Mood Disorders Flashcards
Mood Episodes v. Mood Disorders
Episode= distinct pd of time in which some abnormal mood is present. Disorder = patterns of mood episodes.
Episodes:
- Major depressive episode
- Manic episode
- Mixed episode
- Hypomanic episode
Main Mood Disorders:
- Major depressive disorder (MDD)
- Bipolar I disorder
- Bipolar II disorder
- Dysthymic disorder
- Cyclothymic disorder
Major Depressive Episode (DSM-IV Criteria)
Symptoms cant be due to substance use or medical conditions, and they must cause social or occupational impairment. Must have at least 5 of the following symptoms for at least 2 weeks (and must include either 1 or 2):
- depressed mood
- Anhedonia
- Change in appetite or body weight (increased or decreased)
- Feelings of worthlessness or excessive guilt.
- Insomnia or hypersomnia
- Diminished concentration
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Recurrent thoughts of death or suicide
A person who has been previously hospitalized for a major depressive episode has a 15% risk of committing suicide later in life.
Manic Episode (DSM-IV Criteria)
A pd of abnormally and persistently elevated, expansive or irritable mood, lasting at least 1 week and including at least 3 of the following (four if mood is irritable):
- distractibility
- inflated self-esteem or grandiosity
- Increase in goal-directed activity (socially, at work or sexually)
- Decreased need for sleep
- Flight of ideas or racing thoughts.
- More talkative or pressured speech (Rapid and uninterruptible)
- Excessive involvement in pleasurable activities that have a high risk of negative consequences (e.g. buying sprees, sexual indiscretions).
These symptoms cannot be due to substance use or medical conditions, and they must cause social or occupational impairment.
Mixed episode
Criteria are met for both manic episode and depressive episode. These criteria must be present nearly every day for at least 1 week. As with mania, this is a psychiatric emergency.
Hypomanic episode
A hypomanic episode is a distinct period of elevated, expansive or irritable mood that includes at least 3 of the symptoms listed for the manic episode criteria (four if the mood is irritable). Significant differences b/w mania and hypomania:
Mania:
- lasts at least 7 days
- causes severe impairment in social or occupational functioning
- may necessitate hospitalization to prevent harm to self or others
- may have psychotic features
Hypomania:
- lasts at least 4 days
- no marked impairment in social or occupational functioning
- does not require hospitalization
- no psychotic features
Mood disorders
often have chronic courses that are marked by relapses with relatively normal functioning b/w episodes. they may be triggered by a medical condition or drug– always investigate medical or substance induced causes before making a diagnosis.
Medical causes of a depressive episode
- CVA disease
- endocrinopathies (Cushings/ Addison/ hypoglycemia/ hypo/hyperthyroidism/ hyper/hypocalcemia)
- Parkinson’s disease
- viral illnesses (eg Mono)
- carcinoid syndrome
- cancer (esp lymphoma and pancreatic carcinoma)
- collagen vascular disease (eg, SLE)
Medical causes of a manic episode
- Metabolic (hyperthyroidism)
- Neurological disorders (temporal lobe seizures, MS)
- neoplasms
- HIV infection
Medication/Substance induced depressive episodes
- EtOH
- antihypertensives
- barbiturates
- corticosteroids
- levodopa
- sedative-hypnotics
- anticonvulsants
- antipsychotics
- withdrawal from psychostimulants (eg, cocaine, amphetamines)
Medication/substance-induced mania
- corticosteroids* (most common presentation)
- symphathomimetics
- dopamine agonists
- antidepressants
- bronchodilators
- levodopa
Major Depressive Disorder (MDD)
DSM-IV criteria:
- at least one major depressive episode
- no history of manic or hypomanic episode
Epi: lifetime prevalence 15% Onset at any age, but ave is 40 2x prevalent in women than men prevalence in elderly from 25% to 50%
Assc’d Sleep Problems:
- multiple awakenings
- initial and terminal insomnia
- hypersomnia
- REM sleep shifted to earlier in night and stages 3 & 4 decreased
Etiology of MDD
abnormalities of serotonin/catecholamines– decreased brain and CSF levels of serotonin and its main metabolite, 5-HIAA, are found in depressed pts.
Drugs that increase availability of serotonin, norepi and dopamine often alleviate Sx of depression.
Other neuroendocrine abnormalities:
- high cortisol (hyperactivity of HPA axis as shown by failure to suppress cortisol levels in dexamethasone suppression tests).
- Abnormal thyroid axis– Thyroid disorders are assc’d w/ depressive Sx, 1/3 of pts w/ MDD who have otherwise normal thyroid levels show blunted response of TSH to infusion of thyrotropin-releasing hormone (TRH).
Many other neurotransmitters and hormonal factors have also shown potential involvment, including GABA and endogenous opiates.
Psychosocial/life events in MDD
loss of a parent before age 11 is assc’d with later devolopment of major depression. Stable family and social functioning have been shown to be good prognostic indicators in the course of major depression.
Course and prognosis of MDD
If left untreated, usually self-limited 6-13 months. Risk of subsequent episode 50% within first 2 years of first episode.
15% pts eventually commit suicide.
Approx. 75% pts treated successfully w/ medical therapy. (antidepressants).
Treatment of MDD
SSRIs– side effects inc; headache, GI disturbance, sexual dysfunction and rebound anxiety
TCAs–most lethal in overdose, side effects incl. sedation, weight gain, orthostatic hypotension and anticholinergic effects.
MAOIs–used for refractory depression, risk of hypertensive crisis when used with sympathomimetics or tyramine-rich foods. Risk of serotonin syndrome when used with SSRIs. Most common side effect is orthostatic hypotension.
Adjuvant medications– stimulants like methylphenidate used in certain patients like terminally ill with refractory symptoms. Action is rapid, but potential for dependence limits its use.
Antipsychotics–used in ppl with psychotic features.
Also used is pyschotherapy (behavioral, cognitive, supportive, dynamic, and family therapy).
ECT may be helpful.
