Mood Disorders Flashcards
What are the features of somatic syndrome
- markedly reduced appetite
- weight loss
- early morning wakening
- diurnal variation in mood
- psychomotor retardation
- loss of libido
- marked anhedonia
- lack of emotional reactivity
Describe some of the psychotic symptoms that can occur in depression with psychosis
Delusions: mood congruent usually
Worthlessness: guilt, ill health, poverty, imminent disaster
Nihilistic delusions
Persecutory delusions
2nd person auditory hallucinations
Olfactory hallucinations eg rotting flesh
What % of those with depression will die by suicide
5-15%
What is the treatment for mild / moderate depression
Low intensity psychological interventions
Medication: 1st line treatment would usually be an SSRI eg citalopram, sertraline, fluoxetine or paroxetine
What is the treatment for moderate / severe depression (depression that has failed to respond to treatment)
Medication
High intensity psychological interventions
Consider secondary care referral
What is the treatment for severe depression with life threatening presentations and severe self neglect
Medication
High intensity psychological interventions
ECT
Crisis resolution and home treatment
MDT
Inpatient
How is relapse of depression prevented
Continued pharmacotherapy for 6 months after a depressive episode
Then continued pharmacotherapy for 2 years to reduce risk of relapse from recurrent depression
What are symptoms of hypomania
Mild elevation or mood instability
Increased energy
Mild overspending
Increased sociability and overfamiliarity
Distractability
Increased sexual energy
Decreased need for sleep
How to confirm a diagnosis of hypomania
Symptoms need to have been present for 4 days
What are the symptoms of mania
Elevated mood, expansive, irritable
Increased activity
Reckless behaviour
Disinhibition
Marked Distractability
Markedly increased sexual energy
Sleep impaired or absent
Grandiosity
Flight of ideas
How is a diagnosis of mania confirmed
Symptoms need to have been present for a week or have to be severe enough to necessitate inpatient admission
How can bipolar affective disorder be diagnosed
When there has been 2 episodes of mania or one episode of mania and one of depression
Describe the epidemiology of bipolar affective disorder
1% lifetime risk
Equal prevalence in men and women
Onset generally late teenage to early 20s
Aetiology of bipolar affective disorder
Genetics
Life events: prolonged stressful circumstances can predispose episodes
Substance misuse
Describe the prognosis of bipolar affective disorder
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
Common causes of bipolar relapse
Non concordance with medication
Life events, social stressors
Disruption of circadian rhythm
Substance misuse
Childbirth
Natural course of the illness
What is encephalitis
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
What investigations would you do for encephalitis
Clinical history
General and neurological examination
Routine blood and CSF analysis
Neuro imaging
EEG
Antibody testing
What is autoimmune limbic encephalitis
Medial temporal lobe involvement
Sub acute onset (3mos)
Altered mental state, cognitive dysfunction, seizures
What is acute disseminated encephalomyelitis
Often post infective and in the under 40s
Multi focal neurological deficits
Variable encephalopathy
What is anti NMDA receptor encephalitis
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
What is bickerstaff encephalitis
Impairment of consciousness, ataxia and opthalmoparesis
Post infective
Often Monophasic with a good prognosis
What is autoimmune psychosis
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
Epidemiology of depression
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
Biological causes of depression
Genetic predisposition: 40-50% MZ twin concordance
Chronic disease: pain, cancer, heart disease
Hormonal changes: post partum depression
Psychological causes of depression
Negative thinking style
Personality type: increased risk with neuroticism
Social causes of depression
Chronic stress
Substance misuse
Parenteral separation in childhood
Social isolation
Adverse life events
Describe the pathophysiology of depression
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
What are the 3 core symptoms of depression
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
Biological symptoms of depression
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
What are cognitive symptoms of depression
Reduced concentration / memory
Poor self esteem / worthlessness
Guilt
Hopelessness
Suicide / self harm
Psychotic symptoms of depression
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
What is the psychological approach to management of depression
1st line for mild depression and 1st like in combination with antidepressants for mild - moderate depression
CBT is first line
What is the biological approach to management of depression
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
What is the social approach to management of depression
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
Describe the prognosis of depression
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%
What is a depressive episode
Must have 2 of the core symptoms of depression for at least 2 weeks + 2 biological or cognitive symptoms
What is recurrent depressive disorder
When a patient with a depressive episode goes on to have a further depressive episode
