Mood and Other Disorders Flashcards
Adjustment Disorder diagnostic criteria ?
Emotional or behavioral issues in response to identifiable stressors (such as the death of a loved one) within 3 months of the event
like start of PA school
Adjustment Disorder: Clinically significant as follows ?
Displays marked stress
- Anxiety, low mood, insomnia, worry, poor concentration
Significant social, occupational or other impairment
No not represent normal bereavement
IF YOU SEE SOMEONE DIE IT IS MORE LIKE ACUTE STRESS INJURY
Once stressors end this should resolve in ~ 6 months – if not consider other comorbidities
Adjustment Disorder sub-classifications
Depressed mood
Anxiety
Disturbance of conduct
Mixed emotions
Adjustment Disorder prevalence ?
~12% of the U.S. population
Adjustment Disorder etiology and risk factors ?
The most frequent confirmed diagnoses associated with adjustment disorder were personality disorders, organic mental disorders (something wrong in the brain like dementia), and psychoactive substance abuse disorders
Adjustment Disorder genetics ?
unclear
Adjustment Disorder DDx ?
Depression
Posttraumatic Stress
Disorder
Acute Stress Disorder
Personality Disorders
Adjustment Disorder prognosis ?
Very good
Adjustment Disorder medications ?
SSRIs
Benzodiazepines - mainly used for alcohol withdrawal to prevent siezures or for anxiety
Adjustment Disorder procedures / therapy /surgery ?
Counseling (i.e. CBT)
Major Depressive Disorder diagnostic criteria ?
-Five or more during the same 2 week period and represent a change in previous functioning:
Depressed mood
Markedly diminished interest or pleasure
Significant weight loss/gain
Insomnia/hypersomnia
Psychomotor agitation or retardation - very amped up or very amped up
Feelings of worthlessness / guilt - big ones
Diminished ability to concentrate
Recurrent thoughts of death/suicide
- Do not meet mixed episode
- Cause significant distress
- Not due to drugs or metabolic
- Not better explained by other disorder (i.e. death of a loved one)
what can help document and is an assessment to give to patients for Major Depressive Disorder
PHQ-9
PHQ-9 (Patient History Questionnaire): The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM-IV (Diagnostic and Statistical Manual Fourth Edition). This can help track a patients overall depression severity as well as the specific symptoms that are improving or not with treatment.
Major Depressive Disorder prevalence ?
3.6-6.7%
Major Depressive Disorder etiology and risk factors ?
Life events and Personality (worried type)
Major Depressive Disorder genetics ?
Familial but not well understood
Major Depressive Disorder DDx ?
Medical / Neuro / Infectious /
Medications
Substance Abuse
Neoplasms (Pancreas, bronchogenic, CNS tumors…)
Metabolic (hypothyroidism…many others)
Collagen-Vascular (i.e. SLE)
Postpartum
Major Depressive Disorder prognosis ?
Many recover but ~15% commit suicide
Major Depressive Disorder medications ?
SSRI (typically 9 months to lifetime)
MAOI’s (many side effects)
Major Depressive Disorder procedures / therapy / surgery ?
CBT
ECT (electroconvulsive therapy)
Interpersonal
Couples / Marriage
Persistent Depressive Disorder (Dysthymia) diagnostic criteria ?
Think: Low-grade persistent depression
Depressed mood most of day for more days than not for at least 2 years
2 or more:
Poor appetite / overeating ( not as bad as weight loss or weight gain)
Insomnia or hypersomnia
Low energy or fatigue
Low self esteem
Poor concentration
Feeling hopeless
no thought of suicide or passive death wish
During 2 yrs never more than 2 months without symptoms
Never a manic or hypomanic episode or cyclothymic disorder ( this is bipolar)
Not another disorder (i.e. schizoaffective, etc)
Cause significant distress or impairment
Not attributable to drugs or metabolic causes
Persistent Depressive Disorder (Dysthymia) prevalence ?
~3.2% of U.S and women more than men ( less than major depression)
Persistent Depressive Disorder (Dysthymia) etiology and risk factors ?
