Mood Disorders I and II

Question 1

What is the criteria for Major Depresison Disorder?

Answer 1

* Must be SAD or express ANHADONIA (loss of interest/pleasure), or irritability if a child + 4 additional symptoms

(5 out of 9 total WITHOUT it being due to a medical condition or due to direct physiological effects of a substance)

S: saddness

I: decreased interest/pleasure

G: guilt / feelings of worthlessness

E: decreased Energy / fatigue

C: decreased concentration / indecisiveness

A: decreased appetite / wt loss

P: psychomotor agitation or retardation (observed by others)

S: suicidal thoughts

S: change in sleep (insomnia or hypersomnia)

Question 2

Risk Factors for MDD:

gender preference:

peak age onset:

genetics?

ethnic preference:

other?

Answer 2

Risk Factors for MDD:

gender preference: Women > men (2:1) – changes post-menopausal

peak age onset: 20-30s

genetics? moderate genetic risk (if one parent 10-15% chance, 2 parents 20-10% chance, MZ twins 50%, DZ twins 15-20%)

genetic cluster regarding family history (genetics, psychological and environmental disruptions)

ethnic preference: Higher in hispanic women and American Indians; lower in AA males, asians

other? single, divorced, widowed, negative childhood (loss, neglect, abuse)

income, profession, religion, geography have minimal impact

Question 3

Is this a single event episode, multiple? chronic?

Answer 3

with INC # of events –> increased risk.

ppl with 1 event - 50%

2 events - 70%

3+ 95%

For most its a reoccuring CHRONIC illness, with tiggers to relapse over time are less and less (will just come back withouth triggers = stress vulnerability model)

Question 4

How do people develop MDD? (5)

Answer 4

1. Genetic predisposition - SMALLER hippocampus, abnormal serotonin transport protein (now can be measured through genetic testing)
2. Poor physiological coping strageies or skills - secondary to trauma, loss, dysfunction, societal situations, lack of resiliency..
3. Triggering events - biological (MEDS! substances, diseases), psychological, environmental
4. Change in brain processes that cause us to interpret external or internal stimuli in different ways - negative cognitions, pessimisms, physical changes, withdrawal, retreat, lack of rewards, altered self awareness
5. Symptoms that hinger our ability to reach our previous neurobiological homeostasis via neurogenesis through enrichment – social connections; inability to return to normal due to difficult in making/keeping social connections, exercise, new learning

Question 5

MDD is a ________ brain disorder.

Although we don’t have a biological marker, the closest marker is a theory based on chronic ____ [low/high] level _____ [dec/inc] of _______ [hormone] secondary to stress –> causing disruption in healthy neurogenesis and may add to neurodegeneration.

Answer 5

MDD is a NEURODEGENERATIVE brain disorder.

Although we don’t have a biological marker, the closest marker is a theory based on chronic LOW level INCREASES of CORTISOLsecondary to stress –> causing disruption in healthy neurogenesis and may add to neurodegeneration.

Question 6

What three monoamines have been implicated in depression?

Answer 6

NE, DA and SE

especially serotonin!

Question 7

What are the three major theories explaining the pathophysiology of MDD?

Answer 7

1. Inflammatory theory
2. Structural theory
3. Network theory

Question 8

Explain the inflammatory theory of MDD:

Answer 8

Low levels of chronic inflammation from either reactive illness* (lupus, CAD) or *persistent heightened level of corticosteriods from stress produce a toxic inflammatory milieu where neurodegeneration INC and neurgenesis is inhibited.

It is though that IL 6 (interfers with serotonin metabolism) might be the main culprit

Thought that cytokines released also can lead to higher risk for heart disease and Alzheimers. HYPERSECRETION of cortisol can cause acute and more severe depression (Cushing’s disease)

Question 9

Explain the structural theory of MDD:

Answer 9

Depression is caused by abnormal changes in brain areas that can be identified premorbidly and are exacerbated in active illness.

