most common Adults with depression, 75% had psychiatric diagnosis before 18 years, 50% before age 15 years Worse physical health outcomes Suicide: 1% all deaths, 2/3 depressed Violence against others Marital family relationships, child neglect
What are the symptoms of depression?
Symptoms pervasive, Impairing, Present for at least 2 weeks: Low mood/sadness Anhedonia Loss of energy Changes to: Appetite / Weight-(+/-) Sleep- (+/-) Poor Concentration Thoughts:Pessimism,Guilt Self esteem/confidence Libido Psychomotor agitation/retardation Self harm / Suicide Associated with anxiety disorders, eating disorders and conduct problems. Mild, moderate, severe With/without psychotic features
ICD 10 1.Dep D/O- Single episode 2.Dep D/O- Recurrent 3.Persistent: Dysthymic D/O DSM-5 1.Major Depressive Disorder 2.Persistent Depressive D/O 3.Disruptive Mood Dysregulatn 4.Premenstrual Dysphoric D/O
Subgroup seasonal patterns
What is adolescent depressive disorder?
Irritability instead of sadness/low mood
Especially in boys
Somatic complaints and social withdrawal are common
Psychotic symptoms rare before
mid- adolescence
2-6%
Females 2x more likely than males at 15yo
- High rates of persistence and recurrence (20% in 1 yr) Lewinson 1994
- Adol DepDisorder -> 40-70% recurrence in adulthood
-> 2-7x increased risk as an adult Rao et al, 1998
What is the treatment for depression?
The amine hypothesis suggests that depression results from hypo-activity of monoamine neurotransmitter reward systems
Increased gonadal hormones ->? Direct CNS effect mood (Oestradiol)
Mild depression Cognitive behavioural therapy [Individual or group] Interpersonal psychotherapy for adolescents Moderate – Severe Depression Antidepressants eg SSRI’s: fluoxetine Could be SSRI + CBT Lasts on average 4 to 6 months Relapse common (50%+ >1 episode)
Experience sampling/Eco. Momentary Ass (EMA)(Armey et al 2015) ?
Neural predictors: animal studies, imaging (PET fMRI) ->
Fronto-limbic interactions, hippocampal size, neurogenesis (Heller 2015)
Exercise: ?Mild to moderate, ?Neuroinflammation/trophins
Pharmacogenetics (Zajkowska, 2014)
Therapygenetics (Eley et al 2012)
Internet-based therapies (Cuijpers et al, 2015)
Prevention, guided self help, blended, relapse prevention, maintenance