Life events
Personality (worried type)
Persistent Depressive Disorder (Dysthymia) genetics ?
Familial but not well understood
Persistent Depressive Disorder (Dysthymia) DDx ? ?
Massive list…
Medical /Neuro / Infectious /
Medications
Substance Abuse
Neoplasms (Pancreas, bronchogenic, CNS tumors…)
Metabolic (hypothyroidism…many others)
Collagen-Vascular (i.e. SLE)
Postpartum
Persistent Depressive Disorder (Dysthymia) prognosis ?
~40% recover in 2 yrs and 30% in 5 years ( not that great)
its pretty resistant to treatment
**Major depression can remit or go away this one tends to stick around for a while **
Persistent Depressive Disorder (Dysthymia) medications ?
SSRI (typically 9 months to lifetime)
MAOI’s (many side effects)
Persistent Depressive Disorder (Dysthymia) procedures / therapy / surgery ?
CBT
Couples / Marriage Counseling
Bipolar I is recurrent _____ with ______ episodes
Recurrent Major Depressive Episodes with MANIC Episodes
Bipolar I diagnostic criteria ?
Abnormal and persistent elevated, expansive, or irritable mood lasting at least 1 wk
During this period 3 or more present to a significant degree:
Grandiosity - impressive appearance
Decrease need for sleep (i.e. <3 hrs)
Talkative / pressure to keep talking
Flight of ideas / racing thoughts that come out through speaking
Distractibility
Increase in goal-directed activity -
Excessive involvement in pleasurable activities (i.e. spending, sex)
Not due to direct causes (i.e. drugs)
SEVERE enough to caused marked impairment
MAY INCLUDE psychotic features
If a manic episode triggered by antidepressants consider BP activation ( bipolar)
**super talkative, racing thoughts, these people are really smart sometimes CEOs of companies **
Bipolar I prevalence ?
0.6-1.1% men=women, women typically worse + rapid-cycling
Bipolar I etiology and risk factors ?
Generally <50 yo – if older consider medical cause
Generally upper socioeconomic class
Can be misdiagnosed as ADHD - cause of the mania
Bipolar I genetics ?
Strong association – about 66% have family Hx
80% concordance with monozygotic twins
very strongly genetic
Bipolar I DDx and Organic causes of mania and hypomania ?
Medications (i.e. isoniazid, anticonvulsants)
Neuro (i.e. MS, Post stroke) /Neoplasms
knock out inhibition in the brian
Schizophrenia / Schizoaffective Disorder
Major Depressive Disorder (and irritability)
Substance Abuse
Bipolar I prognosis ?
Variable (the earlier the onset the worse the prognosis)
variable cause they like the high
mania is energy to the point where it is not useable (cant harness it)
Bipolar I medications ?
Mood stabilizers (i.e. Lithium),
Anticonvulsants (i.e. valproic acid),
2nd generation antipsychotics (i.e. quetiapine) - fewer side effects and more tolerable then 1st generations,
1st generation antipsychotics (i.e. haloperidol)
Bipolar I procedures /therapy / surgery?
Behavioral, cognitive, interpersonal, social rhythm therapy
Bipolar I Rapid cycling ?
increased risk of suicide (cycles up up and down )
Bipolar I slow cycling ?
may not have a manic episode for years
Lithium carbonate (Lithobid) ?
is considered a first-line agent for long-term prophylaxis in bipolar illness, especially for classic bipolar disorder with euphoric mania. It also can be used to treat acute mania, although it cannot be titrated up to an effective level as quickly as valproate can. Evidence suggests that lithium, unlike any other mood stabilizer, may have a specific anti suicide effect
What is critical to do when taking Lithium carbonate (Lithobid) ?
Monitoring blood levels is critical with this medication.
Serum levels should be determined twice weekly during the acute phase, and until the serum level and clinical condition of the patient has been stabilized.
Indications for Quetiapine (Seroquel, Seroquel XR): (2nd generation antipsychotic) ?
is indicated for acute treatment of manic (immediate release and extended release [XR]) or mixed (XR) episodes that are associated with bipolar I disorder. It can be used as monotherapy or adjunctively with agents such as lithium or divalproex.
