Mood Disorders

Question 1

Mood disorder

Answer 1

life, when the individual is no longer able to manage their own mood and the mood disturbance is sustained and pervasive, it causes significant distress

Question 2

Two main types of mood disorders

Answer 2

1. depressive

2. instability

Question 3

Depressive Mood:

Answer 3

major depression or unipolar
dysthymia
depressive disorder
substance-induced mood disorder
mood disorder due to general medical condition

Question 4

Mood instability:

Answer 4

bipolar disorder type I, II
cyclothymia
substance induced
general medical conditions

Question 5

DSM-IV Major Depressive episode

Answer 5

o Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functions. At least one of the symptoms is either depressed mood or loss of interest or pleasure

1. Depressed mood most of the day, nearly every day as indicated by either subjective report - in children and adolescents it can be an irritable mood
2. Markedly diminished interest or pleasure in all or almost all activities most of the day
3. Significant weight loss when not dieting or weight-gain. Or decrease or increase in appetite nearly every day
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation nearly every day
6. Fatigue or loss of energy nearly every day
7. Feeling of worthlessness or excessive or inappropriate guilty nearly every day
8. Diminished ability to think or concentrate or indecisiveness, nearly every day
9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide

Question 6

Major depressive disorder

Answer 6

o Presence of a single major depressive episode
o The major depressive episode is not better accounted for by schizoaffective disorder and is not superimposed on schizophrenia etc.
o There has never been a manic episode, a mixed episode or a hypomanic episode
o Recurrent - presence of two or more major depressive episodes

Question 7

Melancholia

Answer 7

a subtype of major depressive episode. Characterized by: pervasive anhedonia, distinct quality of depressed mood, diurnal variation, terminal insomnia, severe psychomotor changes, anorexia, excessive guilt, likelihood of response to somatic therapy

Question 8

Atypical depression

Answer 8

subtype of major depressive episode. Characterized by: excessive sleep, excessive appetite, leaden paralysis of limbs, rejection sensitivity.
• Responds better to MAOI or SSRI therapy

Question 9

other depressive disorders

Answer 9

o Post-partum: full episode within 4 weeks of childbirth
o Catatonia: motor problems such as negativity, waxy flexibility, mutism, posturing
o Rapid-cycling: four or more distinct episodes in 1 year
o Seasonal: usually depressed in winter and elevated in summer – respond to light or antidepressants

Question 10

Clinical findings

Answer 10

o Decreased or sometimes increased appetite
o Decreased or sometimes increased sleep
o Low or sad mood
o Inability to enjoy usual activities
o Irritability
o Decreased or sometimes increased psychomotor activity

Question 11

Worthlessness & Guilt - depression

Answer 11

o These feelings are out of the realm of the ordinary
o The patient feels excessively hopeless and worthless
o They feel they should be punished for what to others are minor flaws – sometimes these ideas reach delusional levels

Question 12

Other features of depression: diurnal variation

Answer 12

some feel a better mood later in the day

Question 13

Other features of depression: decreased libido

Answer 13

important to identify because it can also be a side effect of some psychiatric medications

Question 14

Other features of depression: psychosis

Answer 14

the presence of delusions and hallucinations, seen in up to 20% of patients. May be mood-congruent or mood-incongruent. Has an impact on treatment and prognosis
• Delusions may be true

Question 15

Suicide

Answer 15

o 10-15% of patients hospitalized with depression will take their own life
o Suicide attempts are more common in females and completed suicides are more common in males
o Psychosocial stress, loneliness and lack of supports increase risk
o Drug and alcohol use increases risk
o Older age, and Caucasian race also increase risk
o Depressed patients think a lot about death and suicide
o These patients may pan to take their life
o They may feel that people may be better off without them
o They may feel that the world is hopeless place and that others, such as their children also should not live in it
o Asking about suicide does not put the idea in the patients mind

Question 16

Safety with suicide and depression

Answer 16

1. Desire to harm self
2. Desire to harm others
3. Ability to care to for self
4. Ability to care for others who are dependent on them
5. Ability to understand need for treatment
6. Ability to follow treatment recommendations

Question 17

course and outcome with depression

Answer 17

o The onset may be sudden or gradual
o May or may not be related to life stressor
o Usually resolves in 6 months
o 20% of episodes may become chronic
o Suicide is a high risk
o Comorbidity with drug and alcohol use is common and worsens prognosis

Question 18

Mood Instability

Answer 18

• Comprised of a combination of mood disorders
• Bipolar Disorder Type I – the mood episodes can be major depressive, manic, hypomanic and mixed
• Bipolar Disorder Type II – the episodes can be major depressive and hypomanic

Question 19

hypomanic episode

Answer 19

a distinct period of persistently elevated expansive/irritable mood lasting through at least 4 days with the following symptoms
•	Inflated self-esteem or grandiosity
•	Decreased need for sleep
•	More talkative than usual
•	Flight of ideas
•	Distractibility
•	Increase in goal-directed activity
•	Excessive involvement in pleasurable activities that have a high potential for painful consequences

Question 20

manic episode

Answer 20

a distinct period of abnormally and persistently elevated expansive/irritable mood lasting at least 1 week with the following symptoms
•	Inflated self-esteem or grandiosity
•	Decreased need for sleep
•	More talkative than usual
•	Flight of ideas
•	Distractibility
•	Increase in goal-directed activity
•	Excessive involvement in pleasurable activities that have a high potential for painful consequences

Question 21

difference between hypomania and manic?

Answer 21

duration

Question 22

for hypomania the following apply

Answer 22

• Episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic
• The disturbance in mood and the change in functioning are observable by others
• The mood disturbance not severe enough to cause marked impairment in social or occupational functioning, no hospitalization

Question 23

for mania the following apply

Answer 23

• Symptoms do not meet criteria for mixed episode
• The mood disturbance is sufficiently severe to cause marked impairment in occupational function or in usual social activities or relationships with others, hospitalization is necessary

Question 24

mixed episode

Answer 24

criteria are met both for a manic episode and for a major depressive episode (except duration) nearly every day during at least a 1-week period
• The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, hospitalization is necessary
• The symptoms are not due to the direct physiological effects of a substance or a general medical condition

Question 25

Clinical findings in mania

Answer 25

o Typically expansive and infectious mood
o Other times markedly irritable
o One of the first things to go is insight
o Elevated self-esteem and grandiosity which may be delusional
o Increased energy and activity level
o Need for sleep is markedly reduced
o Increased desire for sexual activity
o Much more social and gregarious
o Increased energy level
o Physically restless/unable to sit still
o Poor judgment and engaging in risky activities
o Speech shows pressure and long, rambling answers
o Flight of ideas as evidenced by their thought process

Question 26

Dysthymia

Answer 26

chronic, low-grade depression characterized by tow or more of the following:
o Anorexia, insomnia, decreased energy, low self-esteem, difficulty concentrating and hopelessness
o Needs to last at least 2 years without a two month well period
o Can be accompanied by Major Depression – known as double depression

Question 27

Cyclothymia

Answer 27

characterized by low grade depression alternating with hypomania
o A chronic disorder
o Does not reach the depths of major depression or heights of mania
o Primarily a disorder of mood instability

Question 28

differences between bipolar type I and type II and bipolar NOS

Answer 28

• Bipolar Disorder Type I – at least one manic or mixed episode
• Bipolar Disorder Type II – major depression and hypomania
• Bipolar Disorder NOS – mood instability is evident but criteria are not met for one reason or another or data are insufficient

Question 29

depression is more common in

Answer 29

women than men 2:1

Question 30

bipolar is more common in

Answer 30

women

Question 31

who has an earlier onset of bipolar?

Answer 31

men

Question 32

dysthymia is more common in what age group?

