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Mental Health > Mood disorders - MH > Flashcards

Mood disorders - MH Flashcards

1
Q

Mood is

A
  • a sustained emotional tone

- perceived on a continuum

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2
Q

Mood disorders are

A
  • characterized by abnormal depression or euphoria
  • categorized into: depressive and bipolar
  • can have psychotic features
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3
Q

Mood Disorders

A

Depressive Disorders

  • “Depression”- in general
  • Major Depressive Disorder
  • Dysthymic Disorder
  • Mania
  • Hypomania
  • Bipolar Disorders
  • Adjustment Disorder
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4
Q

Depression

A
  • A mood state- irritable, empty, sad…
  • A syndrome- “constellation of symptoms”
  • A specific disorder: a “clinical condition”
  • Ie… Major Depressive Disorder (MDD)
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5
Q

Depressive Disorders stats

A
  • Considered a major public health problem
  • Economic consequence 83B. US & 118 B. UK
  • Life time incidence: F- 20% and M- 10% (2:1)
  • Precipitating event in 25% cases
  • Diurnal variation- mornings worse
  • Median age of onset is 40- but occur anytime
  • *Most adults are not seen by mental health
  • *FM- misses ½ of depressed patients they see
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6
Q

Depression- pathophysiology

A

-Neurochemical- decreased serotonin, norepinephrine, dopamine

Hormonal- HPA axis is hyperactive in depression- leads to:

  • increased cortisol secretion
  • blunted release of TSH, decreased GH, -decreased FSH, LH and testosterone
  • decreased immune functions
  • Sleep- abnormalities 60-65% of mood dxs
  • Genetic- “runs in families” – not like bipolar
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7
Q

Depressive Conditions

A

Major depressive disorder (MDD)

  • With Psychotic features
  • Depression with melancholic or catatonic features
  • Chronic
  • With seasonal pattern(seasonal affective disorder)
  • With postpartum onset (PPD)
  • Atypical features
  • Pseudodementia
  • Depression in children
  • Double depression

Dysthymic Disorder

  • rated as mild, moderate, or severe.
  • occur with or without psychotic symptoms
  • can be mood congruent or incongruent.
  • can be determined to be in full or partial remission. Usually resolved after tx in 6 mo
  • should be diagnosed as chronic when an episode lasts longer than 2 consecutive years.
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8
Q

Major Depressive Disorder Dx

A
  • Diagnostic criteria: DSM-IV
  • A major depressive episode is defined as a syndrome in which at least 5 of the 9 cardinal symptoms of depression have been present during the same 2-week period.
  • The additional criteria are satisfied.
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9
Q

Cardinal Symptoms of depression

A
  • Sleep- insomnia or hyposomnia
  • Interest –loss of interest or pleasure in activities
  • Guilt- feelings of worthlessness or guilt
  • Energy- low
  • Concentration- poor
  • Appetite- “change in” up or down or weight changes
  • Psychomotor- (inability to think, concentrate, decide)
  • Suicide- thoughts of death or suicidal ideation

*Depressed Mood

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10
Q

Dysthymic Disorder

A

-Depressed mood for at least two years.
-Depression is present most of the day
…. For more days than not.

  • Symptom free times may not exceed two months.
  • A Major depressive episode does not occur in first 2 years.
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11
Q

Dysthmic disorder criteria

A

Accompanied by two symptoms:

  • Decreased or increased appetite
  • Insomnia or hypersomnia
  • Low energy
  • Poor concentration
  • Hopelessness
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12
Q

History and Mental Status Exam

A
  • Most important part of the evaluation
  • Obtain from patient and often involves information from family or treatment providers.
  • Consider patient confidentiality and consent
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13
Q

History Goal: Psychiatric Sxs/ MSE

A
  • Establish the presence or absence of each of the nine cardinal symptoms of depression.
  • Determine the chronology of the symptoms
  • Determine the impact of the episode on functional status
  • Elicit alleviating or aggravating factors, stressful life events, social or occupational circumstances
  • Include MSE and- supplements to history-
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14
Q

