Mood Disorders Flashcards
What are the types of mood disorder?
Depressive Disorder
Single of recurrent episodes
Biopolar Disorder
Sustained low mood and sustained high mood, to the point at which it affects the functioning of the individial
- *Mania** (extreme high mood)
- *Hypomania** (mild mania)
- *Mixed affective state** (either a mixture or a rapid alteration (within a few hours) of hypomanic, manic and depressive symptoms)
Persistant Mood Disorder
Cyclothymia - mild periods of elevation/depression for at least 2 years. Common in relatives of BPD
Dysthymia - chronic low mood not fulfilling the criteria of depression
Differentials
- Normal fluctuation in mood
- Adjustment disorders bereavement, PTSD
- Dementia etc.
- Personality disorders
- Anxiety Disorders
What is depression?
Describe the diagnostic approach
A global disease which affects wellbeing at every level.
Lifetime prevalence is 10-20%. 2nd worst for DALYs.
2-3 times more common in those with a chronic physical health problem
Core symptoms - at least one of these, most days, most of the time, for two weeks
- Continuous low mood for at least 2 weeks
- Lack of energy
- Anhedonia (lack of enjoyment)
Somatic symptoms
- Sleep changes - 2/3 insomnia (90% in older), in younger adults 40% hypersomnia. Early morning waking (2 hours before)
- Appetite and weight changes majority will not eat and lose weight, some will eat more and gain
- Diurnal variation of mood. Feel worst in the morning and get better throughout the dya
- Psychomotor retardation / agitation. In severe forms will not get up and eat.
- Loss of libido
Cognitive Symptoms
- Low self esteem
- Guilt/Self Blame
- Hopelessness
- Hypochondrical thoughts
- Poor concentration/attention
- Suicidal Thoughts
Catagorise the diagnosis of depression
Mild
2 core + 2 others (Able to function)
Moderate
2 core + 3-4 others
Severe
3 core + at least 4 others
Severe with psychotic symptoms in keeping with mood
Hallucinations (often auditory, critical voice)
Delusions - hypochondriacal/guilt/nihilistic (I am dead)/persecutory
Describe post-natal depression
- 10-15% of women udually within 1-2 months post partum but can appear later in some women
- 10% of post partum deaths are because of suicide
- Thought content may include worries about that baby’s health or her ability to cope adequately with baby
- Risk factors - personal or family history of depressio, older age, single mother, unwanted pregnancy, poor social support, previous PND
Differentiate the symptoms of hypomania and mania
Several of the following features with considerable interference with work/social activity for at least several days
- Mildly elevated, expansive or irritable mood
- Increased energy/activity
- Increased self esteem moving to pretense
- Sociability, talkitiveness and overfamiliarity
- Increased sex drive
- Hyposomnia
- Difficulty in focusing on one task alone
- Elevated/ expansive/ irritable and angry mood (1 week)
- Increased energy/activity (inc agitation)
- Grandiosity/ increased self-esteem
- Pressure of speech
- Flight of ideas/ racing thoughts
- Distractable
- Hyposomnia
- Increased libido
- Social inhibitions lost
- +/- Psychotic symptoms especially grandiose dellusions
Hypomania and mania is generally part of bipolar
Describe the diagnosis of bipolar
Bipolar I : one more more manic or mixed episodes, +/- one or more depressive episodes
Bipolar II : one or more depressive episodes with at least one hypomanic episode
ICD-10 requires at least 2 episodes, one of which must be a hypomanic, manic, or mixed episode
- Prevalence 1-2%
- Median age of onset - 25 years
- M= F c.f. depression double female
What are the causes of mood disorders
Biological
Genetic esp. bipolar
Brain Illnesses
Physical Illnesses - hypothyroidism etc.
Psychological
Childhood experiences
View of yourself and the world
Personality traits
Social
Work, housing, finance, relationships, support etc.
