Mood disorders (Ch 4) Flashcards
Mood
one’s internal emotional state
external and internal stimuli can trigger moods
Normal to have wide range of moods and to have sense of control over one’s mood
Mood episode
distinct periods of time in which some abnormal mood is present.
Depression, mania, hypomania
Mood disorders
patterns of mood episodes, includes major depressive disorder (MDD), bipolar I disorder, bipolar II disorder, persistent depressive disorder, and cyclothymic disorder
may have psychotic features (delusions or hallucinations)
Major Depressive Episode DSM5 criteria
At least 5 of the following, must have either 1 or 2, for at least 2 week period
- Depressed mood most of the time
- Anhedonia (loss of interest in pleasurable activities)
- Change in appetite or weight (up or down)
- Feelings of worthlessness or excessive guilt
- Insomnia or hypersomnie
- Diminished concentration
- Psychomotor agitation or retardation (i.e. restlessness or slowness)
- Fatigue or loss of energy
- Recurrent thoughts of death or suicide
Manic Episode DSM5 criteria
Distinct period of abnormally and persistent elevated, expansive or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week
Includes at least three of the following (four if mood is only irritable):
- distractibility
- Inflated self-esteem or grandiosity
- Increase in goal-directed activity (socially, at work, or sexually) or psychomotor agitation
- decreased need for sleep
- Flight of ideas or racing thoughts
- More talkative than usual or pressured speech (rapid and uninterruptible)
- Excessive involvement in pleasurable activities that have a high risk of negative consequences (e.g. shopping sprees, sexual indiscretions)
Greater than 50 percent of manic patients have psychotic symptoms
Symptoms of Mania
"DIG FAST" Distractibility Insomnia/impulsive behavior Grandiosity Flight of ideas/racing thoughts Activity/Agitation Speech (pressured) Thoughtlessness
Symptoms of major depression
SIG E. CAPS Sleep Interest Guilt Energy Concentration Appetite Psychomotor activity Suicidal ideation
Hypomanic episode
distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal directed activity or energy, lasting at least 4 consecutive days, that includes at least 3 symptoms listed for manic episode criteria (four if mood is only irritable)
Major Depressive Disorder (MDD) DSM5
At least one major depressive episode
No history of manic or hypomanic episode
Episodes of depressed mood associated with loss of interest in daily activities. May not acknowledge their depressed mood or may express vague, somatic complaints (fatigue, HA, abdominal pain, muscle tension, etc)
Sleep problems associated with MDD
Multiple awakenings
Initial and terminal insomnia (hard to fall asleep, early morning awakenings)
Hypersomnia (excessive sleepiness) is less common
Rapid eye movement (REM) sleep shifted earlier in the night and for greater duration with reduced stage 3 and 4 (slow wave) sleep
Causes of MDD
decreased CSF levels of 5-HIAA (serotonin metabolite) in depressed patients with impulsive and suicidal behavior
Increased sensitivity to b-adrenergic receptors
High cortisol - hyperactive H-P-A axis, fail to suppress cortisol levels with dexamethasone suppression test
Abnormal thyroid axis
GABA, glutamate, endogenous opiates may have a role
Psychosocial/life events - multiple adverse childhood experience risk factor for later developing MDD
Genetics - first degree relatives 2-4 x more like to have MDD
Selective serotonin reuptake inhibitors (SSRIs) side effects
HA, GI disturbance, sexual dysfunction, rebound anxiety
SNRI drugs
venlafaxine (Effexor)
Duloxetine (Cymbalta)
alpha2-adrenergic receptor antagonist drug
mirtazapine (Remeron)
Dopamine-norepinephrine reuptake inhibitor drug
bupropion (Wellbutrin)
TCAs
Most lethal in overdose due to cardiac arrhythmias
Side effects: sedation, wt gain, orthostatic hypotension, anticholinergic effects
Can aggravate prolonged QTc syndrome
Monoamine oxidase inhibitors (MAOIs)
for refractory depression
risk of hypertensive crisis when used with sympathomimetics or ingestion of tyramine-rich foods (wine, beer, aged cheeses, liver, smoked meats)
Risk of serotonin syndrome when used with SSRIs
Most common side effect - orthostatic hypotension
Adjunct medications used to threat MDD
Atypical antipsychotics with antidepressants for MDD with psychotic features or resistant/refractory MDD w/o psychotic features
T3, levothyroxine (T4), lithium to augment antidepressants in refractory MDD
Methylphenidate in terminally ill
Electroconvulsive Therapy (ECT)
For unresponsive or cannot tolerate (pregnant) to pharmacotherapy, need rapid reduction of sxs (immediate suicide risk, refusal to eat/drink, catatonia)
Premedicate with atropine -> general anesthesia (methohexital) -> muscle relaxant (succinylcholine)
Generalized seizure induced, should last 30-60 seconds, no longer than 90 seconds
Need 6-12 tx over 2-3 weeks
Retrograde and anterograde amnesia common - resolve w/in 6 months
Other transient side effects: HA, N, muscle soreness
Melancholic features
more likely in severely ill inpatients, including those with psychotic features
Anhedonia, early morning awakenings, depression worse in the morning, psychomotor disturbance, excessive guilt, anorexia
Atypical features
hypersomnia, hyperphagia, reactive mood, laden paralysis, hypersensitivity to interpersonal rejection
Mixed features
Manic/hypomanic symptoms during majority days during MDE
elevated mood, grandiosity, talkativeness/pressured speech, flight of ideas/racing thoughts, increased energy/goal-directed activity, excessive involvement in dangerous activities, and decreased need for sleep