Avg number of episodes experienced is 5
What is dysthymia
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
How much is suicide risk increased in someone presenting with self harm
100x
Epidemiology of suicide
Elderly
Male
Homosexual / transgender
Unmarried / unemployed
Lives alone / social isolation
Low socioeconomic status
Farmer, nurse, doctor
Clinical risk factors of suicide
Psychiatric illness (highest in anorexia and depression)
Physical illness
Alcohol dependence
Previous self harm
FH of depression, alcoholism, suicide
What are some immediate management considerations after a suicide attempt
- Is inpatient care required to preserve patient safety
- Would the patient benefit from the input of home treatment / crisis team
- Do they have existing social support that can be called upon
- Is it possible to reduce means of self harm
What are some long term management considerations after a suicide attempt
Treat underlying psychiatric illness
Optimise social functioning
Crisis planning
What are the 2 types of bipolar affective disorder
Type I: experience manic episodes and major depression
Type II: experience hypomania and major depression, absence of manic episodes
What is the epidemiology of bipolar affective disorder
1% lifetime risk
Avg age of onset = 20
M=F
Aetiology of bipolar
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
Biological features of bipolar affective disorder
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
Cognitive features of bipolar affective disorder
Elevated self esteem / grandiosity that can lead to delusions of grandeur
Poor concentration
Accelerated thinking
Impaired judgement
Psychotic features of bipolar affective disorder
Disordered thought form
Abnormal beliefs
Perceptual disturbances
Features of hypomania
Mild elevation of mood / irritability
Increased energy, decreased sleep
Mild overspending / risk taking
Distractability
Increased sexual energy
Features of mania
Generally requires hospital admission
Significantly elevated mood
Highly active, little to no sleep
Reckless decisions
Grandiosity
Describe the biological management of mania
Antidepressants discontinued
Benzodiazepines can help in reducing severe behavioural disturbances
Anti manic agent started (risperidone, olanzapine, quetiapine, lithium, valproate)
Describe the psychological / social management of mania
Psychoeducation once the patient is more stable in mood
Creation of a non stimulatory environment
Describe the biological management of acute depression in bipolar
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
Describe the psychological / social management of acute depression in bipolar
High intensity CBT and Psychoeducation
Identify and nullify social stressors
Describe the long term biological management of bipolar
Lithium, valproate or olanzapine based on sex, comorbidity and patient preference
All are teratogenic
If one is ineffective consider switching to another
Long term psychological / social management of bipolar
Psychoeducation to recognise early signs of relapse
CBT may be used
Avoidance of known episode precipitants
Support for education, finance, housing
Describe the prognosis of bipolar affective disorder
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
What is relapse of bipolar associated with
Non concordance to lithium
Life events
Circadian rhythms
Disruption
Childbirth
Substance abuse
Side effects of lithium
GI upset
Dry mouth
Metallic taste
Limitations of lithium
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
What are the neurological, renal and CV effects of lithium toxicity
Neuro: tremor, seizures, delirium, coma
Renal: AKI, nephrotic syndrome, diabetes insipidus
CV: QT prolongation, sinus node dysfunction
What is used to treat severe lithium toxicity with neurological symptoms
Urgent haemodialysis
MOA of valproate as a mood stabiliser
Na channel blocker
Increases GABA levels
Side effects of valproate
Weight gain
Sedation
Hair loss
Tremor
Blood dyscrasias
Liver failure
What is cyclothymia
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
Characterisation of borderline personality disorder
Intense emotions which can change quickly, difficulties with relationships, feelings of emptiness, fears of abandonment, impulsive behaviour and self harm
Order of NICE recommendations for depression
- Guided self help
- Group CBT
- Group behavioural activation
- Individual CBT
- Individual behavioural activation,
- Group exercise
- Group mindfulness and meditation
- Interpersonal psychotherapy
What should be done before a patient starts ECT treatment
Antidepressant medication should be reduced but not stopped
What can selective serotonin reuptake inhibitor discontinuation syndrome present with
Diarrhoea
Vomiting
Abdominal pain
What is procyclidine used for
Acute dystonia secondary to antipsychotics
What is conversion disorder
Loss of motor or sensory function
Mostly caused by stress
How is hypomania different to mania
Hypomania is elevated mood, pressured speech and flight of ideas without any psychotic symptoms
Next step of symptoms of hypomania in primary care
Routine referral to community mental health team
What is clang associations (speech)
Flight of ideas where the ideas are related only by rhyme or being similar sounding
How does depression differ from dementia
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