Describe the non-pharmacological treatment of mood disorder
Biological
ECT - Electrodes are placed on two sides of the brain and current is passed through anaethasied patient. 2/7 for 6/52.
- Indicated in severe depressive illness, where other treatments have not been effective
- Life threatening illness (food/fluid)
- Prolonged and severe manic episode
- Catatonia or psycomotor retardation
- High suicide Risk
- Stupor
- *rTMS** - Repetitive Transcranial Magnetic Stimulation. Involves magnetic stimulation of the brain. Non invasive. 5 days a week for 6 weeks.
- *tDCS** - Transcranial Direct Current Stimulation. Similar to rTMS but less evidence thus far
Psychological treatment
- Psychoeducation
- CBT
- IPT
- Psychodynamic
- Mindfullness
Social Interventions
Targeted interventions in family, housing, finance and employment.
Describe the pharmacological treatments of mood disorder
What is the prognosis?
Antidepressants e.g. SSRIs, SNRIs, TCAs, NASSAs, MAOIs
Avoid antidepressants in BPD - poor evidence and risk of manic switch
Mood Stabilisers e.g. Lithium, Valporate, Carbamezepine, Lamotrigine
Antipsychotics
Aniolytics
Depression
First episode - continue ADs for at least 6-12 months
Multiple episodes continue for much longer to life
80% will have further depressive episode 10% severe unremitting.
Bipolar
Poor prognosis suggested by severe episodes, early onset, cognitive deficits
Treatment more effective earlier on in illness
80% relapse after first episode within 5-7 years
Define the term neurosis
Neuron (Gr) nerve
-osis: diseased or abnormal condition
Originally used to describe all functional conditions.
It was then taken over by psychoanalysis : Emotional distress (inc. unconscious conflict) is expressed, including physical symptoms. Neurosis is rooted in ego defence mechanisms. Main feature is anxiety.
Practical current use
Collective term for disorders characterised by distress, that are non-organic, have a discrete onset, and where delusions and hallucinations are absent
- Functional (we don’t have a clear organic cause)
- Not psychotic (i.e. patients are distressed, but do not have delusions or hallucinations)
- Essentially synonymous with anxiety disorders
What underpins all anxiety disorders
Fear leads to physiological and cognitive arousal and this leads to behavioural changes because of the fear.
This can cause safety behaviours which can be subtle but allow them to feel that they can manage. But while they provide short term comfort, they reinforce the at risk belief and therefore maintain the long term disorder.
Lang’s three system model
Thoughts - behaviour - feelings. All linked together
Padesky’s Anxiety Equation
Estimate of danger / Estimate of coping
When danger is percieved or anticipated there is an autonomic sympathetic response which releases adrenaline and noradrenaline.
This causes the symptoms of racing thoughts, inability to concentrate, cognitive bias, GI upset.
People with an anxious preocupation will notice something more, e.g. social perception, health, and this maintains anxiety problems
Primary evolutionary function is to protect in response to danger. Fight, flight, or freeze. But when the percieved danger does not exist the brain can still respond to a psychological ‘imagined’ threat.
The brain is unable to distinguish between physical and psychological threat (and so responds to a false alarm)
What are the anxiety disorders (neurosis)?
Panic Disorder (with or without agoraphobia)
Social Anxiety Disorder (social phobia)
Specific Phobias - A marked fear of specific objects or situations and marked avoidance of such object or situations which reinforces the behaviour.
Health Anxiety (hypochondriasis)
Obsessive Compulsive Disorder (OCD)
Predominantly obsessional thoughts, predominately compulsive thoughts, mixed
Body Dysmorphic Disorder (BDD)
- Characterised by a preoccupation with an imagined defect in appearance
- Leads to time conuming behaviours e.g. mirror gazing, comparisons, excessive camouflaging, skin picking and reassurance seeking.
