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Psychiatry > Mood Disorders > Flashcards

Mood Disorders Flashcards

1
Q

What are the features of somatic syndrome

A
  • markedly reduced appetite
  • weight loss
  • early morning wakening
  • diurnal variation in mood
  • psychomotor retardation
  • loss of libido
  • marked anhedonia
  • lack of emotional reactivity
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2
Q

Describe some of the psychotic symptoms that can occur in depression with psychosis

A

Delusions: mood congruent usually
Worthlessness: guilt, ill health, poverty, imminent disaster
Nihilistic delusions
Persecutory delusions

2nd person auditory hallucinations
Olfactory hallucinations eg rotting flesh

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3
Q

What % of those with depression will die by suicide

A

5-15%

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4
Q

What is the treatment for mild / moderate depression

A

Low intensity psychological interventions
Medication: 1st line treatment would usually be an SSRI eg citalopram, sertraline, fluoxetine or paroxetine

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5
Q

What is the treatment for moderate / severe depression (depression that has failed to respond to treatment)

A

Medication
High intensity psychological interventions
Consider secondary care referral

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6
Q

What is the treatment for severe depression with life threatening presentations and severe self neglect

A

Medication
High intensity psychological interventions
ECT
Crisis resolution and home treatment
MDT
Inpatient

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7
Q

How is relapse of depression prevented

A

Continued pharmacotherapy for 6 months after a depressive episode
Then continued pharmacotherapy for 2 years to reduce risk of relapse from recurrent depression

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8
Q

What are symptoms of hypomania

A

Mild elevation or mood instability
Increased energy
Mild overspending
Increased sociability and overfamiliarity
Distractability
Increased sexual energy
Decreased need for sleep

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9
Q

How to confirm a diagnosis of hypomania

A

Symptoms need to have been present for 4 days

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10
Q

What are the symptoms of mania

A

Elevated mood, expansive, irritable
Increased activity
Reckless behaviour
Disinhibition
Marked Distractability
Markedly increased sexual energy
Sleep impaired or absent
Grandiosity
Flight of ideas

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11
Q

How is a diagnosis of mania confirmed

A

Symptoms need to have been present for a week or have to be severe enough to necessitate inpatient admission

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12
Q

How can bipolar affective disorder be diagnosed

A

When there has been 2 episodes of mania or one episode of mania and one of depression

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13
Q

Describe the epidemiology of bipolar affective disorder

A

1% lifetime risk
Equal prevalence in men and women
Onset generally late teenage to early 20s

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14
Q

Aetiology of bipolar affective disorder

A

Genetics

Life events: prolonged stressful circumstances can predispose episodes

Substance misuse

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15
Q

Describe the prognosis of bipolar affective disorder

A

Average length of a manic episode is 6 months

Following this, at least 90% will have a further episode of mood disturbance

On average 10 episodes of mood disturbance over 25 year period

Less than 20% have a 5 year period of clinical stability

20-30x more likely to die by suicide than the general population

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16
Q

Common causes of bipolar relapse

A

Non concordance with medication
Life events, social stressors
Disruption of circadian rhythm
Substance misuse
Childbirth
Natural course of the illness

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17
Q

What is encephalitis

A

Neurological disorder caused by brain inflammation
Usually infective cause
5-10/100,000 per year

Non infective causes are often autoimmune and can mimic infective presentations as well as other neurological and psychiatric presentations

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18
Q

What investigations would you do for encephalitis

A

Clinical history
General and neurological examination
Routine blood and CSF analysis
Neuro imaging
EEG
Antibody testing

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19
Q

What is autoimmune limbic encephalitis

A

Medial temporal lobe involvement
Sub acute onset (3mos)
Altered mental state, cognitive dysfunction, seizures

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20
Q

What is acute disseminated encephalomyelitis

A

Often post infective and in the under 40s
Multi focal neurological deficits
Variable encephalopathy

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21
Q

What is anti NMDA receptor encephalitis

A

Predominantly affects the young and female
Psychosis, delusions, agitation, aggression, catatonia, seizures, irritability, insomnia, dysarthria, cognitive impairment, decreased levels of consciousness

Abnormal EEG

Positive antibody tests

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22
Q

What is bickerstaff encephalitis

A

Impairment of consciousness, ataxia and opthalmoparesis
Post infective

Often Monophasic with a good prognosis

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23
Q

What is autoimmune psychosis

A

Recently been recognised that isolated psychotic presentations often test positive for neuronal antibodies (anti NMDA receptor antibodies)

Psychiatric disturbance with neurological features

  • acute inset
  • neurological signs
  • adverse response to antipsychotics
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24
Q

Epidemiology of depression

A

Recurrent depressive disorder carries a lifetime risk of 10-25% in woman, 5-12% in men
2:1 F to M ratio
Late 20s avg onset
0.1% require admission