Depression: The Patient’s story

A
  • Anhedonia- loss of pleasure and interest; previous passion
  • Withdrawal from family and friends
  • No motivation- low frustration-

Vegetative signs

  • Loss of libido
  • Weight loss and anorexia
  • Weight gain or hyperphasia,
  • Low energy level, fatigability
  • Abnormal menses
  • Early morning awakening (terminal insomnia approximately 75% of depressed patients have sleep issues
  • Diurnal variation
  • Constipation, dry mouth, headache
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15
Q

MSE- what you will notice:

A
  • General Appearance- poor eye contact, tearful, inattentive to personal appearance, agitation or psychomotor retardation, downcast
  • Affect- constricted, intense
  • Mood- depressed, irritable, frustrated, sad
  • Speech- monosyllabic, long pauses, soft, low, monotone, little or no spontaneity
  • Thought content- pervasive feelings of hopelessness, worthlessness and guilt, obsessive rumination, suicidal ideation* 60%/15%, somatic preoccupations, indecisiveness, poverty of content, mood congruent hallucinations or delusions, little spontaneity
  • Sensorium- distractibility, difficulty concentration, complaints of poor memory, apparent disorientation, abstract thought impairment.
  • Insight/judgment- impaired due to cognitive distortions of personal worthlessness
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16
Q

Associated Features

A

-Somatic complaints can mask depression
Cardiac, GI, GU, low back pain and orthopedic c/o

Content of delusions/hallucinations

  • Mood congruent- (guilt, poverty, nihilism, deserved persecution,)
  • Mood incongruent- thought insertion, broadcasting, control or persecutory delusions unrelated to depressive themes.
17
Q

Age Specific Considerations

A

Prepubertal
-Somatic complaints; agitation; single voice auditory hallucination; anxiety disorders; phobias

Adolescent
-Substance abuse/antisocial behavior; restlessness; truancy; school issues; promiscuity; increased sensitivity to rejection, poor hygiene

Elderly
-Cognitive deficits (memory loss, disorientation, confusion; Pseudodementia or dementia syndrome of depression; apathy; distractibility

18
Q

Medical History

A

Many general medical conditions throughout all organ systems and drugs to cause or contribute to depressive episodes

Evaluate

  • Current and Past medical history
  • Medication use
  • Review of symptoms
    • ASSESS SUICIDE RISK- A MUST!
19
Q

Comorbid psychiatric disorders & FHx

A
  • Anxiety symptoms
  • Alcohol and other substance use
  • Cognitive symptoms and functioning
  • Prior history of hypomania, manic or psychotic episodes.
  • Family history of mood or other psychiatric disorders
20
Q

Comorbid medical conditions-

A
  • Severe new onset depression including melancholia and psychotic depression
  • New- onset depression in an older adult
  • New –onset or recurrent depression that is not understood in the context of psychosocial stressors
  • Depression that has not responded to treatment
  • Depression with sufficient coexisting cognitive impairment, anxiety, substance abuse or comorbid psychopathology
21
Q

Lab Assessment

A

-Complete blood count
-Electrolytes and glucose
-BUN and creatinine
-Hepatocellular enzymes
-TSH
-RPR
-Serum B12 and folate
-Urinalysis
+/< EKG

22
Q

MDD: Course and Prognosis

A
  • 15% of depressed patients eventually commit suicide
  • An untreated, averaged depressed episode lasts 10 months
  • At least 75% patients have a second episode, usually within the first 6 months of the initial
  • Patients with depression have an average of 5 episodes in a lifetime

Prognosis- with treatment

  • 50% usually recover
  • 30% partially recover
  • 20% have a chronic course
23
Q

Treatment- overview

A

-MDD- treatable in 70-80% of a patients

DELICATE BALANCE-
-Psychotherapy in conjunction with antidepressants is more effective than either treatment alone

24
Q

Therapy- The Basics

A
  • Sleep
  • Exercise
  • Adequate fluid intake
  • Eating Healthy
  • Spirituality or Centering
25
Q