Aripiprazole (Abilify, Abilify Discmelt) (2nd generation antipsychotic) indications ?
is indicated for the acute and maintenance treatment of manic or mixed episodes associated with bipolar I disorder. It can be used alone or in combination with lithium or valproate.
Haloperidol (Haldol) (1st generation antipsychotic) uses?
is used for the acute treatment of mania or mixed episodes in patients with bipolar disorder. It can be used alone or in combination with lithium or valproate in an adult patient. Haloperidol blocks postsynaptic dopamine receptors (D2) in the mesolimbic system and increases dopamine turnover by blockade of the D2 somatodendritic autoreceptor
Bipolar II is recurrent major depressive episodes with what ?
HYPOMANIC or MANIC Episodes
**bipolar II is hypomanic sxs. **
Bipolar II diagnostic criteria ?
Abnormal and persistent elevated, expansive, or irritable mood lasting at least 1 wk
During this period 3 or more present to a significant degree: Grandiosity Decrease need for sleep (i.e. <3 hrs) Talkative / pressure to keep talking Flight of ideas / racing thoughts Distractibility Increase in goal-directed activity Excessive involvement in pleasurable activities (i.e. spending, sex)
NOT severe enough to caused marked impairment
NO psychotic features otherwise it is BP Type I
Not due to direct causes (i.e. drugs)
**this one cannot have any psychotic features at all **
Bipolar II prevalence ?
0.6-1.1% men=women, women typically worse
Bipolar II etiology and risk factors ?
Generally <50 yo – if older consider medical cause
Generally upper socioeconomic class
Can be misdiagnosed as ADHD
Bipolar II genetics ?
Strong association – about 2/3rds have family Hx
80% concordance with monozygotic twins
Bipolar II DDx and Organic causes of mania and hypomania ?
Medications (i.e. isoniazid, anticonvulsants)
Neuro (i.e. MS, Post stroke) / Neoplasms
Schizophrenia / Schizoaffective Disorder
Major Depressive Disorder (and irritability)
Substance Abuse
Bipolar II prognosis ?
Variable (the earlier the onset the worse the prognosis)
Medications do reduce the length of an acute episode
Bipolar II medications ?
Mood stabilizers (i.e. Lithium),
Anticonvulsants (i.e. valproic acid),
2nd generation antipsychotics (i.e. quetiapine),
1st generation antipsychotics (i.e. haloperidol)
Bipolar II procedures . therapy / surgery ?
Behavioral, cognitive, interpersonal, social rhythm therapy
Major depressive disorder with seasonal pattern and Bipolar with seasonal pattern diagnostic criteria ?
Major depressive disorder with:
Regular time relationship with particular times of the year (e.g. winter, fall)
Full remission in between.
Occurs over 2 years without non seasonal episodes
Seasonal depressive episodes outnumber non-seasonal episodes over pt
lifetime.
Does not include caused by social stressors that are seasonal . (e.g. unemployed in winter)
**still sxs. in the summer then it is not seasonal
cant have nonseasonal episodes **
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) and Bipolar with peripartum onset diagnostic criteria ?
Does not meet all criteria for Major Depression or Bipolar
Qualifier applies if:
- full criteria are not currently met for a major depressive episode
- onset during pregnancy or in the 4 weeks following delivery
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) and Bipolar with peripartum onset: extra features ?
Can have severe anxiety or panic
Can have psychotic episodes
Command hallucinations to kill infant
Hallucinations that infant is possessed - severe
make sure they are not having hallucinations about the baby
common and happends a lot
screen for it a lot in the US
specifically do to a lack of light from winter - they have broad spectrum light boxes for tx
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) prevalence ?
3% and 6% of women in weeks or months after delivery
more than bipolar
50% of episodes begin prior to delivery ( before they deliver)
Psychosis occurs in 1:500-1000 women
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) etiology and risk factors ?
