Mood Disturbances - Burton

Question 1

What is a primary and secondary mood disorder?

Answer 1

Primary - does not result from another medical or psychiatric condition
Secondary - results from another medical or psychiatric condition, such as anaemia, hypothyroidism, or substance misuse.

Question 2

What are the main types of primary mood disorders?

Answer 2

Unipolar - depressive disorder, dysthymia

Bipolar - bipolar disorder, cyclothymia

Question 3

What is dysthymia?

Answer 3

Described as mild chronic depression, and as such is characterised by depressive symptoms that are not sufficiently severe to meet the criteria for depressive disorder.

Question 4

What is hypomania?

Answer 4

A lesser degree of mania, with symptoms similar to those of mania but less severe or extreme. No psychotic symptoms and no marked impairment of social functioning.

Question 5

How do you meet the criteria for bipolar disorder in the ICD-10?

Answer 5

Patient must have suffered at least two episodes of mood disturbance, at least one of which must have been mania or hypomania.

Question 6

Can you diagnose bipolar or hypomania with no depressive symptoms?

Answer 6

Yes, as sooner or later a depressive episode is almost certain to happen.

Question 7

What is cyclothymia?

Answer 7

Mild chronic bipolar disorder. Characterised by recurrent episodes of mild elation and depressive symptoms that are not sufficiently severe or prolonged to meet the criteria for bipolar or dysthymia.

Question 8

What are the three groups of symptoms in depression?

Answer 8

Core symptoms
Psychological symptoms
Physical symptoms

Question 9

What are the core symptoms of depression?

Answer 9

Low mood

Loss of interest and enjoyment

Question 10

What are the psychological symptoms?

Answer 10

Poor concentration
Poor self-esteem
Inappropriate guilt
Pessimism
Recurring thoughts of death or suicide

Question 11

What are the physical symptoms?

Answer 11

Sleep disturbance (often early morning waking)
Fatigability
Loss of appetite and weight loss
Loss of libido 
Anhedonia
Agitation or retardation

Question 12

What are the core symptoms of depression in the ICD-10?

Answer 12

Persistent low mood
Anhedonia
Low energy

Question 13

What are the non-core symptoms of depression in the ICD-10?

Answer 13

Reduced concentration and attention
Reduced self-esteem and self-confidence
Ideas of guilt
Pessimism
Ideas of self-harm or suicide
Disturbed sleep
Poor appetite

Question 14

How long should you have symptoms of depression for a diagnosis?

Answer 14

At least two weeks, shorter periods may be reasonable.

Question 15

How many symptoms should be present for diagnosis of mild, moderate and severe depressive episodes?

Answer 15

Mild - Two core + two non-core
Moderate - 2/3 core + 3/4 non-core
Severe - 3 core + 5/6 non-core, psychotic symptoms may be present and high risk of suicide.

Question 16

What are the psychiatric differential diagnoses for depressive disorders?

Answer 16

Depression 
Dysthymia
Cyclothymia
Bipolar disorder
Mixed affective states
Schizoaffective disorder
Schizophrenia and other psychotic disorders
Adjustment disorder
Seasonal affective disorder
PTSD
Generalised anxiety disorder
OCD
Eating disorder

Question 17

What are the organic differential diagnoses for depressive disorders?

Answer 17

Neurological: stroke, alzheimer’s and other dementias, parkinson’s, huntington’s, MS, epilepsy, intracranial tumours

Endocrine: Cushing’s syndrome, Addison’s disease, hypothyroidism, hyperparathyroidism

Metabolic: Iron deficiency, B12 or folate deficiency, hypercalcaemia, hypomagnesaemia

Infective: Influenza, infectious mononucleosis, hepatitis, HIV/AIDS

Neoplastic: Non-metastatic effects of carcinoma

Drugs: L-dopa, steroids, beta blockers, digoxin, cocaine, amphetamines, opioids, alcohol

Question 18

When is peak prevalence of depressive disorders in men and women?