Atrophy of the prefrontal cortex, amygdala and hippocampus, AND enlargement of the insula and anterior cingulated cortex

Enhancing neurogenesis in those areas that are atrophied or altering GABA in the insual are areas of exploration

Question 10

Explain the Network Hypothesis for MDD:

Answer 10

NOt a specific altered brain area that leads to depression but aberrancies in the TRACTS between the areas. White matter abnormalities in tracts between the MEDIAL PREFRONTAL CORTEX, AMYGDALA and HIPPOCAMPUS.

Glucose activity is DEC in the hippocampus and dorsalateral prefrontal cortex and INC in the amygdala, ventral striatum and subgenual cingulate gyrus

Thought that depression is a result of miscommunication and misinterpretation of various brain regions involved with interpreting emotions

• Depression will only improve if neurogenesis can occur in those tracts to retun the interaction and perception to normal*
• Abnormalities can be seen in various neuroimaging, show less activity at limbic system and prefronta alreasy of focus*

Question 11

What can depression be a risk factor for (4):

Answer 11

1. More major depression! The longer the depression the greater the chornicity of illness. If <6 months 60% chance of remission; if > 24 months, 10-15% chance of remission
2. Other co-morbid psychiatric illnesses (60%) of the time - Etoh and anxiety diorders most common
3. Cardiac events (due to cytokines and inflammation )
4. CNS - CVA, parksonism, demetia, seizures, strokes, Alzheimers

Question 12

Other conditions that may cause or mimic major depression: (4)

Answer 12

1. Psychosocial - loss, abandonment, lack of nuturing, emptiness, anger towards inward, developmental arrest at a dependent stage with a disordered parten, low self-estmee, failures, lack of self object stability, consistency
2. Environment - poverty, deaths, famine, wars, oppresison, abuse, torture, drugs, learned helplessness, side effects of meds, chemical toxins, ID, medical conditions
3. Other medical conditions - **once the condition is stable the depressive symptoms should dissipate** examples: EBV (mono) – fatigue, decreased mood….; infectious, neoplasms (pancreatic CA, brain tumors, lymphomas), endocrime (hyper/hypo thyroidims, hypo/hyperadrenocortical function - Cushing’s and Addison’s), diabetes; Metabolic/nutritional (uremia, pellagra, anemia), Neurologica (frontaltemporal dementia, Parkinson’s Huntington’s subdural hematoma, temporal lobe epileps, MS, head trauma)
4. Substance/medication-induced - corticosteroids, BC, antipsychotics, interferons, RESERPINE, isotretinoin (Accutane), beta blockers, central actinv anti-hypertensives, all of the pschoactive substances (alcohol, cocaine, marijuana, opioids, sedatives/hypnotics)

Question 13

What are examples of “specifiers” that can be added to a dx in order to better quialify them and lead to better/more appropriate treatment:

Answer 13

MD with…

anxious distress

mixed features (anxiety and sadness)

melancholic features (worse in teh AM, terminal insomnia, excessive guilt, marked wt loss, total lack of pleasure-anhedonia)

atypical features (wt gain, over sensitive mood reactivity, oversleeping, leaden paralysis - feel like can’t move arms or legs)

mood congruent psychotic features (about 10% of epidoses- hallucinations and delusions that have depressive contentn “i feel like I am rotting and the devil is telling me bad things”

mood in-congruent psychotic features

catatonia

peripartum onset

seasonal pattern

Question 14

Persistent Depressed Disorder

Duration:

Depressed mood for:

Symptoms (6):

Tx:

Answer 14

Persistent Depressed Disorder

Duration: 2 YEARS, has never been symptoms free for longer than 2 months

Depressed mood for: most of the day on more days than not, course tends to be non-remitting; can have MDD ON TOP of this disorder

Symptoms (6): TWO of the SIX

• poor appetite or overeating
• low energy or fatigue
• insomnia or hypersomnia
• poor concentration or difficult decision making
• feelings of hopelessness

Tx: difficult to treat

Question 15

Premenstrural Dysphoric Disorder

Duration:

SX: (11 total)

Answer 15

In the MAJORITY of menstrual cycles, symtoms occurin during the final week before start of menstruation, and as soon as period comes, goes away within 2-3 days.