First pregnancy
Increased risk if had with previous pregnancies
Previous depression anxiety
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) genetics ?
More common in family with bipolar
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) DDx ?
Bipolar
Anxiety
Depression
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) prognosis ?
Variable with reasonable prognosis
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) medications ?
SSRI’s - unless they are having psychotic thoughts
Antipsychotic may be beneficial if psychosis
Need to stop breast feeding
**SSRIs are the safest in pregnancy **
Major depressive disorder with peripartum onset (Mood disorder with postpartum onset) procedures / therapy / surgery ?
Therapy
CBT
Cyclothymic Disorder diagnostic criteria ?
Think: Low-grade persistent Bipolar
They are moody, impulsive, erratic, and volatile but do not meet full criteria for Bipolar Disease
Irregular and abrupt changes in mood
For at least 2 years numerous depressive and hypomanic episodes
Not without symptoms for more than 2 months
No major depressive or manic episodes within the 2 year period
Not better accounted for by schizoaffective disorder and are not superimposed on other psychotic disorders
Not due to direct substances (i.e. drugs) or medical conditions (i.e. hyperthyroidism)
Causes clinically significant distress or impairment
**this has to be over a long period of time **
What is Psychoeducation ?
refers to the education offered to individuals with a mental health condition and their families to help empower them and deal with their condition in an optimal way. Frequently psychoeducational training involves individuals with schizophrenia, clinical depression, anxiety disorders, psychotic illnesses, eating disorders, and personality disorders, as well as patient training courses in the context of the treatment of physical illnesses. Family members are also included. A goal is for the consumer to understand and be better able to deal with the presented illness. Also, the patient’s own capabilities, resources and coping skills are strengthened and used to contribute to their own health and wellbeing on a long-term basis.
What is Interpersonal psychotherapy (IPT) ?
is a time-limited treatment that encourages the patient to regain control of mood and functioning typically lasting 12–16 weeks. IPT is based on the principle that there is a relationship between the way people communicate and interact with others and their mental health.
Cyclothymic Disorder prevalence ?
0.4-1% men = women
Cyclothymic Disorder etiology and risk factors ?
Unknown but probably similar to Bipolar
Cyclothymic Disorder genetics ?
Familial risk but unclear association
Cyclothymic Disorder DDx ?
Borderline personality disorder
Medical conditions (see Bipolar)
Cyclothymic Disorder prognosis ?
Variable but between 15-50% probability BP I or BP II will develop
Cyclothymic Disorder medications ?
Unclear data but low dose SSRIs may be helpful
TCA’s, bupropion
Cyclothymic Disorder procedures / therapy / surgery ?
Psychoeducational therapy
Interpersonal psychotherapy
Premenstrual Dysphoric Disorder diagnostic criteria ?
Severe form of premenstrual syndrome
Five (or more) of the following symptoms occurred during the final week before the onset of menses, started to improve within a few days after the onset of menses, and were minimal or absent in the week post menses.
Marked irritability or anger
Markedly depressed
Market anxiety
Decreased interest in activities
Difficulty in concentrating
Lethargy / fatigue
Marked change in appetite
Insomnia / hypersomnia
Overwhelmed
Physical (i.e. breast tenderness, bloating, joint pain)
**related to a shift in hormones **
Premenstrual Dysphoric Disorder prevalence ?
3-8%
Premenstrual Dysphoric Disorder etiology and risk factors ?
Hx of anxiety, depression, SAD ( seasonal defective dx), or mother with condition
ETOH, obesity, caffeine, lack of exercise
Premenstrual Dysphoric Disorder genetics ?
Variants in the estrogen receptor alpha gene are associated with PMDD
Premenstrual Dysphoric Disorder DDx ?
Anemia
Bipolar / Anxiety / Depression
Hypo/hyperthyroidism
Somatoform disorders
SLE
Premenstrual Dysphoric Disorder prognosis ?
variable
Premenstrual Dysphoric Disorder medications ?