Answer 32

elderly

Question 33

etiology: genetics

Answer 33

• Bipolar Disorder Type I – at least one manic or mixed episode
• Bipolar Disorder Type II – major depression and hypomania
• Bipolar Disorder NOS – mood instability is evident but criteria are not met for one reason or another or data are insufficient

Question 34

etiology: social and environmental

Answer 34

ο Stressors are commonly seen to precipitate depressive episodes including ones that fit Major Depression
ο Stressors may precipitate physiology changes that lead to depression
ο Abusive upbringing can lead to a diathesis that predisposes an individual to depression

Question 35

Etiology: neurobiology

Answer 35

• Monoamine hypothesis:
o Multiple lines of evidence suggest a role for biogenic amines in the development of unipolar illness
o Changes in metabolites such as 5HIAA (lower in patients with suicidality)
o NE, 5HT, DA

Question 36

Etiology: neuroimaging

Answer 36

o Subgenual prefrontal cortex linked to depression
• Shows increased blood flow when sadness is induced
• Thought to control evaluation of consequences of social behavior
• Anatomic studies show reduction in volume of this area; it has projections to the hypothalamus
• Both unipolar and bipolar patients show increased white matter hyperintesities

Question 37

Etiology: neuroendocrine

Answer 37

o Function of adrenal, thyroid and growth hormone axes appears to be affected thus indicating a pituitary/hypothalamus dysfunction
• Sustained elevation of cortisol is a robust finding in depression
• Thyroid axis abnormalities are present in up to 10% of depressed patients (but all depressed patients should be screened)
• Growth hormone: decreased sleep-related release and decreased

Question 38

Etiology: neurophysiology

Answer 38

o Sleep abnormalities: increased sleep onset, decreased REM latency, longer first REM period
o Circadian rhythms
o PET study shows hypermetabolism in frontoparietal areas and thalamus during transition from wakefulness to non-REM

Question 39

Treatment: Depression - psychotherapy

Answer 39

• Includes: supportive, cognitive behavioral, interpersonal, psychodynamic
• Aims to change underlying personality structure and work on improving insight, its open ended, more time-consuming, expensive

Question 40

Treatment: Depression - medications

Answer 40

• Placebos produce improvement in 30% of patients but only 50% sustain
• Produce an improvement in 65% of patients
• If they continue treatment only 10-20% will relapse
o Relapse is when original episode is not over and symptoms return
o Recurrence is when the original episode is over but then the symptoms return
o Remission is relief from all symptoms – it’s the goal
• Don not attempt to reduce dose
• First line of therapy should usually be an SSRI (tolerated better and safer in overdose)
• Citalopram, es-citalopram, fluoxetine, paroxetine, sertraline, fluvoxamine)

Question 41

Treatment: Depression - duration

Answer 41

• For CBT and interpersonal treamtne one to two sessions a week for 8-16 weeks
• For ECT three sessions/week for a total of 6-12 sessions
• For medications, 6-9 months of treatment followed by a taper for the first episodes

Question 42

Treatment: Depression - other

Answer 42

• Bright Light Therapy: helpful in SAD
• Electro-convulsive therapy (ECT)
• rTMS
• Vagal nerve stimulation
• Deep brain stimulation

Question 43

Treatment: Mania - safety

Answer 43

• Potential to engage in acts that are highly dangerous to themselves and others
• Psychosis is common
• Lack of insight is a core feature
• Mood changes bring with them a change in attitude toward themselves and world
• Is the patient safe enough to be treated in the outpatient setting?
• If behavior is detrimental to their own or to other’s safety – hospitalize
• Delay major decisions
• Always check to see if patient has guns!!!

Question 44

Treatment: Mania - medications

Answer 44

• Usual combination of medications that is implemented in acute mania includes:
• Mood stabilizer – lithium or valproate or carbamazepine
• An atypical antipsychotic (when the patient is psychotic/agitated)
• High potency benzodiazepine

Question 45

Suicidality in Bipolar disorder

Answer 45

10-15%
• Usual combination of medications that is implemented in acute mania includes:
• Mood stabilizer – lithium or valproate or carbamazepine
• An atypical antipsychotic (when the patient is psychotic/agitated)
• High potency benzodiazepine