Catatonia
catalepsy (immobility), purposeless motor activity, extreme negativism or mutism, bizarre postures, echolalia
Especially responsive to ECT
Psychotic features
presence of delusions and/or hallucinations
24-53% of older, hospitalized patients with MDD
Anxious distress
feeling keyed up/tense, restless, difficulty concentrating, fears something bad happening, feelings of loss of control
Peripartum onset
Onset of MDD during pregnancy or 4 weeks following delivery
Seasonal pattern
Temporal relationship between onset of MDD and particular time of year
Fall-onset SAD responds to light therapy
Bereavement
reaction to a major loss, not a mental illness
only lasts for several months
Normal bereavement does not include gross psychotic symptoms, disorganization, or active suicidality
Bipolar I disorder
episodes of mania and of major depression (not required for dx) - aka manic-depression
Between manic episode may be interspersed euthymia, major depressive episodes, or hypomanic episodes
Onset before 30, mean age 18
First degree relatives with bipolar are 10x more likely to develop the illness
Highest genetic link of all major psych disorders
Course chronic with relapses, as disease progresses, episodes more frequent
25-50% will attempt suicide, 10-15% succeed
Pharmacotherapy for Bipolar I disorder
Lithium - mood stabilizer, partial reduction of mania. Long term use reduces suicide risk. Acute overdose can be fatal d/t its low therapeutic index
Anticonvulsants: carbamazepine and valproic acid - mood stabilizers. useful in rapid cycling bipolar disorder and those with mixed features
Atypical antipsychotics - risperidone, olanzapine, quetiapine, ziprasidone - effective as mono/adjunct therapy for acute mania
Antidepressants discouraged as mono therapy -> activating mania or hypomania
Psychotherapy in Bipolar I disorder
may prolong remission once the acute mania episode has been controlled
ECT for Bipolar I disorder
works well in manic episodes, may require up to 20 treatments
Effective for refractory or life-threatening acute mania or depression
Bipolar II disorder
aka recurrent major depressive episodes with hypomania
Hx of one or more major depressive episodes and at least one hypomanic episode
Onset usually before 30
Rapid cycling
at least four mood episodes (manic, hypomania, depressed) within 12 months
Persistent Depressive Disorder (Dysthymia)
Chronic depression most of the time, may have discrete major depressive episodes
onset often in childhood, adolescence, and early adulthood
Early and insidious onset with a chronic course
Treatment with psychotherapy and pharmacotherapy
SSRIs, TCAs, MAOIs
Persistent Depressive Disorder (Dysthymia) DSM5 criteria
Depressed mood for majority of time most days for at least 2 years (children or adolescents for at least 1 year)
At least two of the following: "CHASES" poor CONCENTRATION or difficulty making decisions feelings of HOPELESSNESS poor APPETITE or overeating inSOMNIA or hyperSOMNIA low ENERGY or fatigue low SELF-ESTEEM
During 2 year period, and not symptom free for more than 2 months at a time
Cyclothymic Disorder
Alternating periods of hypomania and periods of mild-to-moderate depressive symptoms
May coexist with borderline personality disorder
Onset 15-25
Treat with antigenic agents (mood stabilizers or second gen antipsychotics) as used to treat bipolar disorder
Cyclothymic Disorder DSM5 criteria
Numerous periods with hypomanic symptoms (but not full hypomanic episode) and periods of depressive symptoms (but not full MDE) for at least 2 years
Never have been symptoms free for more than 2 months during those 2 years
No history of major depressive episode, hypomania, or manic episode
Premenstrual dysphoric disorder
Mood lability, irritability, dysphoria, and anxiety occur repeatedly during premenstrual phase of the cycle
May worsen prior to menopause but cease after menopause
SSRIs first line treatment - daily or during luteal phase only
OCPs may reduce symptoms
GnRH agonists have been used
Rare causes need Bilateral oophorectomy with hysterectomy to resolve sxs
Premenstrual dysphoric disorder DSM 5 criteria
at least 5 symptoms are present: in the final week before menses, improve within a few days after menses, and are minimal/absent in week postmenses
At least one: affective lability, irritability/anger, depressed mood, anxiety/tension
At least one (total of at least 5 with above sxs): anhedonia, problems concentrating, anergia, appetite changes/food cravings, hypersomnia/insomnia, feeling overwhelmed/out of control, physical sxs (breast tenderness/swelling, joint/muscle pain, bloating, wt gain)
Sx cause clinically significant distress or impairment in functioning
Disruptive Mood Dysregulation Disorder (DMDD)
Chronic, severe, persistent irritability occurring in childhood and adolescence
Very high rates of comorbidity, especially with ODD, ADHD, mood disorders, and anxiety disorders
Psychotherapy - parent management training for patient and family first line
Medications for comorbidities
Stimulants, SSRIs, mood stabilizers, second gen antipsychotics treat primary sxs of DMDD
Disruptive Mood Dysregulation Disorder DSM5 criteria
Severe recurrent verbal and/or physical outburst out of proportion to situation
Outbursts 3 or more per week, inconsistent with developmental level
Mood between outburst persistently angry/irritable most of the day, nearly every day, and observed by others
Sxs for at least 1 year, no more than 3 months without sxs
Sxs start before age 10, dx made between 6-18
No episodes meeting full criteria of manic/hypomanic episode longer than 1 day
this disorder cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder
