Mood Disorders Flashcards
why is there a decrease in depression in older patients
under-reporting
what is euthymia
normal mood
what is hyperthymia
elevated mood
what is cyclothymia
varied mood
what is dysthymia
persistent low mood
what is anhedonia
loss of enjoyment/pleasure
what is anergia
loss of energy
whast is stupor
absence of relational functions like action and speech
what is psychomotor retardation
subjective/objective slowing of thoughts/movement
MSE depression - appearance/behaviour?
reduced facial expression
furrowing of brows
reduced eye contact and gesturing
hard to establish rapport
MSE depression - mood?
associated with what pt describes
low, down, miserable, unhappy, sad, empty, black, numb
MSE depression - affect?
depressed, limited reactivity, emotional paralysis
MSE depression - thought?
usually normal form flow may be slowed or absent may have delusion in content guilt, nihilism, hypochondriasis, poverty suicidal cotards syndrome
MSE depression - perception?
may have increased self referential thinking - people talking aobut them
hallucinations possible - 2nd person and derogatary
MSE depression - cognition?
slowed, often poor memory
pseudo-dementia
MSE depression - insight?
insight almost always preserved and aware of symptoms
MSE depression - speech?
reduced rate, pitch, intonation, volume
limited content
general criteria (not core) for the patient to meet a depression diagnosis
no evidence of mania
>2wks
must be clearly abnormal and severely impact function
core features of depression
at least 2/3
low mood and present almost every day for at least 2 weeks
low energy
loss of interest or pleasure in activities
additional features of depression
need at least 4 loss of confidence/self esteem feelings of guilt wishing to die difficulty in concentration change in psychomotor activity, either subjective/objective agitation/retardation sleep disturbance change in appetite
grading of severity of depression
moderate - 2 core symptoms and 4 others to give 6
severe - all 3 and 5 others to give 8
features fo psychotic depression
paranoid, mood congruent or hypochondriacal
cotards syndrome
what is cotards syndrome
nihilistic delusion in which the patient belives they are not alive or do not exist
what is disruptive mood dysregulation disorder
alterantive to bipolar disorder in children 6-18 and cannot be better explained by another disorder
criteria for DMDD
Severe recurrent temper outbursts inconsistent with developmental level >3x per week persistently angry most of the day and nearly every day present more than >1yr with relief >3m
what is bipolar I
current or past episode of mania
what is bipolar II
current/past hypomanic episode with current/pasdt depressive episode
what is bipolar III
hypomanic episode following antidepressants
what is bipolar affective disorder
two or more episodes where mood/activity levels are significantly disturbed
mania, hypomania or depression
distinguishing depression from bipolar
single episode mania/hypomania before depression is highly likely bipolar
first episode mania/hypomania on background of recurrent depression means it is bipolar and no longer depression
criteria for hypomanic episode
present 4 consecutive days >/= 3 of the following increased activity/restless increased talkativeness difficulty concentrating decreased need for sleep increased libido mild spending spree/reckless and irresponsbile behaviour
criteria for manic episode
elevated/irritable mood and definitely abnormal at least 1 week unless needs admitted >/=3 of increased activity/restless talkativeness flight of ideas loss normal social inhibition decreased need for sleep grandiosity/inflated self esteem distractible reckless behaviour marked increase sexual energy
typical onset bipolar
20s
FHx implies lower sge onset
how much of the time are bipolar pts symptomatic
50%
1/3 manic 2/3 depressed
poor outcomes BAD?
early onset poor SE status multiple comorbidity FHx rapid mood flux mixed presentation psychosis
true/false - genetic influence over mood disorders are polygenic
true
brain regions implicated in mood disorders?
orbitofrontal cortex ventromedial frontal cortex dorsolateral prefrontal cortex hippocampus amygdala anterior cingulate cortex
cognitive deficits associated with depression?