Answer 18

Men - old age

Women - middle age

Question 19

What is the ratio of men to women in depressive disorders?

Answer 19

1:2 M:F

Question 20

What is the prevalence of depression in first degree relatives of people with depression compared to general population?

Answer 20

15% in 1st degree relatives

5% in general population

Question 21

What is the concordance rate of major depressive disorder in monozygotic twins compared to dizygotic twins?

Answer 21

46% dizygotic

20% monozygotic

Question 22

What does the monoamine hypothesis of depression say?

Answer 22

Depression results from a depletion of monoamine neurotransmitters, particularly serotonin and noradrenaline.

Question 23

What are the investigations for depressive disorders?

Answer 23

Physical examination
FBC
Urea and electrolytes
Liver function tests
Thyroid function tests
ESR
B12 and folate
Toxicology screen
Antinuclear antibody
HIV test
Dexamethosone suppression test

Question 24

What role does endocrine abnormalities have in depression?

Answer 24

Depression often occurs in Cushing’s, Addison’s, hypothyroidism, and hyperparathyroidism.

Plasma cortisol levels are increased in about 50% of depression suffererer, and that 50% of depression sufferers fail to respond to the dexamethosone suppression test.

Question 25

What are the common psychological treatments for depression?

Answer 25

Counselling
CBT
Dynamic psychotherapy
Family therapy
Interpersonal therapy

Question 26

What medications are people given for ECT?

Answer 26

Standard anaesthetic (propafol)
Muscle relaxant (suxamethonium)

Question 27

When is ECT indicated?

Answer 27

Treatment-resistant severe depression

Question 28

What is the average length of a major depressive episode?

Answer 28

6 months

Question 29

What are the three degrees of severity for manic episode in the ICD-10?

Answer 29

Hypomanic
Mania without psychotic symptoms
Mania with psychotic symptoms

Question 30

What are the symptoms of mania without psychotic symtoms?

Answer 30

Elation, increased energy, pressure of speech, decreased need for sleep.

Normal social inhibitions are lost, lack of concentration.

Self-esteem is inflated, and grandiose or over-optimistic ideas are freely expressed.

Question 31

How long should symptoms last for a diagnosis of mania to be made?

Answer 31

At least one week and should be severe enough to disrupt ordinary work and social activities more or less completely.

Question 32

What are the psychiatric differential diagnoses for mania and bipolar disorder?

Answer 32

Schizoaffective disorder
Schizophrenia
Puerperal psychosis
Cyclothymia
Attention deficit hyperactivity disorder

Question 33

What are the organic differential diagnoses for mania and bipolar disorder?

Answer 33

Drugs (alcohol, amphetamines, cocaine, hallucinogens, anti-depressants, L-dopa, steroids)
Sleep deprivation
Delirium
Brain disease of the frontal lobes (dementia, stroke, multiple sclerosis, tumour, epilepsy, aids, neurosyphilis)
Endocrine disorders (hypothyroidism, Cushing’s)
Systemic lupus erythematosus

Question 34

What is the lifetime risk for bipolar disorder?

What are the effects of gender and geography?

Answer 34

0.5-1%

All races, populations and genders are equally affected.

Question 35

What is the mean age of onset of bipolar disorder?

Answer 35

21 years

Keep in mind a first episode of mania after 50 ought to prompt an investigation for a primary cause (endocrine, brain disease)

Question 36

What is the unusual epidemiological fact about bipolar disorder?

Answer 36

More common in higher socioeconomic groups.

Question 37

What is the most common medication in a manic episode and in a depressive episode?

Answer 37

Manic - antipsychotic

Depressive - antidepressant

Question 38

How does should treatment progress in a patient with a manic episode?

Answer 38

Start an antipsychotic and wait for the person to recover before considering a long-term mood stabiliser.

Patient should not be started on mood stabiliser as unable to consent and may affect long-term compliance.

Question 39

How long will a manic episode and a depressive episode last on average untreated?

Answer 39

Manic - 4 months

Depressive - 6 months