Causes significant distress or impairment

NOT an exacerbation of another similar disorder (ie-MDD)

AT LEAST ONE of the following:

Marked affective lability

Marked irritability and anger or interpersonal conflicts

Marked depressed mood, feelings or hopelessness

Marked anxiety, tension and/or feelings on edge

AND at least ONE of the following:

DEC interest

Poor concentration

Lethargy

Change in appetite

Hyperinsomnia or insomnia

Sense of being out of control

Physical symptoms-breast tenderness, bloating, mus pain

*A TOTAL OF 5 or MORE symptoms

Question 16

MDD + melancholia:

SX (5)

TX

Tests?

Answer 16

MDD symptoms AND also:

• lack of reactivity of any pleasureable situaiton
• early AM mood worse
• early morning awakening

marked agitation or retardation

• excessive guilt

Rx: Anti-depressions!

Test: dexamethasone Suppression Test (DST) usually positive unable to supress cortical levels

Question 17

Atypical MDD:

Answer 17

• oversleeping
• overeating
• leaden paralysis
• interpersonal sensitivity
• mood reactivity, leading to roller-coaster type of mood

Question 18

MDD Psychotic

SX (3)

RX

Answer 18

10% of all MDD

• MDD features but also presence of psychotic element*
• Nihilism (no future, world will end)
• deflusions “I am bad” “I have cancer-rotting in me”
• hallucinations, usually negative, usually AUDITORY

RX: anti-psychotic or ECT essential!

newer SSRIs may not work welll

Need to R/O bipolar, and schizophrenia!

Question 19

Seasonal MDD:

SX

RX

Answer 19

20% of people at this latitude have a seasonal mood fluctuations

SX- similar to atypical depression but patients tend to become “HYPER IN SUMMER” while October - February is bad

RX: light therapy of some help, anti-depressants just as effective

Question 20

Bereavement/grief VS MDD

Answer 20

Bereavement, for most people, is normal life reaction. Will have many of the same symptoms as MDD but individual can still experience pleasure and joy at times. However, loses are a precipitant of MDD and one should not hesitate to treat as MDD if symptoms are severe enough. Don’t wait and normalize - longer the delay of treatment, worse depression can get

expectations are that by 3 months, many of hte symptoms have resolved and the person moves on a bit more with their life

Question 21

Adjustment disorder with depressed mood:

Answer 21

= Some signs of depression that cause clinical concern but with an acute stressor that occurred within 3 months o_f the onset of symptoms_

Tx: brief therapy or social interventions are all that’s needed

Criteria for other disorders are NOT MET and the symptoms abate by 6 months after the end of the stressor

Question 22

Special populations that require extra attention:

Answer 22

ELDERLY!

New incident rate increases >65 y/o

Males have a high rate of suicide

SX: often masked depression, they are irritable, a_ngry, don’t care, often somatic in presentation, don’t try, may be confused with dementia (pseudodementia)_

RX: treatable

TEENAGERS:

Hard because many times teenagers are not familiar with what depresison is and how it looks or feels; we may dismiss the teenager as “bad teens” - yet look for behavioral changes. High suicide rate (they don’t know whats going on)

Question 23

What is the criteria needed to be diagnosed with Bipolar I Disorder:

Answer 23

Requires at least ONE MANIC episode although most commonly there will be episdoes of major depression an dother mood states in the the history

MANIC espidoes:

• Distinct period of abnormally and persistent elevated, expansive or irritable mood present for most of the day for at least ONE WEEK

AND 3 (or 4 if the mood is only irritable) of the following symptoms

• inflated self-esteem or grandiosity
• decreased need for sleep
• More talkative than usual or pressure to keep talking
• flight of ideas / subjective experience of racing thoughts
• distractibility
• INC in goal-directive activities or psychomotor agitation
• Excessive involvement in pleasurable actvities that have a high potential for painful consequences (buying, speeding, sexual indiscretions, foolish business ventures)

*Marked impairment in functioning in job, social activities or relationships with others or there are psychotic features

*symptoms NOT caused by a substance or medical condition

Question 24

Bipolar individuals:

____ % of the time will be spent in a depressive phase

____ % spent in hypmanic or manic phase

____ % spent in the euthymic state (normal, non-depressed, reasonably positive individual)

When bipolar individuals are in their euthymic phases, do they have normal functioning, back to baseline?