poor attention
slow memory
slow reaction time
impaired planning
functions of the hippocampus
learning, cognition, HPA axis
connection to amygdala for emotion and fear
connection to prefrontal cortex for memory, cognition and mood
what parts of the brain are responsible for approaching and seeking behaviours and what is the principle neurotransmitter?
mesolimbic and cortical projections ventral and dorsal striatum amygdala anterior cingulate orbitofrontal cortex dopamine
what parts of the brain are responsible for defence and survival behaviours and what is the principle neurotransmitter?
central nucleus of amygdala hippocampus ventroanterior and medial hypothalamus periaqueductal grey matter 5-HT
ways of mood monitoring
IDS-30-SR
QIDS
MADRS
mood diary
what is MADRS good for?
profound depression with little to no engagement
how to chose AD?
go for fewest side effect profiules first
if person responds to drug or class stick with it
match side effects to symptoms
top 4 ADs
escitalopram
sertraline
mirtazapine
venlafaxine
what SSRI has a good cardiac safety profile
sertraline
what size effects does mirtazapine have and what side effects is it more protective of
promotes sleep and weight gain
less likely to cause nausea and sexual side effects
what choices to make if an AD isnt working?
check congruence increase dose swap medicine combine - often SSRI/SNRI and mirtazapine augment with Li or antipsychotic
how long to keep on AD for depression?
6m for first episode
1-2yrs for 2nd episode
management of acute mania/hypomania
stop AD max antimanic dose admit if manic antipsychotic - olanzapine, quetiapine, risperdone OR Li, valproate, ECT, carbamazepine may need IM BZD may be indicated fo symptom control
management of acute bipolar depression
AD ONLY if with antimanic - valproate, Li or antipsychotic
SSRI - fluoxetine preferred
quetiapine, olanzapine, lurasidone
maintenance management of bipolar disorder
Li gold standard
can give antipsychotics, lamotrigine (depressive), valproate (manic/hypomanic)
psychoeducation
discuss monitoring of lithium?
serum Li, U&E, ECG, TFT, Ca, weekly then move to every 3-6m
true/false - in a pt woith hypothyroidism secondary to lithium you should discontinue Li
false - start levothyroxine
what may happen if an AD is given on its own to a pt with bipolar
it can precipitate a manic episode
what may an SSRI cause in the elderly?
hyponatraemia
administration of ECT?
2x weekly and usually inpatient
general anaesthetic with muscle relaxant
dose of electricity titrated to give seizure 15-30s
seizure monitored with EEG and can be ceased with BZD
what gen anaesthetic is given for ECT and why can that pose an issue
propofol
can raise seizure threshold
what is needed to give ECT without consent
2nd independent dr opinion, unless in an emergency
physical side effects of ECT?
headache temp cognitive issues memory problems muscle ache confusion nausea cerebrovascular anaesthetic cardiovascular prolonged seizure
examples of psychological therapies
CBT behavioural activation CBASP acceptance and commitment therapy psychoeducation
what is personality and what are the 5 factors of persoanlity
relatively predictable patterns of thinking, feeling and behaving, consistent across time space and context openness conscientiousness extraversion agreeableness neuroticism
what is a disorder of personality
individual and characteristic pattern of experience deviating from culturally expected and accepted range
pervasive, inflexible, distress and cannot be explained vt any other mental disorder
rating scales for persoanlity disorder
ZAN-BPD PAS PDQ-4 MMPI BDQ IPDE
diagnostic features of paranoid PD
> /= 4
excess sensitivity to setback
tendency to bear grudge
suspiciousness or misconstrued perception of friendly activity
tenacious sense of personal rights
recurrent suspicions of partners sexual fidelity
persistent self referential attitude
preoccupation with unsubstantiated conspiratorial events of world at large
diagnostic features of schizoid PD
>/= 4 little/no activities give pleasure flat affect or emotional coldness struggle/unable to show warm feelings little interest in sexual experiences with others solitary activities indifferent to praise/critisism excess preoccupation with fantasy/introspection insensitive to prevailing social norms
diagnostic features of schizotypal PD
>/= 5 ideas of reference odd thinking, magical thinking unusual perceptual experiences odd thinking/speech suspicious/paranoid ideation inappropriate/constricted affect odd, eccentric or peculiar behaviour lack of close friends or confidants excess social anxiety, associated with paranoia and not diminishing with familiarity
diagnostic features of dissocial PD
> /= 3
unconcern for feelings of others
irresponsible and disregard for social norms
low tolerance to frustration, aggression and violence
incapacity to experience guilt, or to profit from adverse experience
proneness to blame others
diagnostic features of impulsive EUPD
> /= 3
acting unexpectedly without considering consequences
quarrelsome and conflicts with others
outburst of action/violence
difficulty maintaining course that offers no immediate reward
unstable mood
diagnostic features of borderline EUPD
>/= 2 impulsive and >/= further of disturbed, uncertain self image intense and unstable relationships excess effort to avoid abandonment chronic emptiness recurrent threats or acts of self harm
diagnostic features of histrionic PD
> /= 4
self dramatisation and theatricality
suggestible
shallow, labile affect
seeking activities where subject is feature of attention
inappropriately seductive in appearance/behaviour
overly concerned with physical attractiveness
diagnostic features of anxious PD
> /= 4
pervasive feelings of tension/apprehension
belief oneself is inferior to others
excess preoccupation about criticism/rejection in social situation
unwilling to get involved unless certain of being liked
restricted lifestyle
avoidance of activities that have significant interpersonal contact due to rejection, disapproval
diagnostic features of dependent PD
> /= 4
encouraging/allowing others to make their important life decision
subordination of ones own needs to those of other on whom they are dependent
unwilling to make reasonable demands on one depends on
feeling uncomfortable/helpless when alone
preoccupation with fears of being left to take care of themselves
limited capacity to make everyday decisions without excessive advice or reassurance
diagnostic features of anankastic PD
> /= 4
excess doubt/caution
preoccupied with details, rules, list, order
perfectionism
excess conscientiousness
rigid/stubborn
excess adherence to social convention
undue preoccupation with productivity leading to exclusion of pleasure and relationships
unreasonable insistence that others submit to their way of doing things
diagnostic features of narcissistic PD
> /= 5
grandiose self importance
fantasies of infinite success, control or brilliance
belief they are extraordinary or belief they can only be understood by others of same
desire for unwarranted admiration
sense of entitlement
interpersonal oppressive behaviour
resentment of others who are resentful of them
egotistical behaviour/attitude
when may low dose antipsychotic be good for PD? what type?
can help paranoid BPD
reduce suspiciousness in schizoid, paranoid or schizotypal
haloperidol, quetiapine, olanzapine
when may AD be of benefit in PD
dissocial, emotionally unstable, histrionic and narcissistic mood difficulty
reduce anxiety in anankastic, avoidant and dependent
when may mood stablisers be of use in PD
lamotrigine
mood and impulsivity in EUPD and BPD
first and second line therapies for impulse control
first - SSRI
2nd - olanzapine, valproate, carbamazepine, low dose antipsychotic
first, second, third line therapies for affective dysregulation
1st - SSRI/mirtazapine
2nd - alternative SSRI/mirtazapine
3rd - low dose antipsychotic, valproate, carbamazepine, olanzapine
therapies for cognitive perceptual symptoms
low dose antipsychotic
pharmacological mx of interpersonal difficulties
none, it would be inappropriate
management of dissocial PD
group based psychological therapies
psychological therapies for EUPD
dialectal behavioural therapy
mentilisation based therapy
STEPPS
when to admit for EUPD
acute increase suicidal risk
use carefully as can cause harm
crisis plan
pharmacological therapies for EUPD
lamotrigine
topiramate
AD if needed
antipsychotics