Hormone Tx Estrogen
Estrogen - OCP with estrogen tend to work
NSAIDs
Beta blockers - BB work better if it is all anxiety type sxs but it can slow heart rate
SSRIs
Anxiolytics / mood stabilizers
over a short period of time - so SSRI? no cause they feel fine in between
Premenstrual Dysphoric Disorder procedures / therapy / surgery ?
CBT
helps a little bit
Paranoid Personality Disorder diagnostic criteria ?
A pervasive distrust and suspiciousness of others motives and interpreted as malevolent, beginning by early adulthood and in a variety of contexts, by four (or more) of the following:
Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her
Preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates
Reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her
Reads hidden demeaning or threatening meanings into benign remarks or events
Persistently bears grudges
Perceives attacks on his or her character or reputation that are not apparent to others
Recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner
**these dx are hard to diagnose because people do not like to talk to them **
Paranoid Personality Disorder prevalence ?
0.5-4.5% slightly more common in women
Paranoid Personality Disorder etiology and risk factors ?
Enhanced in families with schizophrenia and delusional disorders
Environment risk for fearful children to have a higher probability
Paranoid Personality Disorder DDx ?
Schizoid personality (very high association with Paranoid Personality)
Schizotypal personality
Narcissistic personality disorder
Schizophrenia
Paranoid Personality Disorder prognosis ?
Variable with reasonable prognosis however may revert under stress
Paranoid Personality Disorder medications ?
Little evidence of effectiveness of Medications
Antipsychotic may be beneficial if delusional
Paranoid Personality Disorder procedures / therapy / surgery ?
Individual however no therapeutic techniques proven beneficial
Cognitive therapy may be of some benefit
Schizophrenia diagnostic criteria ?
Two or more for a significant portion of time within a 1 month period and continuous for at least a 6 month period:
- Delusions
- Hallucinations - visual
- Disorganized speech
- Grossly disorganized
- Diminished emotional expression
- Diminished self-care
- Marked decreased level of functioning in work and/or social and/or academic
After 1 year of symptoms additional qualifiers:
See DSM 5 (First, multiple, acute, remission,…with catatonia ( pinch them and they dont know or feel it)
Substance abuse a significant comorbidity
** these people are always in the ED and they cannot hold jobs **
Schizophrenia prevalence ?
1% worldwide
Schizophrenia etiology and risk factors ?
Most likely genetic and perinatal
Schizophrenia genetics ?
Risk in 1st deg relatives is 10%. If both parents have schizophrenia, the risk of in their child is 40%
Concordance ~10% for dizygotic 40-50% for monozygotic
Schizophrenia DDx ?
Alcohol-Related or Cocaine-
Related Psychosis
Bipolar Affective Disorder
Brief Psychotic Disorder - shorter period of time
Delusional Disorder - delusional with no hallucinations
Depression
Secondary to General Medical Conditions
Schizoaffective Disorder / Schizophreniform Disorder
Schizophrenia prognosis ?
Generally poor
Schizophrenia medications ?
1st gen (i.e. Haldol)- acutely psychotic ( sedating) -Geodon works acutely as well - ziprasadone
2nd gen antipsychoitics (i.e. Abilify) - most of the time now
Schizophrenia procedures / therapy / surgery ?
Primarily antipsychotic medications
Transcranial magnetic stimulation (TMS) possibly
Schizophreniform Disorder diagnostic criteria ?
Schizophreniform disorder is characterized by the presence of the symptoms of schizophrenia, but it is distinguished from that condition by its shorter duration, which is at least 1 month but less than 6 months.
Think “Schizophrenia Lite” meaning it’s a form of schizophrenia but less than 6 months
**schizo is more than 6 months **
Schizoaffective Disorder diagnostic criteria ?
Schizophrenia WITH a major mood disorder (i.e. depressive or manic, usually BP1) concurrent
Delusions or hallucinations for 2+ weeks
Symptoms of major mood disorder
See DSM 5 for subtypes (e.g. catatonia)
**like Bipolar with hallucinations **
**depressed and then they have hallucinations **
Schizoaffective Disorder prevalence ?
rare: 0.5% - 0.8%
Schizoaffective Disorder etiology and risk factors ?
unclear
Schizoaffective Disorder genetics ?
unclear
Schizoaffective Disorder DDx ?
Amphetamine-Related
Psychiatric Disorders
Bipolar Affective Disorder / Brief Psychotic Disorder
Cocaine-Related Psychiatric Disorders
Cushing Syndrome
Depression / Hallucinogens
Hyperparathyroidism
Phencyclidine (PCP)-Related Psychiatric Disorders
Schizophrenia
Schizoaffective Disorder prognosis ?
highly variable
Schizoaffective Disorder medications ?
Generally a combination of an SSRI and antipsychotics
(SSRIs) are greatly preferred to the other classes of antidepressants – less prob. of adverse effects if overdose
Schizoaffective Disorder procedures / therapy / surgery ?
Behavioral therapy
Schizoid Personality Disorder diagnostic criteria ?
Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings (removed from social settings), beginning by early adulthood and present in a variety of contexts, as indicated by 4 or more:
-Neither desires nor enjoys close relationships, including being part of a family
they do not want to be friends with anyone
- Mostly choses solitary activities
- Has little if any interest in having sexual experiences with another
- Lacks close friends or confidants other than 1st deg relatives
-Appear indifferent to praise or criticism of others:
very flat, and dont care about any one around them
-Shows emotional coldness, detachment or flattened affect
Does not occur exclusively during schizophrenia or other conditions… it occurs all the time ( something that is there all the time - low level - not from another cause)
Low level long time!
**schizo part think hallucinations etc. **
Schizoid Personality Disorder prevalence ?
0.5-7% more men
Schizoid Personality Disorder etiology and risk factors ?
Not well understood
Possible relationship to Asperger syndrome ( because of the social detachment)
Schizoid Personality Disorder DDx ?
Rule out transient causes of detachment i.e. depression
Schizoid Personality Disorder prognosis ?
May live relatively well adjusted lives just in isolation
May not seek out mental health counseling
May be challenging in work situations (i.e. supervisor or employee who is isolated may need to adjust career options)
-they just want to work alone, go home and mind there own business
Schizoid Personality Disorder medications ?
Little evidence of effectiveness
Schizoid Personality Disorder procedures / therapy / surgery ?
Usually come at request of family members
Group and family counseling may be beneficial
Individual therapy may not be beneficial because these patients tend to intellectualize and distance themselves from treatment
Schizotypal Personality Disorder diagnostic criteria ?
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with close relationships-by cognitive/perceptual distortions and eccentricities of behavior… five (or more) (odd beliefs in magic)
Ideas of reference
Odd beliefs or magical (e.g., superstitions, clairvoyance, telepathy)
Unusual perceptual experiences
Odd thinking
Suspiciousness or paranoid ideation
Inappropriate or constricted affect
-they do not take care of themselves very well
Odd appearance
-maybe they wear different socks etc…
Lack close friends even 1st deg relatives
Excessive social anxiety that does not diminish with familiarity and associated with
paranoid fears
Does not occur exclusively during the course of Schizophrenia, or other mood disorders…
**think schizoid with weird magical thoughts ( not like the devil is in you and they need to cut it out, it is more like they can hear other peoples thoughts) **
** they dont want to be apart of a group and they have magical thoughts **
Schizotypal Personality Disorder prevalence ?
3-5% slightly more men
Schizotypal Personality Disorder etiology and risk factors ?
Significantly more prevalent with biological relatives of schizophrenic individuals and thus appears a reasonably strong genetic component
Schizotypal Personality Disorder DDx?
Considered to be a schizophrenia spectrum disorder
Schizotypal Personality Disorder prognosis ?
Generally poor
Schizotypal Personality Disorder medications ?
Low-dose antipsychotics
Lithium and mood stabilizers may be of some benefit
Schizotypal Personality Disorder procedures / therapy / surgery ?
Group therapy to address social anxiety and awkwardness can be beneficial
Individual counseling may have some benefit to teach patients to understand and corroborate their odd ideas and thoughts with environmental evidence and not personal impressions / feelings