Does their lifespan change?

Is there an increased risk for suicide?

What is a main causitive factor for some of these changes?

Answer 24

Bipolar individuals:

40-45 % of the time will be spent in a depressive phase

5-10 % spent in hypomanic or manic phase

45 % spent in the euthymic state (normal, non-depressed, reasonably positive individual)

When bipolar individuals are in their euthymic phases, do they have normal functioning, back to baseline? No - there is evidence of brain function abnormalities, processing abilities are impaired, verbal memory, attention and executive functioning are less than baseline.

Does their lifespan change? 8-10 years less primarily due to metabolic syndrome co-morbidies

Is there an increased risk for suicide? 15-20X higher

What is a main causitive factor for some of these changes? their insight into their illness is always suspect leading to issues of substance abuse, non-compliance with medications and treatment, and potentially challenging live courses

Question 25

What is the criteria for Bipolar II Disorder?

Answer 25

Patient must have experienced a Major Depressive Episode but in addition at least ONE PERIOD of time where they have symptoms of HYPOMANIA (distinct period of abnormally and persistent elevated, expansive or irritable mood and increased activity or energy last at least 4 DAYS in a row for most of those days) and 3 or more of the following:

• inflated self-esteem or grandiosity
• decreased need for sleep
• More talkative than usual or pressure to keep talking
• flight of ideas / subjective experience of racing thoughts
• distractibility
• INC in goal-directive activities or psychomotor agitation
• Excessive involvement in pleasurable actvities that have a high potential for painful consequences (buying, speeding, sexual indiscretions, foolish business ventures)

The hypomanic symptoms are usually observed by others but not so severe to cause marked impairmetn in functioning or require hospitalization. NO PSYCHOSIS present (if there is psychosis - bipolar I)

Question 26

Is the course of Bipolar I and Bipolar II different?

When would you say a person has Bipolar I vs Bipolar II?

Answer 26

Although Bipolar II is less severe than Bioplolar I, the course of ilness of Bipolar II is just as severe as Bipolar I (as stated on a previous flashcard - increased risk for suicide, decreased life expectancy..)

If the patient meets the criteria for a manic episode –> bipolar I

Question 27

Cyclothymic Disorder criteria:

Answer 27

2 years of minimum of mood cycling but never enough criteria for bipolar I or II or MDD

Question 28

Bipolar Unspecified criteria:

Answer 28

Diagnosis encompasses many potential patietns who have some symptoms of mania and hypomania at times but enver enough to meet full criteria.

Anyone with significant mood fluctuations and irritability that are not induced by substances may fall into this criteria.

This diagnosis is largely speculative but may encompass 3-4% of hte population who often are never diagnosed

Question 29

Bipolar Epidemiology:

Bipolar I: _____% lifetime prevalence

Bipolar II: _____% lifetime prevalence

Cyclothymic Disorder/Unspecified Bipolar disorder: _____% lifetime prevalence

Men Vs Women?

Age onset?

Genetic?

Other?

Greater chances for?

Answer 29

Bipolar Epidemiology:

Bipolar I: 0.6-0.8% lifetime prevalence

Bipolar II: 0.5-0.8% lifetime prevalence

Cyclothymic Disorder/Unspecified Bipolar disorder: 3-4% lifetime prevalence

Men = Women

Age onset: late teenage years, first episode usually begins iwth depression; childhood bipolar unusual unless there is significant genetic history

Genetic? Highly hereditable- 65-85%, chance of inheritance with 2 parents with bipolar - 50%

Other: more prevalent in HIGHER socioeconomic brackets, overexpressed in high functioning professions- physicians, researchers, lawyers, entertainers, business executives

Greater chance of becoming psychotic (hallucinations, delusions, disorganized thoughts) than those with unipolar depression

Question 30

What is the pathophysiology behind Bipolar?