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25
Q

Biological causes of depression

A

Genetic predisposition: 40-50% MZ twin concordance
Chronic disease: pain, cancer, heart disease
Hormonal changes: post partum depression

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26
Q

Psychological causes of depression

A

Negative thinking style
Personality type: increased risk with neuroticism

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27
Q

Social causes of depression

A

Chronic stress
Substance misuse
Parenteral separation in childhood
Social isolation
Adverse life events

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28
Q

Describe the pathophysiology of depression

A

Neurochemistry: HPA axis Overactivity and monoamine deficiencies

Neuroanatomy: recurrent early onset depression is associated with decreased size of hippocampus, amygdala and some frontal cortex areas

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29
Q

What are the 3 core symptoms of depression

A

Depressed mood - varies little from day to day and is unresponsive to circumstances

Markedly reduced interest in almost all activities - loss of ability to derive pleasure from formerly enjoyed activities

Lack of energy - leading to decreased activity

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30
Q

Biological symptoms of depression

A

Early wakening
Diurnal variation in mood - mood typically worse in the morning
Loss of appetite with unintentional weight loss
Psychomotor retardation or agitation
Loss of libido

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31
Q

What are cognitive symptoms of depression

A

Reduced concentration / memory
Poor self esteem / worthlessness
Guilt
Hopelessness
Suicide / self harm

32
Q

Psychotic symptoms of depression

A

Delusions and hallucinations are both generally mood congruent
Akinesis can be present
Nihilistic delusions: patient doesn’t believe in concept of life - may think world has ended and its all one dream
Cotard’s syndrome - patient may believe they are dead

33
Q

What is the psychological approach to management of depression

A

1st line for mild depression and 1st like in combination with antidepressants for mild - moderate depression
CBT is first line

34
Q

What is the biological approach to management of depression

A

Antidepressants are recommended in mild - moderate or moderate - severe depression that has not responded to psychological interventions.
SSRIs usually first line
Lithium or atypical antipsychotics in resistant cases
ECT in severe, resistant cases

35
Q

What is the social approach to management of depression

A

Avoidance of alcohol, health eating, regular exercise, good sleep hygiene

Support with education, work, finances, housing and social inclusion

Help with access to benefits and housing

Consider how carers are coping

36
Q

Describe the prognosis of depression

A

Without treatment a first episode will generally remit within 6 months - 1 yr
60% recovery by 1 year, 80% will go on to have a further depressive episode
Chronic depression occurs in 10-25%

37
Q

What is a depressive episode

A

Must have 2 of the core symptoms of depression for at least 2 weeks + 2 biological or cognitive symptoms

38
Q

What is recurrent depressive disorder

A

When a patient with a depressive episode goes on to have a further depressive episode
Avg number of episodes experienced is 5

39
Q

What is dysthymia

A

Chronically depressed mood that has its onset in early adulthood and may retain throughout the patients life with periods of wellness in between
Mood is not severe enough to satisfy the criteria for a depressive episode and doesn’t present as discrete episodes
Does not have severe effects on patients ability to function

40
Q

How much is suicide risk increased in someone presenting with self harm

A

100x

41
Q

Epidemiology of suicide

A

Elderly
Male
Homosexual / transgender
Unmarried / unemployed
Lives alone / social isolation
Low socioeconomic status
Farmer, nurse, doctor

42
Q

Clinical risk factors of suicide

A

Psychiatric illness (highest in anorexia and depression)
Physical illness
Alcohol dependence
Previous self harm
FH of depression, alcoholism, suicide

43
Q

What are some immediate management considerations after a suicide attempt

A
  1. Is inpatient care required to preserve patient safety
  2. Would the patient benefit from the input of home treatment / crisis team
  3. Do they have existing social support that can be called upon
  4. Is it possible to reduce means of self harm
44
Q

What are some long term management considerations after a suicide attempt

A

Treat underlying psychiatric illness
Optimise social functioning
Crisis planning

45
Q

What are the 2 types of bipolar affective disorder

A

Type I: experience manic episodes and major depression
Type II: experience hypomania and major depression, absence of manic episodes

46
Q

What is the epidemiology of bipolar affective disorder

A

1% lifetime risk
Avg age of onset = 20
M=F

47
Q

Aetiology of bipolar

A

MZ concordance 65-80%
1st degree relatives have a 7x increased risk of bipolar
The most important environmental risk factor is child birth
50% risk of mania post partum in those with untreated bipolar

48
Q

Biological features of bipolar affective disorder

A

Decreased need for sleep
Increased energy
Actions can become repetitive and lead to manic stupor
Excessive Overactivity can lead to physical exhaustion, dehydration and death

49
Q

Cognitive features of bipolar affective disorder

A

Elevated self esteem / grandiosity that can lead to delusions of grandeur
Poor concentration
Accelerated thinking
Impaired judgement

50
Q

Psychotic features of bipolar affective disorder

A

Disordered thought form
Abnormal beliefs
Perceptual disturbances

51
Q

Features of hypomania

A

Mild elevation of mood / irritability
Increased energy, decreased sleep
Mild overspending / risk taking
Distractability
Increased sexual energy

52
Q

Features of mania

A

Generally requires hospital admission
Significantly elevated mood
Highly active, little to no sleep
Reckless decisions
Grandiosity

53
Q

Describe the biological management of mania

A

Antidepressants discontinued
Benzodiazepines can help in reducing severe behavioural disturbances
Anti manic agent started (risperidone, olanzapine, quetiapine, lithium, valproate)

54
Q

Describe the psychological / social management of mania

A

Psychoeducation once the patient is more stable in mood
Creation of a non stimulatory environment

55
Q

Describe the biological management of acute depression in bipolar

A

Consider increasing mood stabiliser dose
SSRI can be co-prescribed but should be gradually discontinued once the patient has been in remission for 8 weeks
- antidepressants are thought to increase the manic risk so should always be given with a mood stabiliser

56
Q

Describe the psychological / social management of acute depression in bipolar

A

High intensity CBT and Psychoeducation
Identify and nullify social stressors

57
Q

Describe the long term biological management of bipolar

A

Lithium, valproate or olanzapine based on sex, comorbidity and patient preference
All are teratogenic
If one is ineffective consider switching to another

58
Q

Long term psychological / social management of bipolar

A

Psychoeducation to recognise early signs of relapse
CBT may be used
Avoidance of known episode precipitants
Support for education, finance, housing

59
Q

Describe the prognosis of bipolar affective disorder

A

Untreated a patient will have 8-10 manic / depressive episodes over their lifetime
Following a manic episode there is a 90% chance of further episodes
Rapid cycling (>4 events per year) is associated with poor prognosis
Depressive episodes are more common than manic

60
Q

What is relapse of bipolar associated with

A

Non concordance to lithium
Life events
Circadian rhythms
Disruption
Childbirth
Substance abuse

61
Q

Side effects of lithium

A

GI upset
Dry mouth
Metallic taste

62
Q

Limitations of lithium

A

Narrow therapeutic range
Requires regular blood tests to monitor plasma level
Not suitable in renal impairment as is renally excreted
Serum concentration can be increased by thiazides, ACEIs and NSAIDs
Not suitable for those with cardiovascular disease
Not suitable for those with thyroid disease

63
Q

What are the neurological, renal and CV effects of lithium toxicity

A

Neuro: tremor, seizures, delirium, coma
Renal: AKI, nephrotic syndrome, diabetes insipidus
CV: QT prolongation, sinus node dysfunction

64
Q

What is used to treat severe lithium toxicity with neurological symptoms

A

Urgent haemodialysis

65
Q

MOA of valproate as a mood stabiliser

A

Na channel blocker
Increases GABA levels

66
Q

Side effects of valproate

A

Weight gain
Sedation
Hair loss
Tremor
Blood dyscrasias
Liver failure

67
Q

What is cyclothymia

A

Analogous to dysthymia
Begins in early adulthood and follows a chronic course with intermittent periods of wellness
Instability of mood that is not severe enough to meet threshold for bipolar diagnosis

68
Q

Characterisation of borderline personality disorder

A

Intense emotions which can change quickly, difficulties with relationships, feelings of emptiness, fears of abandonment, impulsive behaviour and self harm

69
Q

Order of NICE recommendations for depression

A
  1. Guided self help
  2. Group CBT
  3. Group behavioural activation
  4. Individual CBT
  5. Individual behavioural activation,
  6. Group exercise
  7. Group mindfulness and meditation
  8. Interpersonal psychotherapy
70
Q

What should be done before a patient starts ECT treatment

A

Antidepressant medication should be reduced but not stopped

71
Q

What can selective serotonin reuptake inhibitor discontinuation syndrome present with

A

Diarrhoea
Vomiting
Abdominal pain

72
Q

What is procyclidine used for

A

Acute dystonia secondary to antipsychotics

73
Q

What is conversion disorder

A

Loss of motor or sensory function
Mostly caused by stress

74
Q

How is hypomania different to mania

A

Hypomania is elevated mood, pressured speech and flight of ideas without any psychotic symptoms

75
Q

Next step of symptoms of hypomania in primary care

A

Routine referral to community mental health team

76
Q

What is clang associations (speech)

A

Flight of ideas where the ideas are related only by rhyme or being similar sounding

77
Q

How does depression differ from dementia

A

Depression can cause memory loss due to lack of concentration

Dementia progresses much more slowly and takes time for patients to notice the symptoms. Usually others notice the symptoms not the patient themselves and the patient is not usually worried about memory loss

Psychiatry (6 decks)

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