Mood Disorders Flashcards
Mood disorder
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
Two main types of mood disorders
- depressive
2. instability
Depressive Mood:
major depression or unipolar dysthymia depressive disorder substance-induced mood disorder mood disorder due to general medical condition
Mood instability:
bipolar disorder type I, II
cyclothymia
substance induced
general medical conditions
DSM-IV Major Depressive episode
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
- 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
- Markedly diminished interest or pleasure in all or almost all activities most of the day
- Significant weight loss when not dieting or weight-gain. Or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feeling of worthlessness or excessive or inappropriate guilty nearly every day
- Diminished ability to think or concentrate or indecisiveness, nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide
Major depressive disorder
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
Melancholia
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
Atypical depression
subtype of major depressive episode. Characterized by: excessive sleep, excessive appetite, leaden paralysis of limbs, rejection sensitivity.
• Responds better to MAOI or SSRI therapy
other depressive disorders
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
Clinical findings
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
Worthlessness & Guilt - depression
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
Other features of depression: diurnal variation
some feel a better mood later in the day
Other features of depression: decreased libido
important to identify because it can also be a side effect of some psychiatric medications
Other features of depression: psychosis
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
Suicide
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
Safety with suicide and depression
- Desire to harm self
- Desire to harm others
- Ability to care to for self
- Ability to care for others who are dependent on them
- Ability to understand need for treatment
- Ability to follow treatment recommendations
course and outcome with depression
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
Mood Instability
- 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
hypomanic episode
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
manic episode
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
difference between hypomania and manic?
duration
for hypomania the following apply
- 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
for mania the following apply
- 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
mixed episode
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
Clinical findings in mania
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
Dysthymia
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
Cyclothymia
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
differences between bipolar type I and type II and bipolar NOS
- 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
depression is more common in
women than men 2:1
bipolar is more common in
women
who has an earlier onset of bipolar?
men
dysthymia is more common in what age group?
elderly
etiology: genetics
- 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
etiology: social and environmental
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
Etiology: neurobiology
• 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
Etiology: neuroimaging
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
Etiology: neuroendocrine
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
Etiology: neurophysiology
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
Treatment: Depression - psychotherapy
- Includes: supportive, cognitive behavioral, interpersonal, psychodynamic
- Aims to change underlying personality structure and work on improving insight, its open ended, more time-consuming, expensive
Treatment: Depression - medications
• 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)
Treatment: Depression - duration
- 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
Treatment: Depression - other
- Bright Light Therapy: helpful in SAD
- Electro-convulsive therapy (ECT)
- rTMS
- Vagal nerve stimulation
- Deep brain stimulation
Treatment: Mania - safety
- 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!!!
Treatment: Mania - medications
- 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
Suicidality in Bipolar disorder
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