What do patients with bipolar exhibit (2)

Answer 30

Depressive phase similar to MDD - neurodegenerative

Manic state is difficult to study and has mixed results, other than an increased perfusion and glucose metabolism in all areas of the brain

Patients with bipolar have enlarged ventricles and increased white matter hyperdensities

fMRI, arterial spin, showed blood flow to the anterior cirgulate cortex more specific for Bipolar depression vs unilateral MD.

Question 31

Hints that a person might be bipolar when presenting with depression (13):

Answer 31

Early age onset (before 20)

Psychotic depression

1st episode of depression is postpartum especially if psychotic

Rapid onset and offset of depressive symptoms

Recurrent depression with more than 5 episodes

Bipolar family Hx [evidence for gene defect w/ chrom 18q or 22q]

Seasonal Mood disorder

Atypical depression

Hypomania associated with antidepressants

Repeated loss of efficacy of antidepressants over time

Traint mood lability, hyperthymic temperament

Depression with mixed mood states

Bipolar sx (hypomania) can at times be imitated by substances (cocaine, caffeine, prednisone) or general medication conditions (hyperthyroidism, closed head injury) and therefore a good medical work up is always a first step to dx

Question 32

What is suicidal ideation?

What is the prevalence among the population?

What are some things patients might say that could alert you to suicide ideation?

Answer 32

Thoughts of dying or wishes they were dead

Usually presenti when someone is under a lot of stress and feels there is no way out.

Relatively common, 20% of adolescencs will experience this at some point and 10% of adults in a given year

34% of individuals with suicidal ideation plan an attempt

Statements such as: I wish I were dead. The world would be a better place withouht me.

These thoughts are often fleeting but can begin to persist on a daily basis

Question 33

What is suicidal intent?

What is the prevalence of these individuals that will commit suicide?

Answer 33

Suicidal intent goes beyond just thinking about it; people have already though to WAYS in which to execute it; person has done research, looked at websites, asked others, begun to sercure the mean to commit suicide or thought out when and how they would do it

72% of people who think of a plan actually attempt

Question 34

What is considered a suicide attempt?

What is the ratio of attempts to completions?

What is essential when obtaining a psychiatric triage after an attempt?

Answer 34

The actual carrying out of an act that could end one’s life

The ratio of attempts to completions is 12:1

depends on means and place of action

*Important to determine whether someone really wanted to die vs just relieve pain or get help

Question 35

Completed suicide is the ____ leading cause of death in the US

What are the top 3 means people achieve this by? When do people decide?

Male to female ratio, for successful, for attempt

Ethnicities

Age

other high risk groups

Answer 35

10th leading cause of death in the US

Top 3 reasons: firearms (51%), suffocation (usually hanging - 25%), poisoning (17%)

10% decide in the last ten minutes of their lieves

Successful Suicides: male to female 4:1

Sucide atempt: female to male 3:1

Top ethnicities: Caucasions > AA > Hispanics

Age: Higest risk are middle age > elderly (sudden, usually after terminal disease) > adolescents (least warning, most impulsive)

Other: veterans returning from war

Question 36

Most serious risk factors of suicide attempt/completion (12):

Answer 36

Currently has a feasible plan in mind

Hx of prior attempts

Psychosis (esp command hallucinations)

High anxiety

Impulsivity

Presence of a mental disorder

Substance abuse (esp. if intoxicated)

Hopelessness

Lack of support

Family history of completed suicide

Significant negative life event in the last 3 months

Presence of guns in the house

Question 37

What are protective factors when assessing for suicide?

Answer 37

Supportive family

Strong faith or religion

Being on medications for psychiatric illness

these are meant for risk analysis but does not make the patient immune from taking action

Question 38

What is the pathophysiology behind suicide?

Answer 38

Lower serotonin R #s

Lower serotonin levesl in the CNS

Lack of effective coping strageties, presence of impulsivity also have strong correlation with attemps

70% of patients who ultimately complete suicde make the decision within the last 5 mins- which makes intervention near impossible.

Question 39

What are 4 preventive actions a clinican can take?

Answer 39

1. Ask- don’t think you will be putting the thought in someone’s head
2. Use behavioral incidents - “what exactly were you thinking” “did you actually go out and buy a gun”
3. Do a risk analysis based on each patient’s unique situation
4. Remove the means; make sure the patient is safe