Treatment pharmacologic

A

-Almost always in MDD and often dysthymia

  • If a family history of a positive response to a particular drug- try it first
  • If not, begin with SSRI- monitor for 2-3 weeks
  • Response in usually 4-6 weeks (75% positively)
  • If not, increase dose/add adjuvant/ if s.a.- change
  • Maintenance for 6 months helps prevent relapse
26
Q

Mania- the Patient’s story

A

Erratic and uninhibited behavior

  • Excessive spending of money, gambling
  • hypersexuality, promiscuity
  • Overextended in activities and responsibilities
  • Low frustration tolerance

Vegetative signs

  • Increased libido
  • Weight loss/anorexia
  • Insomnia- or expressed as “no need to sleep”
  • Excessive energy
27
Q

Manic MSE

A
  • General Appearance- agitation, seductive, colorful clothes, excessive makeup, inattentive to personal appearance or bizarre combinations, intrusive, entertaining, hyperexcited
  • Affect- labile, intense
  • Mood- euphoric, expansive, irritable, demanding, flirtatious
  • Speech- pressured, loud, dramatic, exaggerated, incoherent
  • Thought content- high elevated self-esteem, grandiosity, delusions, egocentric, hallucinations (that are mood-congruent in self-worth and power, grandiose- not often paranoid)
  • Thought process- flight of ideas, racing thoughts neologisms, clang associations, circumstantiality, tangentiality
  • Sensorium- highly distractible, difficult with concentration, abstract thinking generally is intact, memory usually ok
  • Insight and judgment- extremely impaired, often total denial, inability to make organized thoughts or rational decisions.
28
Q

Bipolar Disorders- E/E

A
  • 30 mean age of onset
  • Genetic disposition- greater than in depression
  • 50% of patients have a parent with a mood disorder
  • 20-25% risk if patient has first degree relative
  • M and F ratio equal
29
Q

Bipolar Psychotic symptoms

A

Grandiose delusions:

  • of exceptional talent
  • of assistance, of reference and persecution
  • of exceptional mental and physical fitness
  • of wealth, aristocratic ancestry or other grandiose identity

Fleeting auditory or visual hallucinations:

30
Q

Bipolar treatment

A
  • Pharmocotherapy- Lithium is toc for bipolar I (80% effective) and cyclothymic disorders
  • In acute tx- add antipsychotic- (Haldol)
  • Lithium trial should last 4 weeks before dc
  • If MDD occurs during- add antidepressant or increase dose of lithium
  • Pre-clinical work up prior to starting lithium
  • As in depression- psychotherapy in conjunction with antimanic drugs is more effective than either alone
  • Psychotherapy is NOT indicated when a patient is experiencing a manic episode.
  • Calming is necessary- pharmacological and physical steps must be taken to protect and calm the patient.
31
Q

Bipolar Course and Prognosis

A

-About 1/3 of dysthymic patients develop Bipolar II
-45% of manic episodes recur.
-Untreated manic episodes last 3-6 months
80-90% of manic patients eventually experience a full depressive episode

Prognosis is fair

  • 15% recover
  • 50-60% partially recover
  • 30% have chronic symptoms with social deterioration
32
Q

Adjustment Disorder

A
  • Pathological behavioral response to a psychosocial stressor resulting in impaired social or vocational functioning
  • Stressors are in the range of normal- marriage, job loss, divorce, illness, birth of a baby, leaving home, going to college
  • Most symptoms diminish over time without treatment, especially if stressor removed
  • Subgroup- maintains chronic course- co-dxs
33
Q

Adjustment Disorder - etiology

A

-Most frequent in adolescents, but at any age

Etiology:

  • Genetic- high anxiety temperament, prone to overreacting to stressful events
  • Biologic- greater vulnerability with history of illness or disability
  • Psychosocial- greater vulnerability with a person who lost a parent or who had poor mother experiences

Mental Health (11 decks)

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