Post-Traumatic Stress Disorder (PTSD)
Acute stress reaction, adjustment disorder
Generalised Anxiety Disorder (GAD)
Mixed anxiety and depressive disorder
Describe panic disorder
What is the cognative model of panic
Panic Disorder (with or without agoraphobia)
- A fear of your own physiological and psychological reactions.
- Bodily changes viewed as signs of impending collapse insanity of death.
- Feeling totally out of control.
- Accompanying avoidance of situations that may trigger these reactions is agoraphobia.
- Presents with sense of dreat, shaky, feeling faint, wobbly legs, rapid heart beat and choking.
Trigger :can be internal e.g. changes in bodily milleiu, pH or HR; or extental
Percieved threat causes anxiety
Causes sympathetic arousal and physical / cognative symptoms
These are misinterpreted as signs of disaster e.g. MI and causes more symptoms in a positive feedback
They then try to impliment safety mechanisms, which helps, but does not deal with underlying fear
Describe social phobia
Describe the cognative model of social phobia
- At it’s core lies a negative evaluation by others
- Can lead to avoidance of feared situations (counter-productive) use of safety behaviours, anticipatory anxiety, and unhelpful ‘post mortems’ following soical encounters. A degree of this is fairly common.
Taking to a stranger activates concern.
Worries that they must perform or will be seen as inadequite
They then start to see themselves through other people. Should be focusing on out there, looking in and processing self disengages from natural social interaction making things more difficult
Causes physical symptoms such as sweating or shaking which confirms original fear of self as inadequite.
Escaping from the situation can appear the only option
Describe OCD
Describe the cognative behavioural model of OCD
- Unwanted, recurring, distressing, intrusive thought or images = obsessions e.g. contamination, aggression, sexual imagery, doubting
- Most people have such thoughts but attaching significance to such intrusive thoughts might make you think you are dangerous or mad which can cause anxiety.
- Ego dystonic (not syntonic) causes the anxiety - they are not dangerous!
- To manage the distress caused by intrusions the patient conducts neutralising behaviours persistently and repetitively without leading to an actual reward or pleasure.(=compulsions)
- Compulsions can be overt: washing, checking, ordering; or covert: praying counting, repeating words.
- Exposure and response prevention (ERP) and SSRI treatment
Trigger produces intrusive thought.
This is intepreted as a sign of danger which causes anxiety
Compulsary and neutralising behaviour helps but keep the focus on the valency of the intrusive thought
They know their ideas are excessive but the anxiety is very difficult to sit with leading the the neutralisation.
What are the symptoms of neurosis
Psycholgoical
- Anticipatory fear of impending doom
- Worrying thoughts that are innappropriate or excessive
- Exaggerated Startle Response
- Restlessness
- Poor concentration and Attention
- Irritability
- Depersonalisation and derealisation
- Depressive symptoms
CVS
Palpitations, chest pain
Resp
Hyperventialtion, cough, chest tightness
GIT
Abdominal pain, loose stools, N&V, dysphagia, dry mouth
GUT
Polyuria, failure or erection, menstrual discomfort
Neuromuscuar
Tremor, myalgia, headache, paraesthesia, tinnitus
Describe PTSD
- Caused by exposure to event or situation of exceptionally threatening or catastrophic nature which would be likely to cause pervasive distress in almost everyone
- Puts you in the victim catagory with potential mediolegal sequela
- Characterised by re-experiencing e.g. nightmares or flashbacks. Avoidance as brain cannot process the memory. Hyperarousal as constantly on guard for threats.
- Commonly co-morbid with other anxiety disorders, depression, substance abuse
- Treatment is psychological - eye movement desensitization and reprocessing, CBT, exposure therapy
Describe GAD
- A complex worry problem, difficult to diagnose.
- Specific content of (type I) worries changes / varies
- Includes ‘worries about worries’ (type II worries)
- Usually accompanied by low level physical symptoms (e.g. insomnia, muscle tension, GI problems, headache)
- Often maintained by the belief that worry is useful (positive worry beliefs) e.g. it motivates, shows responsibility.
What problems are associated with anxiety disorders?
What are the important differentials?
- Increased autonomic arousal
- Avoidance
- Time consuming anxiety reducing behaviours
- Worry
- Procrastination / inability to make decisions
- Reduced concentration
- Impact on functioning — work, social, health, etc
- Impaired sleep pattern
- Alcohol and drug dependence
- Medical risks: hyperthyroid, hypoglycaemia, anaemia, Cushing’s, COPD, CCF, malignancies
DDx
Adjustment disorders or bereavement. These can be pathological but generally will resolve
Other functional psychiatric illness esp. depression. Need to work out which comes first and treat that
Organic problems: Endocrine, neurological (dementia, MS, Lupus), drug induced (steriods, anthypertension, alcohol and rec drugs), infection
Why might depression be more common in women?
What social factors contribute to depression?
Puberty
Issues around sexuality identity and family
Because girls typically reach puberty before boys do, they’re more likely to develop depression at an earlier age - gender gap lasts until after menopause.
Premenstrual problems
Small number of females have severe and disabling symptoms - premenstrual dysphoric disorder (PMDD)
Pregnancy
Dramatic hormonal changes occur during pregnancy, and other issues such as job or relationship stress
Postpartum depression occurs in about 10 to 15 percent of women.
Perimenopause and menopause
In perimenopause, hormone levels may fluctuate erratically.
Life circumstances and culture
Unequal power and status.
Work overload.
Sexual or physical abuse. and make it harder to treat.
What are the advantages and disadvantages of SSRIs as compared to tricyclic antidepressants?
Overall efficacy between the two classes is comparable except:
Depressed in-patients. TCAs may be more effective than SSRIs with the strongest evidence for amitriptyline possibly because of dual action in inhibiting both 5-HT and noradrenaline reuptake.
TCAs may be more efficacious for severe depression.
Remission rate. Remission rate for TCAs (44.1%) is higher than for SSRIs (37.7%) 12.
SSRIs have a modest advantage in terms of tolerability against most TCAs
In both acute and long-term treatment with less anticholinergic, antihistaminergic and cardiotoxic side-effects than TCAs
However TCA have fewer sexual and gastrointestinal side effects
The selective pharmacology of SSRIs means fewer interactions
SSRIs are designed to avoid blocking the alpha1-adrenergic receptor, so they do not potentiate antihypertensive medications, in contrast to TCAs.
Since SSRIs have been designed to avoid blocking the histamine receptor, they do not pharmacodynamically potentiate alcohol or other CNS depressants.
SSRIs are better tolerated by patients and associated with fewer discontinuations
TCA’s well known anticholinergic effects are often cited by patients as the reason for withdrawing from treatment.
SSRIs are safer in overdose than TCAs
Since all SSRIs have been designed to avoid affecting fast sodium channels in contrast to TCAs, they all have a wide therapeutic index. TCA overdose is life-threatening.
How would you differentiate between dementia and depression in a patient presenting with cognitive impairment?
It was previously thought that depressed patients would be more apathetic in cognitive testing, as opposed to dementia patients who would give the wrong answer. The validity of this theroy has been questioned, however.
• Careful symptom history including:
- detailed description; - time course and progression of symptoms;
as well as - association with other confounding factors which include: - pain; - poor nutritional status; - other medical conditions; and - recent changes in medications.
- Depressive symptoms which are less common in dementia alone such as: - consistently low mood and affect that does not respond to stimulation; hopelessness; - expressions of guilt; - feelings of worthlessness; and - thoughts of self-harm.
- Frontal symptoms, such as disinhibition, perseveration and decreased initiative, suggest dementias with a strong frontal component rather than depression.
- Information about family history of mood disorders, previous personal history of depression
- Laboratory investigations, such as hematology, thyroid function, electrolytes, vitamin B12, and drug levels of medications, known to have a propensity to cause mood symptoms.
